State Form 49867 ≡ Fill Out Printable PDF Forms Online

Question	Answer
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
				Medical Examination Report for
		CDL-PHY		Medical Examination Report for
	State Form # 49867		Commercial Driver Fitness Determination
		(R3/10-04)
		(R3/10-04)					Commercial Driver’s License, Medical Section
							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							Telephone: (317) 615-7335 Fax: (317) 821-2340
to perform its statutory function. Disclosure is
voluntary, and you will not be penalized for refusal.
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
Acuity	Uncorrected	Corrected	Field of Vision

Right Eye	20/	20/	Right Eye	°
Left Eye	20/	20/	Left Eye	°
Both Eyes	20/	20/
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):
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

YYYY

(Not the Medical Examiner’s state license certificate

expiration date)

Signature of Medical Examiner

Date

Telephone

Medical Examiner’s Name (please print)

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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