Federal Motor Carrier Safety Administration (FMCSA) Medical

Federal Motor Carrier Safety Administration

(FMCSA)

Medical Examiner Handbook

As of 2015 this Handbook is no longer in use

 
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Introduction .................................................................................................................................................. 7
Part I – The Federal Motor Carrier Safety Administration (FMCSA)............................................................ 8
About the FMCSA .................................................................................................................................... 8
FMCSA Mission Statement.................................................................................................................. 8
About the Office of Medical Programs ..................................................................................................... 8
The Office of Medical Programs Mission Statement ............................................................................ 8
About the National Registry of Certified Medical Examiners ................................................................... 9
The National Registry of Certified Medical Examiners Mission Statement .......................................... 9
The Medical Examiner ......................................................................................................................... 9
Medical Certification........................................................................................................................... 10
Privacy and the Medical Examination .................................................................................................... 10
Medical Examination Report Form..................................................................................................... 10
Medical Examiner’s Certificate........................................................................................................... 11
Medical Regulations Summary .............................................................................................................. 11
Code of Federal Regulations — LAW ................................................................................................ 11
Medical Standards/Advisory Criteria/Guidelines................................................................................ 12
Medical Regulations Summary Table ................................................................................................ 12
Exemptions ........................................................................................................................................ 14
Important Definitions .............................................................................................................................. 14
Regulation Definitions ........................................................................................................................ 14
Part II - The Job of Commercial Driving..................................................................................................... 16
FMCSA Regulates Interstate Commercial Operation ............................................................................ 16
Drivers................................................................................................................................................ 16
Vehicles.............................................................................................................................................. 16
Truck and Bus Companies................................................................................................................. 16
State Regulations............................................................................................................................... 17
The Driver and the Job of Commercial Driving ...................................................................................... 17
The Driver .......................................................................................................................................... 17
The Job of Commercial Driving.......................................................................................................... 18
FMCSA Commercial Driving Facts and Research................................................................................. 20
Office of Analysis, Research, and Technology .................................................................................. 20
Part III - Medical Examination Guidelines .................................................................................................. 23
About 49 CFR 391.43 ............................................................................................................................ 23
Purpose of Interstate Commercial Driver Physical Examination........................................................ 23
Driver/Medical Examiner Relationship ................................................................................................... 23
Purpose of Physical Examination....................................................................................................... 23
The Issue Is Risk................................................................................................................................ 23
Consider Safety Implications.............................................................................................................. 24
Page 2 of 260

 
Medical Examiner Do's ...................................................................................................................... 24
Medical Examination Report Form - Overview ...................................................................................... 25
Driver Information............................................................................................................................... 26
Health History..................................................................................................................................... 27
Vision ................................................................................................................................................. 33
Hearing............................................................................................................................................... 34
Blood Pressure/Pulse......................................................................................................................... 36
Urinalysis............................................................................................................................................ 38
Physical Examination ......................................................................................................................... 39
Determine Certification Status ........................................................................................................... 43
Certify................................................................................................................................................. 44
Disqualify............................................................................................................................................ 48
Issue Medical Examiner's Certificate ................................................................................................. 49
Part IV - Physical Qualification Standards and Advisory Criteria............................................................... 51
Physical Qualification Standards (Regulations) versus Advisory Criteria (Medical Guidelines) ............ 51
Ongoing Standards and Guidelines Review Process ............................................................................ 51
About 49 CFR 391.41 ............................................................................................................................ 52
Vision ..................................................................................................................................................... 52
Vision Regulation 49 CFR 391.41(b)(10)........................................................................................... 52
Health History and Physical Examination .......................................................................................... 53
Certification and Documentation........................................................................................................ 56
Hearing................................................................................................................................................... 59
Hearing Regulation 49 CFR 391.41(b)(11) ........................................................................................ 60
Health History and Physical Examination .......................................................................................... 60
Certification and Documentation........................................................................................................ 62
Advisory Criteria/Guidance ................................................................................................................ 63
Hypertension.......................................................................................................................................... 64
Blood Pressure (BP) Regulations 49 CFR 391.41(b)(6) and 49 CFR 391.43(f) ................................ 65
Health History and Physical Examination .......................................................................................... 65
Advisory Criteria/Guidance ................................................................................................................ 67
Cardiovascular ....................................................................................................................................... 73
Cardiovascular Regulation 49 CFR 391.41(b)(4)............................................................................... 73
Health History and Physical Examination .......................................................................................... 74
Advisory Criteria/Guidance ................................................................................................................ 75
Respiratory (b)(5)................................................................................................................................. 117
Respiratory Regulation 49 CFR 391.41(b)(5) .................................................................................. 118
Health History and Physical Examination ........................................................................................ 118
Advisory Criteria/Guidance .............................................................................................................. 120
Neurological (b)(7)(8)(9)....................................................................................................................... 136
Page 3 of 260

