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.

Form NameState Form 49867
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesindiana dot physical form, indiana dot physical form 2020, indiana dot physical forms printable, indiana cdl physical form 2021

Form Preview Example






Indiana Department of Revenue








Medical Examination Report for










State Form # 49867


Commercial Driver Fitness Determination






















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.




























Driver’s Information

Driver completes this section







Driver’s Name (Last, First, MI)
















City, State, Zip Code





New Certification

Work. Tel:




















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:
















2. Health History

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

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





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)




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










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.







Field of Vision









Right Eye



Right Eye



Left Eye



Left Eye



Both Eyes









Applicant can recognize and distinguish among



traffic control signals and devices showing



standard red, green and amber colors?



Applicant meets visual acuity requirement



only when wearing:

Corective Lenses

Monocular Visions:



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

Date of Examination

Telephone No.

Name of Ophthalmologist or Optometrist (Print)


License No./State of Issue

4. Hearing - 391.41 (b)(11)


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.






b) If audiometer is used, record hearing

Right Ear



Left Ear



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




























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












Driver qualified

if < 140/90 .
















Record Pulse Rate:



Expiration Date



Stage 1

1 year

1 year if < 140/90




One-time certificate for 3 months




if 140-159/90-99






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.





















Other Testing (Describe and record):





















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Driver’s Name

7. Physical Examination













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






General Appearance

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




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.





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




Mouth and Throat

Irremediable deformities likely to interfere with breathing and swallowing.





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



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.




Abdomen and Viscera

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





wall muscle weakness.




Vascular system

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




Genito-urinary system






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.




Spine, other musculoskeletal

Previous surgery, deformities, limitation of motion, tenderness.




Impaired equilibrium, coordination or speech pattern; paresthesia





asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal





patellar and Babinski’s reflexes, ataxia.











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



(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













Driver must present exemption at time of














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
























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







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



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













Medical Certificate Expiration Date






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

DOT (Interstate)

OP (Operator’s)

CH (Chauffeur’s)

CDL (Commercial

Driver’s License


Signature of Medical Examiner



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.


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














(Not the Medical Examiner’s state license certificate













expiration date)
































Signature of Medical Examiner




























Medical Examiner’s Name (please print)








Physician Assistant

Advanced Practice Nurse

Medical Examiner’s:

Issuing State





License or Certificate No.
































Signature of Driver






Driver’s License No.




















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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How to Edit State Form 49867 Online for Free

The entire process of completing the indiana cdl physical forms is pretty hassle-free. Our experts made certain our PDF editor is not hard to use and can help prepare any form without delay. Have a look at the four steps you will need to take:

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You will have to provide the following data to fill out the file:

indiana cdl medical form fields to complete

Fill in the cid cid Ear disorders loss of, cardiovascular condition cid, cid cid Heart surgery valve, cid cid High blood pressure, cid Medication, cid cid Loss of or altered, cid History of sleep apnea, cid cid Muscular disease cid cid, cid cid Stroke or paralysis cid, I certify that the above, Medical Examiners Comments on, Drivers Signature, and Date areas with any content that is demanded by the program.

stage 2 to finishing indiana cdl medical form

In the CDLPHY Page of, and American LegalNet Inc field, describe the relevant particulars.

indiana cdl medical form CDLPHY Page  of, and American LegalNet Inc blanks to insert

The Drivers Name, Testing Medical Examiner completes, Vision b Standard At least, Horizontal Field of Vision, Complete this section if vision, Acuity Uncorrected Corrected, Right Eye Left Eye Both Eyes, Applicant can recognize and, Right Eye Left Eye, cid Yes cid No, cid Corective Lenses cid Yes cid No, Date of Examination, Telephone No, Name of Ophthalmologist or, and Signature field could be used to point out the rights and responsibilities of both sides.

Completing indiana cdl medical form stage 4

Look at the sections Applicant can recognize and, cid Corective Lenses cid Yes cid No, License NoState of Issue, a Must first perceive forced, cid Check if hearding aid used for, cid Check if hearing aid is, Numerical readings must be, Right Ear Feet Right Ear Hz, Average, Left Ear Feet Left Ear Hz, Average, Blood PressurePulse b Numerical, Expiration Date, Recertification, and Diastolic and then fill them in.

Finishing indiana cdl medical form step 5

Step 3: Once you've clicked the Done button, your document is going to be readily available export to every device or email you specify.

Step 4: To protect yourself from all of the troubles later on, you will need to have a minimum of several duplicates of the document.

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