Form LIC61 at a glance
What it is: LIC61 is the Physical Examination Form; its PHYSICIAN'S CLEARANCE certifies the examination of the applicant or licensee.
Who signs: The physician enters the Name of Physician and signs on the Signature of Physician line. The applicant enters the Name of Applicant and signs on the Signature of Applicant line.
Where and when to file: The form must be completed within 90 days prior to submission and must be stamped by the Examining Physician.
A filled-in Form LIC61 example: an applicant and the Examining Physician start the form
How to fill out Form LIC61, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Applicant Information
Under APPLICANT INFORMATION, enter First Name, Last Name, Date of Birth, Social Security No., Home Address, Phone No., City, State and Zip.
In accordance with Federal and State Laws, the New York City Department of Buildings requires that all applicants for licenses/license holders provide their Social Security Number (SSN). DOB will use the SSN to conduct background investigations and maintain accurate license and related records.
Health History, to be filled in by the Examining Physician
Health History is to be filled in by the Examining Physician; please print.
Mark YES or NO for each of: Asthma; Muscular Disease; Head or Spinal Injuries; Kidney; Psychiatric Disorder; Seizures, Fits, Convulsions or Fainting; Tuberculosis; Cardiovascular Disease; Extensive Confinement by Illness or Injury; Diabetes; Gastrointestinal Ulcer; Any Other Nervous Disorder; Nervous Stomach; Ethanol Use; Suffering from any Other Disorder; Rheumatic Fever; RX Drug Use; Permanent Defect from Illness, Disease or Injury; Over the Counter Drug Use.
If the answer to any of the above is YES, explain.
Mark General Fitness and Health as Good, Fair or Poor.
Vision
Under Vision, For Distance: mark Right/20, Both/20, Without Corrective Lenses or With Corrective Lenses.
Enter Right and Left for Evidence of Disease or Injury, Color Test and Horizontal Field of Vision.
Hearing
Under Hearing, enter Right and Left, then Right and Left for Evidence of Disease or Injury.
For Audiometric Test, mark Decibel loss at 500HZ, 1,000HZ, 2,000HZ, 3,000HZ or 4,000HZ.
Thorax
Under Thorax, enter Heart. Fill in the line If organic disease is present, is it fully compensated?
Enter Blood Pressure (Systolic, Diastolic), Pulse (Before Exercise, After Exercise) and Lungs.
Throat and Abdomen
Enter Throat. Under Abdomen, enter Scars, Abdominal Masses and Tenderness.
Mark Hernia Yes or No. If so, where? Enter it on the line. Is truss worn? Mark Yes or No.
Mark Gastrointestinal: Ulceration or other disease? Yes or No.
Under Genito-Urinary, enter Scars and Urinal Discharge.
Reflexes, Remarks and Extremities
Under Reflexes, enter Rhomberg, Pupillary, Light Right and Left, Accommodation Right and Left, and Knee Jerks Right and Left, each with Normal, Increased and Absent.
Enter Remarks. Under Extremities, enter Upper, Lower and Spine.
Laboratory and Other Special Findings, General Comments
Under Laboratory & Other Special Findings, enter Urine Spec. Gr., Alb. and Sugar, Other Laboratory Data (Serology, etc.), Radiological Data and Electrocardiograph. Enter General Comments.
Physician Information, to be filled in by the Examining Physician
Physician Information is to be filled in by the Examining Physician; please print: enter Name of Physician, Address of Physician, City, State, Zip, Physician's Signature and Date.
Physician's Clearance
PHYSICIAN'S CLEARANCE is to be filled in by the Examining Physician; please print. It also prints: "A complete examination form for this person is on file in my office."
The physician certifies "I have examined the applicant or licensee" and, with the knowledge of his/her duties (see addendum), finds him/her. Mark Qualified, Qualified only when wearing corrective lenses, Qualified only when wearing a hearing aid, Qualified (see attached Accommodation Statement) or Not qualified.
Examination address and date, and the signatures
Enter the Address of Examination and the Date of Examination.
The physician enters the Name of Physician and signs on the Signature of Physician line.
The applicant enters the Name of Applicant and signs on the Signature of Applicant line.
Addendum: License Regulations
Hoist Machine Operator: This license authorizes a NYC licensee to take charge of or operate power operated hoisting machines (depending on the class of license) used for hoisting purposes or cableways under the jurisdiction of the Department, including but not limited to cranes.
Rigger: This license authorizes a NYC licensee to hoist or lower an article outside of any building in the city. This may include the use of suspended scaffolds. Tower or climber crane rigger licensees may supervise the erection and dismantling of tower or climber cranes.
Lift Director: This license authorizes a NYC licensee to oversee crane and derrick operations on construction sites, including supervising lifting activities, coordinating with crane operators and rigging crews, and implementing safety protocols during operations such as load picks, crane movements, and assembly and disassembly procedures.
Common questions about Form LIC61
Is there a deadline?
The form must be completed within 90 days prior to submission and must be stamped by the Examining Physician.
Sources
[1] LIC61, Physical Examination Form (Rev. 07/26), New York City Department of Buildings (the Official source link on this page).