 
Neurological Regulations 49 CFR 391.41(b)(7)(8)(9) ...................................................................... 137
Health History and Physical Examination ........................................................................................ 138
Advisory Criteria/Guidance .............................................................................................................. 140
Musculoskeletal (b)(1)(2)(7)................................................................................................................. 167
Musculoskeletal Regulations 49 CFR 391.41(b)(1)(2)(7)................................................................. 167
Health History and Physical Examination ........................................................................................ 168
Advisory Criteria/Guidance .............................................................................................................. 170
Diabetes Mellitus.................................................................................................................................. 172
Diabetes Mellitus Regulation 49 CFR 391.41(b)(3) ......................................................................... 173
Health History and Physical Examination ........................................................................................ 173
Advisory Criteria/Guidance .............................................................................................................. 175
Other Diseases .................................................................................................................................... 181
Other Diseases Regulation 49 CFR 391.41(b)(9)............................................................................ 182
Health History and Physical Examination ........................................................................................ 182
Advisory Criteria/Guidance .............................................................................................................. 183
Psychological Disorders (b)(9)............................................................................................................. 185
Psychological Regulation 49 CFR 391.41(b)(9)............................................................................... 186
Health History and Physical Examination ........................................................................................ 186
Advisory Criteria/Guidance .............................................................................................................. 189
Drug Abuse and Alcoholism................................................................................................................. 201
Drug Abuse and Alcoholism Regulations 49 CFR 391.41(b)(12)(13) .............................................. 202
Health History and Physical Examination ........................................................................................ 202
About 49 CFR 382 Alcohol and Drug Rules..................................................................................... 204
Advisory Criteria/Guidance .............................................................................................................. 205
Medications/Drug Use 49 CFR 391.41(b)(12) ..................................................................................... 208
Medications/Drug Use Regulation 49 CFR 391.41(b)(12) ............................................................... 208
Health History and Physical Examination ........................................................................................ 209
Advisory Criteria/Guidance .............................................................................................................. 211
Appendix A: Medical Examination Report Form ...................................................................................... 213
Medical Examination Report Form - Page 1 ........................................................................................ 213
Driver Information............................................................................................................................. 213
Health History................................................................................................................................... 213
Medical Examination Report Form - Page 2 ........................................................................................ 213
Vision ............................................................................................................................................... 213
Hearing............................................................................................................................................. 214
Blood Pressure/Pulse....................................................................................................................... 214
Urinalysis.......................................................................................................................................... 214
Medical Examination Report Form - Page 3 ........................................................................................ 215
Physical Examination ....................................................................................................................... 215
Page 4 of 260

 
Certification and Documentation...................................................................................................... 215
Appendix B: Federal Exemption Programs.............................................................................................. 217
49 CFR 381.300 What is an exemption? ............................................................................................. 217
Federal Vision Exemption Program ..................................................................................................... 217
Qualified by Operation of 49 CFR 391.64: "Grandfathered" ............................................................ 217
Federal Diabetes Exemption Program................................................................................................. 218
About the Federal Diabetes Exemption Program............................................................................. 218
Relevance to Driving........................................................................................................................ 219
Health History and Physical Examination ........................................................................................ 219
Appendix C: Skill Performance Evaluation .............................................................................................. 223
Fixed Deficit of an Extremity ................................................................................................................ 223
Appendix D: Cardiovascular Recommendation Tables ........................................................................... 225
Preface................................................................................................................................................. 225
ANEURYSMS ...................................................................................................................................... 226
AORTIC CONGENITAL HEART DISEASE ......................................................................................... 227
AORTIC CONGENITAL HEART DISEASE (Continued)...................................................................... 228
AORTIC REGURGITATION................................................................................................................. 229
AORTIC STENOSIS ............................................................................................................................ 230
ATRIAL SEPTAL DEFECTS ................................................................................................................ 231
ATRIAL SEPTAL DEFECTS (Continued) ............................................................................................ 232
ATRIAL SEPTAL DEFECTS (Continued) ............................................................................................ 233
BUNDLE BRANCH BLOCKS AND HEMIBLOCKS.............................................................................. 234
CARDIOMYOPATHIES AND CONGESTIVE HEART FAILURE (CHF) .............................................. 235
COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD)............................ 236
COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) (Continued) ........ 237
COMMERCIAL DRIVERS WITHOUT KNOWN CORONARY HEART DISEASE (CHD) .................... 238
CONGENITAL HEART DISEASE........................................................................................................ 239
CONGENITAL HEART DISEASE (Continued) .................................................................................... 240
CONGENITAL HEART DISEASE (Continued) .................................................................................... 241
CONGENITAL HEART DISEASE (Continued) .................................................................................... 242
CONGENITAL HEART DISEASE (Continued) .................................................................................... 243
HEART TRANSPLANTATION ............................................................................................................. 244
HYPERTENSION................................................................................................................................. 245
IMPLANTABLE DEFIBRILLATORS..................................................................................................... 246
MITRAL REGURGITATION................................................................................................................. 247
MITRAL STENOSIS............................................................................................................................. 248
PACEMAKERS .................................................................................................................................... 249
PACEMAKERS (Continued) ................................................................................................................ 250
PACEMAKERS (Continued) ................................................................................................................ 251
Page 5 of 260

