State Form 49867 PDF Details

State Form 49867 is a request for an exemption from the state property tax. This form can be used to apply for either a full or partial exemption from the state property tax. The deadline for submitting this form is August 1st, and it must be accompanied by all required documentation. Failure to submit this form on time may result in a loss of your exemption eligibility. For more information, please contact your local county assessor's office.

You will see info about the type of form you want to fill out in the table. It will show you the amount of time you'll need to fill out state form 49867, what parts you will have to fill in, etc.

QuestionAnswer
Form NameState Form 49867
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesindiana dot physical, indiana dot physical form 2021, indiana cdl physical form 2020, indiana cdl physical examination form

Form Preview Example

 

 

 

 

 

Indiana Department of Revenue

 

 

 

 

 

 

 

Medical Examination Report for

 

 

 

 

CDL-PHY

 

 

 

 

State Form # 49867

 

Commercial Driver Fitness Determination

 

 

 

 

(R3/10-04)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commercial Driver’s License, Medical Section

 

 

 

 

 

 

 

 

 

 

 

*Social Security Number

 

 

 

 

5252 Decatur Boulevard, Ste. R,

This state agency is requesting disclosure of your

 

 

 

 

Indianapolis, IN 46241

Social Security number, under IC 4-1-8-1, in order

 

 

 

 

Telephone: (317) 615-7335 Fax: (317) 821-2340

to perform its statutory function. Disclosure is

 

 

 

 

 

 

 

 

 

 

 

voluntary, and you will not be penalized for refusal.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Driver’s Information

Driver completes this section

 

 

 

 

 

 

Driver’s Name (Last, First, MI)

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip Code

 

 

Age

Sex

New Certification

Work. Tel:

 

 

 

 

 

 

 

M

Recertification

(

)

 

 

 

 

 

 

 

F

Follow Up

Home Tel:

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

Birthdate (MM DD YYYY)

Date of Exam (MM DD YYYY)

State of Issue

Driver License No.

License Type

CDL Class:

 

 

OP

CDL

A

 

 

CH

OR

B

 

 

 

(K) CDL

C

2. Health History

Driver completes this section, but medical examiner is encouraged to discuss with driver.

Yes No

 

Yes No

Yes

No

Any illness or injury in last 5 years?

Liver disease

 

Digestive problems

Head/brain injuries, disorders or illnesses

Diabetes or elevated blood sugar controlled by:

Seizures, epilepsy

 

diet

pills

insulin

Medication ________________________

Nervous or psychiatric disorders, e.g.; severe depression

Eye disorders, or impaired vision (except

Medication ______________________________

corrective lenses)

 

Loss of, or altered consciousness

Ear disorders, loss of hearing or balance

Fainting, dizziness

 

 

Heart disease or heart attack; other

Sleep disorders

 

 

cardiovascular condition

History of sleep apnea. Treatment ________________

Medication ________________________

Pauses in breathing while asleep

Heart surgery (valve replacement/bypass,

Daytime sleepiness including with driving

angioplasty, pacemaker or IC defibrillator)

Narcolepsy

 

 

High blood pressure

 

Loud Snoring

 

 

Medication ________________________

Insomnia/deprivation of sleep

Muscular disease

 

Stroke or paralysis

 

 

Shortness of breath

 

Missing or impaired hand, arm, foot, leg, finger, toe

Lung disease, emphysema, asthma

Spinal injury or disease

Chronic low back pain

Chronic bronchitis

 

Regular, frequent alcohol use

 

Kidney disease, dialysis

Narcotic or habit forming drug use

For any YES answer, please indicate onset date, diagnosis, treating physician’s name and address and any current limita- tions. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate. I authorize this information to be released to the Indiana Department of Revenue .

Driver’s SignatureDate

Medical Examiner’s Comments on Health History (The medical examiner must review and discuss with the driver any “yes” answers and potential hazards of medications, including over-the-counter medications, used while driving)

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Driver’s Name

 

DL#

 

SS#

 

 

 

 

 

Testing (Medical Examiner completes Section 3 through 7)

3. Vision - 391.41 (b) (10)

Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70° peripheral in hori- zontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner’s Certificate.

Instructions: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.

Numerical readings must be provided.

Acuity

Uncorrected

Corrected

Horizontal

 

 

Field of Vision

 

 

 

 

 

 

 

 

Right Eye

20/

20/

Right Eye

°

 

Left Eye

20/

20/

Left Eye

°

 

Both Eyes

20/

20/

 

 

 

 

 

 

Applicant can recognize and distinguish among

 

 

traffic control signals and devices showing

 

 

standard red, green and amber colors?

