Form Ds 874 – Fill Out and Use This PDF

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 http://www.dmv.ny.gov/art19.htm. They are also available from the driver’s carrier named below 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.

1DRIVER/CARRIER INFORMATION (to be completed by the driver and/or driver’s carrier)

Driver’s Last Name	First		M.I.	Date of Birth (Month/Day/Year)				Age			Sex
											Male Female
StreetAddress			City				State			Zip Code
Client/License ID Number		State	Class of Driver’s License		Endorsements	Restrictions					Expiration Date
(from Driver License)

2HEALTH HISTORY (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: ______________________________________________________________________________________________________

List all medications (including over-the-counter medications) used regularly or recently.

Additional comments/medications on attached DS-874C

I certify that the above information 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.

➧

(Driver’s Signature)

(Date)

Medical Examiner’s Comments:

TESTING (SECTIONS 3 THROUGH 8 TO BE COMPLETED BYTHE MEDICALEXAMINER)

3VISION 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.

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
			➧
License Number/State of Issue				(Signature of Examiner)

4BLOODPRESSURE/PULSERATE 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.

Driver’s Name: Last _________________________________________ First __________________________ MI _____ Driver’s License/Client ID #_________________________

5 HEARING 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.

7 PHYSICALEXAMINATION (to be completed by the medical examiner) - Height __________ (in.) Weight __________ (lbs.)

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 moreserious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for.

BODYSYSTEM

CHECK FOR:

Yes* No

BODYSYSTEM

CHECK FOR:

Yes* No

1.

General appearance

Marked overweight, tremor, signs of alcoholism,

7.

Abdomen andViscera

Enlarged liver, enlarged spleen, masses, bruits, hernia,

problem drinking, or drug abuse

.

significant abdominal wall muscle weakness

2.

Eyes

Pupillaryequality,reactiontolightaccommodation,ocular

8.

Vascular System

Abnormal pulse and amplitude, carotid or arterial bruits,

motility, ocular muscle imbalance extraocular movement,

varicose veins. .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

nystagmus, exophthalmos.Ask about retinopathy, cataracts,

aphakia, glaucoma, macular degeneration and refer to a

9.

Genito-urinary System

Hernias

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

specialist if appropriate

.

3.

Ears

Scarring of tympanic membrane, occlusion of external canal,

10.

Extremities- Limb

Loss or impairment of leg, foot, toe, arm, hand, finger,

impaired.

perceptible limp, deformities, atrophy, weakness,

perforated eardrums. . . .

.

paralysis, clubbing, edema, hypotonia. Insufficient

4.

Mouth andThroat

Irremediable deformities likely to interfere with breathing or

grasp and prehension in upper limb to maintain steering

swallowing

.

wheel grip. Insufficient mobility and strength in lower

5.

Heart

Murmurs, extra sounds, enlarged heart, pacemaker,

limb to operate pedals properly

implantable defibrillator

.

11.

Spine, other

Previous surgery, deformities, limitation of motion,

6.

Lungs and chest,

Abnormal chest wall expansion, abnormal respiratory rate,

musculoskeletal

tenderness

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

not including

abnormal breath sounds including wheezes or alveolar rales,

breast examination

impaired respiratory function, cyanosis.Abnormal findings

12.

Neurological

Impaired equilibrium, coordination or speech pattern;

on physical exam may require further testing such as

asymmetric deep tendon reflexes, sensory or positional

pulmonary tests and/ or xray of chest

.

abnormalities,abnormalpatellarandBabinskireflexes,ataxia.

* MEDICALEXAMINER’S COMMENTS:

Additional comments on attached DS-874C.

8

MEDICALEXAMINER’S CERTIFICATION: New/Initial Certification

Recertification

Follow-Up

I certify that I have examined (Print Driver’s Full Name)__________________________________________________________ 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 above is physically or medically qualified.

the person named above ISNOT physically or medically qualified because____________________________________________________________

the person named above is physically or medically qualified withRestrictions and/or Follow-up as detailed below:

Qualified only when wearing corrective/contact lenses.	Qualified only by use of prosthetic devices or equipment modifications.
Qualified - Certification required every six months fordiabetic condition.	Description/Type: _____________________________________________
Qualified only when wearing a hearing aid.	Qualified, other: _______________________________________________

REMARKS:								Additional comments on attached DS-874C.
Printnameandchecktitleof:									Date:
Examining Physician					Signature of Examiner: ➧
Nurse Practitioner
			*}Address of Examiner:
PhysicianAssistant*
	Advanced Practice Nurse
	(who is not a Nurse Practitioner)				License or Certificate No./Issuing State

*If the examination is conducted by a PhysicianAssistant or anAdvanced Practice Nurse, who is nota Nurse Practitioner, the Supervising Physician must certify as follows:

I certify that the individual who conducted the above examination was acting under my direction and supervision and, if applicable, in accordance with a written practice or protocol agreement.

Print	➧
(Name of Supervising Physician)	(Signature of Supervising Physician)	License or Certificate No./Issuing State