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.
Question | Answer |
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Form Name | State Form 49867 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | indiana dot physical, indiana dot physical form 2021, indiana cdl physical form 2020, indiana cdl physical examination form |
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Indiana Department of Revenue |
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Medical Examination Report for |
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State Form # 49867 |
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Commercial Driver Fitness Determination |
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Commercial Driver’s License, Medical Section |
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*Social Security Number |
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5252 Decatur Boulevard, Ste. R, |
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This state agency is requesting disclosure of your |
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Indianapolis, IN 46241 |
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Social Security number, under IC |
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Telephone: (317) |
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to perform its statutory function. Disclosure is |
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voluntary, and you will not be penalized for refusal. |
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1. |
Driver’s Information |
Driver completes this section |
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Driver’s Name (Last, First, MI) |
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Address |
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City, State, Zip Code |
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Age |
Sex |
New Certification |
Work. Tel: |
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M |
Recertification |
( |
) |
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F |
Follow Up |
Home Tel: |
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( |
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Social Security No.
Birthdate (MM DD YYYY)
Date of Exam (MM DD YYYY)
State of Issue |
Driver License No. |
License Type |
CDL Class: |
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OP |
CDL |
A |
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CH |
OR |
B |
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(K) CDL |
C |
2. Health History |
Driver completes this section, but medical examiner is encouraged to discuss with driver. |
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Yes No |
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Yes No |
Yes |
No |
Any illness or injury in last 5 years? |
Liver disease |
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Digestive problems |
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Head/brain injuries, disorders or illnesses |
Diabetes or elevated blood sugar controlled by: |
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Seizures, epilepsy |
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diet |
pills |
insulin |
Medication ________________________ |
Nervous or psychiatric disorders, e.g.; severe depression |
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Eye disorders, or impaired vision (except |
Medication ______________________________ |
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corrective lenses) |
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Loss of, or altered consciousness |
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Ear disorders, loss of hearing or balance |
Fainting, dizziness |
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Heart disease or heart attack; other |
Sleep disorders |
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cardiovascular condition |
History of sleep apnea. Treatment ________________ |
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Medication ________________________ |
Pauses in breathing while asleep |
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Heart surgery (valve replacement/bypass, |
Daytime sleepiness including with driving |
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angioplasty, pacemaker or IC defibrillator) |
Narcolepsy |
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High blood pressure |
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Loud Snoring |
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Medication ________________________ |
Insomnia/deprivation of sleep |
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Muscular disease |
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Stroke or paralysis |
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Shortness of breath |
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Missing or impaired hand, arm, foot, leg, finger, toe |
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Lung disease, emphysema, asthma |
Spinal injury or disease |
Chronic low back pain |
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Chronic bronchitis |
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Regular, frequent alcohol use |
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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
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
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Driver’s Name |
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DL# |
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SS# |
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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
Numerical readings must be provided.
Acuity |
Uncorrected |
Corrected |
Horizontal |
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Field of Vision |
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Right Eye |
20/ |
20/ |
Right Eye |
° |
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Left Eye |
20/ |
20/ |
Left Eye |
° |
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Both Eyes |
20/ |
20/ |
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Applicant can recognize and distinguish among |
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traffic control signals and devices showing |
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standard red, green and amber colors? |
Yes |
No |
Applicant meets visual acuity requirement |
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only when wearing: |
Corective Lenses |
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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 |
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b) Average hearing loss in better ear < 40dB |
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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,
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: |
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b) If audiometer is used, record hearing |
Right Ear |
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Left Ear |
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loss in decibels. (acc. to ANSI Z24.5- |
500Hz |
1000Hz |
2000Hz |
500Hz |
1000Hz |
2000Hz |
1951) |
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Average: |
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Average: |
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5. Blood Pressure/Pulse - 391.41 (b)(6) Numerical readings must be recorded. Medical Examiner should take two readings to confirm BP
Blood |
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Systolic |
Diastolic |
Pressure |
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Driver qualified |
if < 140/90 . |
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Pulse |
Regular |
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Rate |
Irregular |
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Record Pulse Rate:
Reading |
Category |
Expiration Date |
Recertification |
Stage 1 |
1 year |
1 year if < 140/90 |
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if |
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Stage 2 |
1 year from date of exam if < 140/90 |
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> 180/110 |
Stage 3 |
6 monts from date of exam if |
6 months if <140/90 , |
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< 140/90 |
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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. |
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Urine |
SP. GR. |
Protein |
Blood |
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Sugar |
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Specimen: |
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Other Testing (Describe and record): |
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American LegalNet, Inc. |
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Driver’s Name
7. Physical Examination
DL#SS#
Height |
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(in.) |
Weight |
(lbs.) |
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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.