Yes

No

Applicant meets visual acuity requirement

 

 

only when wearing:

Corective Lenses

Monocular Visions:

Yes

No

Complete this section if vision testing is done by an Ophthalmologist or Optometrist.

Date of Examination

Telephone No.

Name of Ophthalmologist or Optometrist (Print)

Signature

License No./State of Issue

4. Hearing - 391.41 (b)(11)

Standard:

a) Must first perceive forced whispered voice > 5 feet with or without hearing aid, or

 

b) Average hearing loss in better ear < 40dB

 

 

Check if hearding aid used for tests.

Check if hearing aid is required to meet standard.

Instructions: To convert audiometric test results from ISO to ANSI, -14dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5dB for 2,000Hz. To average, add the readings for 3 frequencies tested and divide by 3.

Numerical readings must be recorded.

a) Record distance from individual at which

Right Ear

Left Ear

forced whispered voice can first be heard.

Feet:

Feet:

 

 

 

b) If audiometer is used, record hearing

Right Ear

 

 

Left Ear

 

 

loss in decibels. (acc. to ANSI Z24.5-

500Hz

1000Hz

2000Hz

500Hz

1000Hz

2000Hz

1951)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Average:

 

 

Average:

 

 

5. Blood Pressure/Pulse - 391.41 (b)(6) Numerical readings must be recorded. Medical Examiner should take two readings to confirm BP

Blood

 

Systolic

Diastolic

Pressure

 

 

 

 

 

 

Driver qualified

if < 140/90 .

 

 

 

 

 

Pulse

Regular

 

Rate

Irregular

 

 

 

 

 

Record Pulse Rate:

Reading

Category

Expiration Date

Recertification

140-159/90-99

Stage 1

1 year

1 year if < 140/90

 

 

 

One-time certificate for 3 months

 

 

 

if 140-159/90-99

 

 

 

 

160-179/100-109

Stage 2

One-time certificate for 3 months

1 year from date of exam if < 140/90

 

 

 

 

> 180/110

Stage 3

6 monts from date of exam if

6 months if <140/90 ,

 

 

< 140/90

 

 

 

 

 

Medical examiner should take at least 2 readings to confirm blood pressure.

6. Laboratory & Other Test Finding

Numerical readings must be recorded.

Urinalysis is required. Protein, blood or sugar in the urine may be an indication that further testing is needed to rule out

any underlying medical problem.

 

Urine

SP. GR.

Protein

Blood

 

Sugar

 

 

 

 

 

Specimen:

 

 

 

 

 

 

 

Other Testing (Describe and record):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Driver’s Name

7. Physical Examination

DL#SS#

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 a more serious 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. See Instructions to the Medical Examiner for guidance.

 

Body System

Check for:

 

Yes No

 

 

 

 

1.

General Appearance

Marked overweight, tremor, signs of alcoholism, problem drinking,or drug abuse.

 

2.

Eyes

Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle

 

 

 

 

imbalance, extraocular movement, nystagmus, exophthalmos. Ask about

 

 

 

 

retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a

 

 

 

 

specialist if appropriate.

 

 

3.

Ears

Scarring of tympanic membrane, occlusion of external canal, perforated eardrums

 

 

4.

Mouth and Throat

Irremediable deformities likely to interfere with breathing and swallowing.

 

 

5.

Heart

Murmurs, extra sounds, enlarged heart, pacemaker, inplantable defibrillator

 

6.

Lungs and chest, not including

Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath

 

 

 

breast examination

sounds including wheezes or alveolar rales, impaired respiratory function,

 

 

 

 

cyanosis. Abnormal findings on physcial exam may require further testing such

 

 

 

 

as pulmonary tests and/or xray of chest.

 

 

7.

Abdomen and Viscera

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

 

 

 

 

wall muscle weakness.

 

 

8.

Vascular system

Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins.

 

 

9.

Genito-urinary system

Hernias.

 

 

 

10.

Extremities - Limb impaired.

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

Perceptible limp,

 

 

 

Driver may be subject to SPE

deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia.

 

 

 

Certificate if otherwise qualified.

Insufficient grasp and prehension in upper limb to maintain steering wheel grip.

 

 

 

 

Insufficient mobility and strength in lower limb to operate pedals properly.

 

 

11.

Spine, other musculoskeletal

Previous surgery, deformities, limitation of motion, tenderness.

 

12.

