Form DS-874 at a glance
What it is: Form DS-874 (1/19) is the Medical Examination Report of Driver Under Article 19-A.
Who signs: The driver signs at (Driver's Signature) X (Date). The medical examiner signs at Signature of Examiner. For an Advanced Practice Nurse * (who is not a Nurse Practitioner), the Supervising Physician signs at (Signature of Supervising Physician).
What to bring and attach to Form DS-874
INSTRUCTIONS TO MEDICAL EXAMINER: The complete standards and instructions for conducting this examination are found in Section 6.10 of the Commissioner's Regulations, 15NYCRR6, and can be found at dmv.ny.gov/art19. They are also available from the driver's carrier named in Section 1 or from the Bus Driver Unit. For New/Initial Examinations and Recertification, review/complete ALL items on the form and sign where indicated on last page. For Follow-up Examinations, complete ONLY those items which require follow-up information and/or evaluation from a prior examination. Sign the form where indicated. If additional space is required for further comments and information, use form DS-874C, and attach it to this form.
A filled-in Form DS-874 example: a bus driver fills out Section 1
How to fill out Form DS-874, box by box
Driver/Carrier Information
In Section 1, Driver/Carrier Information, the driver and/or driver's carrier completes Driver's Last Name, First, M.I., Date of Birth (Month/Day/Year), Age and Sex.
Enter Street Address, City, State and Zip Code.
Enter the License ID Number (from Driver License), State, Class of Driver's License, Endorsements, Restrictions and Expiration Date.
Enter the Carrier/DBA Name, Legal Name (if different) and 19-A Business ID Number.
Health History
Section 2, Health History, is to be completed by the driver and reviewed by the medical examiner.
For any YES answer, the driver should indicate the condition, onset date, diagnosis, treating medical examiner's name and address, and any current conditions or comments here.
For Diabetes or elevated blood sugar controlled by, check all that apply: diet, insulin, other medication.
List all medications (including over-the-counter medications) used regularly or recently.
Driver's Signature and Date
The driver signs and dates this certification. By signing, the driver certifies that the information in Driver/Carrier Information and Health History and any other information on any accompanying DS-874C, if used, is complete and true. "I understand that inaccurate, false or missing information may invalidate this examination."
More rules for Form DS-874
Sections 3 through 8 are to be completed by the medical examiner.
In Section 3, Vision, the standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
Numerical readings must be provided. Mark Yes or No: Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green, and amber colors.
Mark Yes or No: Applicant meets visual acuity requirement only when wearing corrective lenses. Mark Yes or No: Does applicant have monocular vision?
Complete next two lines only if vision testing is done by an ophthalmologist or optometrist: Date of Examination, Name of Ophthalmologist or Optometrist (print), Telephone Number, Signature of Examiner and License Number/State of Issue.
In Section 4, Blood Pressure/Pulse Rate, the standard: If the blood pressure is consistently above 160/90 mm. Hg., further testing may be necessary to determine whether the driver is qualified to operate a bus. Numerical reading must be recorded. Medical Examiner should take at least two readings to confirm BP.
Record the 1) and 2) Systolic/Diastolic Blood Pressure Readings and the Pulse Rate: Regular or Irregular.
In Section 5, Hearing, the standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB.
Check if hearing aid used for tests. Check if hearing aid required to meet standard. a) Record distance in feet from individual at which forced whispered voice can first be heard. b) If audiometer is used, record hearing loss in decibels (acc. to ANSI Z24.5-1951).
In Section 6, Laboratory and Other Test Findings: Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Other Testing (Describe and record).
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.
In Section 7, Physical Examination: check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space for Medical Examiner's Comments, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment.
In Section 8, Medical Examiner's Certification, mark New/Initial Certification, Recertification or Follow-Up.
Print the driver's full name in: "I certify that I have examined the driver in accordance with the Commissioner's Regulations and with knowledge of the driver's duties."
In accordance with Commissioner's Regulation 6.10, I find: the person named is physically or medically qualified; the person named IS NOT physically or medically qualified because ...; or the person named is physically or medically qualified with Restrictions and/or Follow-up.
For Restrictions and/or Follow-up, mark Qualified only when wearing corrective/contact lenses; Qualified - Certification required every six months for diabetic condition; Qualified only when wearing a hearing aid; Qualified only by use of prosthetic devices or equipment modifications, with Description/Type; or Qualified, other.
Print name and check title of: Examining Physician, Nurse Practitioner, Physician Assistant or Advanced Practice Nurse * (who is not a Nurse Practitioner), then enter Date, Address of Examiner and License or Certificate No./Issuing State. * If the examination is conducted by an Advanced Practice Nurse, who is not a Nurse Practitioner, the Supervising Physician must certify as follows. "I certify that the individual who conducted the examination was acting under my direction and supervision and, if applicable, in accordance with a written practice or protocol agreement."
The carrier must keep the original examination report (not a photocopy) in the employee's 19-A file. Any photocopies must identify the location of the original.
Sources
[1] Form DS-874 (1/19), Medical Examination Report of Driver Under Article 19-A, New York State Department of Motor Vehicles (the Official source link on this page).