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Body System |
Check for: |
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Yes No |
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1. |
General Appearance |
Marked overweight, tremor, signs of alcoholism, problem drinking,or drug abuse. |
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2. |
Eyes |
Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle |
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imbalance, extraocular movement, nystagmus, exophthalmos. Ask about |
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retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a |
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specialist if appropriate. |
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3. |
Ears |
Scarring of tympanic membrane, occlusion of external canal, perforated eardrums |
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4. |
Mouth and Throat |
Irremediable deformities likely to interfere with breathing and swallowing. |
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5. |
Heart |
Murmurs, extra sounds, enlarged heart, pacemaker, inplantable defibrillator |
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6. |
Lungs and chest, not including |
Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath |
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breast examination |
sounds including wheezes or alveolar rales, impaired respiratory function, |
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cyanosis. Abnormal findings on physcial exam may require further testing such |
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as pulmonary tests and/or xray of chest. |
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7. |
Abdomen and Viscera |
Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal |
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wall muscle weakness. |
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8. |
Vascular system |
Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins. |
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9. |
Hernias. |
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10. |
Extremities - Limb impaired. |
Loss or impairment of leg, foot, toe, arm, hand, finger. |
Perceptible limp, |
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Driver may be subject to SPE |
deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. |
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Certificate if otherwise qualified. |
Insufficient grasp and prehension in upper limb to maintain steering wheel grip. |
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Insufficient mobility and strength in lower limb to operate pedals properly. |
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11. |
Spine, other musculoskeletal |
Previous surgery, deformities, limitation of motion, tenderness. |
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12. |
Neurological |
Impaired equilibrium, coordination or speech pattern; paresthesia |
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asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal |
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patellar and Babinski’s reflexes, ataxia. |
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*Comments_____________________________________________________________________________________________
_________________________________________________________________________________________________________________
Note certification status here. See Instructions to the Medical Examiner for guidance. |
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Meets standards in 49 CFR 391.41; qualifies for |
Wearing corrective lenses |
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Meets standards, but periodic evaluation required. |
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Wearing hearing aid |
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Due to |
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driver qualified only for: |
Driving within an exempt intracity zone |
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3 months |
6 months |
1 year |
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Other |
(see 49 CFR |
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Qualified by operation of 49 CFR 391.64 (See page 3 of instructions) |
Skills Performance Evaluation (SPE) Certificate |
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Does not meet standards |
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(See page 3 of instructions) |
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Accompanied by a |
waiver/exemption |
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Driver must present exemption at time of |
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certification. |
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Temporarily disqualified due to (condition or medication) |
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Return to Medical Examiner’s office for follow up on |
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Medical Examiner’s Name (Print) |
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Medical Examiner’s Signature |
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Telephone Number |
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Address |
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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 |
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DL# |
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SS# |
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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
DOT Interstate Medical Examiner’s Certificate
I certify that I have examined |
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in accordance with the Federal Motor Carrier Safety |
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Regulations (49 CFR |
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and if applicable, only when: |
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Wearing corrective lenses |
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Driving within an exempt intracity zone (49 CFR 391.62) |
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Wearing hearing aid |
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Accompnaied by a Skill performance Evaluation Cert. (SPE) |
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Accompanied by a |
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waiver/exemption |
Qualified by operation of 49 CFR 391.64 |
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The information I have |
provided regarding this physical examination is true and complete. A complete |
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examination form with any attachment embodies my findings completely and correctly, and is on file in my |
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office. |
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Medical Certificate Expiration Date |
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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. |
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Signature of Driver
Driver’s License No.
State
Address of Driver
This card to be issued to a
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 |
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MM |
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DD |
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YYYY |
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(Not the Medical Examiner’s state license certificate |
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expiration date) |
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Signature of Medical Examiner |
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Date |
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Telephone |
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Medical Examiner’s Name (please print) |
MD |
DO |
Chiropractor |
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Physician Assistant |
Advanced Practice Nurse |
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Medical Examiner’s: |
Issuing State |
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License or Certificate No. |
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Signature of Driver |
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Driver’s License No. |
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State |
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Address of Driver |
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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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