Neurological

Impaired equilibrium, coordination or speech pattern; paresthesia

 

 

 

 

asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal

 

 

 

 

patellar and Babinski’s reflexes, ataxia.

 

 

 

 

 

 

 

 

*Comments_____________________________________________________________________________________________

_________________________________________________________________________________________________________________

Note certification status here. See Instructions to the Medical Examiner for guidance.

 

Meets standards in 49 CFR 391.41; qualifies for 2-year certificate

Wearing corrective lenses

 

Meets standards, but periodic evaluation required.

 

 

 

 

Wearing hearing aid

 

Due to

 

 

 

driver qualified only for:

Driving within an exempt intracity zone

 

 

 

3 months

6 months

1 year

 

Other

(see 49 CFR 391-62)

 

Qualified by operation of 49 CFR 391.64 (See page 3 of instructions)

Skills Performance Evaluation (SPE) Certificate

Does not meet standards

 

 

 

 

 

(See page 3 of instructions)

 

 

 

 

 

 

 

 

 

 

 

 

Accompanied by a

waiver/exemption

 

 

 

 

 

 

 

 

 

 

 

Driver must present exemption at time of

 

 

 

 

 

 

 

 

 

 

 

certification.

 

Temporarily disqualified due to (condition or medication)

 

 

 

 

 

 

Return to Medical Examiner’s office for follow up on

 

 

 

 

 

 

Medical Examiner’s Name (Print)

 

Medical Examiner’s Signature

 

Telephone Number

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If meets DOT standards, complete the DOT Medical Examiner’s certificate according to 49 CFR 391.43 (h).

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Driver’s Name

 

DL#

 

SS#

 

 

Notice for all CMV drivers:

Drivers must carry one of the Medical Examiner’s Certificate when operating a commercial vehicle.

To the Medical Examiner: Complete only one of these Medical Examiner Certifications.

DOT Medical Examiner’s Certificate to be completed if the driver meets Federal Motor Carrier Safety Regulations

49 CFR 391.41-391.49

DOT Interstate Medical Examiner’s Certificate

I certify that I have examined

 

 

in accordance with the Federal Motor Carrier Safety

Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified;

and if applicable, only when:

 

 

 

 

 

Wearing corrective lenses

 

Driving within an exempt intracity zone (49 CFR 391.62)

Wearing hearing aid

 

Accompnaied by a Skill performance Evaluation Cert. (SPE)

Accompanied by a

 

waiver/exemption

Qualified by operation of 49 CFR 391.64

The information I have

provided regarding this physical examination is true and complete. A complete

examination form with any attachment embodies my findings completely and correctly, and is on file in my

office.

 

 

 

 

 

 

 

 

 

 

 

Medical Certificate Expiration Date

 

 

MM

DD

YYYY

(Not the Medical Examiner’s state license certificate expiration date)

DOT (Interstate)

OP (Operator’s)

CH (Chauffeur’s)

CDL (Commercial

Driver’s License

Interstate)

Signature of Medical Examiner

Date

Telephone

Medical Examiner’s Name (please print)

MD DO Chiropractor

Physician Assistant

Advanced Practice Nurse

Medical Examiner’s:

Issuing State

License or Certificate No.

 

 

 

 

 

 

 

 

 

 

Signature of Driver

Driver’s License No.

State

Address of Driver

This card to be issued to a CDL-K Intrastate license holder only.

Indiana CDL Intrastate Medical Examiner’s Certification

I certify that I have examined ________________________________, in my medical opinion this examinee did not

have at the time of this examination any medical disorder or physical condition which was likely to interfere with his/her ability to safely operate a commercial motor vehicle or a motor vehicle used to convey public passengers. The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office.

Medical Certificate Expiration Date

 

 

 

 

 

 

MM

 

 

DD

 

 

YYYY

(Not the Medical Examiner’s state license certificate

 

 

 

 

 

 

 

 

 

 

 

 

expiration date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Medical Examiner

 

 

 

 

 

Date

 

 

 

 

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner’s Name (please print)

MD

DO

Chiropractor

 

 

 

 

Physician Assistant

Advanced Practice Nurse

Medical Examiner’s:

Issuing State

 

 

 

 

License or Certificate No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Driver

 

 

 

 

 

Driver’s License No.

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of Driver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indiana (Intrastate)

(K)CDL (Commercial Driver’s License Intrastate)

Please make two copies. Send one copy to the Department and keep a copy for your records. Medical Examiner’s Certificate must accompany the Medical Examination Report (Medical Long Form) when filing with the Indiana Department of

Revenue, Motor Carrier Services, CDL Section.

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