 
PERIPHERAL VASCULAR DISEASE ................................................................................................. 252
SUPRAVENTRICULAR TACHYCARDIAS .......................................................................................... 253
SUPRAVENTRICULAR TACHYCARDIAS (Continued) ...................................................................... 254
VALVE REPLACEMENT ..................................................................................................................... 255
VALVE REPLACEMENT (Continued).................................................................................................. 256
VENOUS DISEASE ............................................................................................................................. 257
VENTRICULAR ARRHYTHMIAS......................................................................................................... 258
VENTRICULAR ARRHYTHMIAS (Continued)..................................................................................... 259
VENTRICULAR SEPTAL DEFECTS ................................................................................................... 260
Page 6 of 260

Introduction

This handbook provides information and guidance to the medical examiner who performs the commercial

driver medical examination. Determining driver medical fitness for duty is a critical element of the FMCSA

safety program. Specialists, such as cardiologists and endocrinologists, may perform additional medical

evaluation, but it is the medical examiner who decides if the driver is medically qualified to drive.

Page 7 of 260

Part I – The Federal Motor Carrier Safety Administration (FMCSA)

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On December 9, 1999, President Clinton signed into law the Motor Carrier Safety Improvement Act of

1999. This act transferred the Office of Motor Carriers from the Federal Highway Administration (FHWA)

to establish the Federal Motor Carrier Safety Administration (FMCSA). FMCSA is one of nine U.S.

Department of Transportation administrations. To learn more, visit the DOT Agencies Web page at

http://www.dot.gov/DOTagencies.htm.

FMCSA is headquartered in Washington, DC and employs people in all 50 States and the D

istrict of

Columbia. FMCSA is led by an Administrator, Deputy Administrator, and Chief Safety Officer. The Office

of Medical Programs is located under the Associate Administrator for Policy and Program Development.

FMCSA partners and customers are servic

ed by field organizations. The organizations consist of Field

Operations, Service Centers, and State-level motor carrier division offices.

FMCSA activities contribute to ensuring safety in motor carrier operations through strong enforcement of

saf

ety regulations; targeting high-risk carriers and commercial motor vehicle drivers; improving safety

information systems and commercial motor vehicle technologies; strengthening commercial motor vehicle

equipment and operating standards; and increasing safety awareness.

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"The Federal Motor Carrier Safety Administration (FMCSA) is focused on reducing crashes,

injuries, and fatalities involving large trucks and buses."

In carrying out its safety mandate to reduce crashes, injuries, and fatalities involving large trucks and

buses

, FMCSA:

• Develops and enforces data-dri

ven regulations that balance motor carrier (truck and bus

companies) safety with industry efficiency.

• Harnesses safety information systems to focus on higher-ris

k carriers in enforcing safety

regulations.

• Targets educational messages to carriers, commercial drivers, and the public.

• Partners with stakeholders including Federal, State, and local enforcement agencies, the motor

ca

r

rier industry, safety groups, and organized labor on efforts to reduce bus and truck-related

crashes.

To learn more about FMCSA, visit htt

p://www.fmcsa.dot.gov/about/aboutus.aspx.

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"The mission of the Office of Medical Programs is to promote the safety of America's roadways

through the promulgation and implementation of medical regulations, guidelines and policies that

ensure commercial motor vehicle drivers engaged in interstate commerce are physically qualified

to do so."

Page 8 of 260

To promote safety, the Office of Medical Programs:

• Oversees the national medical certification process for commercial motor vehicle drivers who

oper

ate in interstate commerce.

• Develops and implements medical regulations, policies, and procedures.

• Oversees and supports the Medical Review Board in accordance with the Federal Advisory

Co

mmittee Act.

• Develops and implements the national registry program — a

national medical examiner system

and a linked national driver medical reporting system.

• Conducts and oversees the Agency's medical exemption and certificate programs.

• Serves as the lead Federal agency for the regulation of commercial motor vehicle dr

iver health

and safety and conducts relevant medical research.

To learn more about the Office of Medical Programs, visit http://www.fmcsa.dot.gov/rules-

regulations/topic

s/medical/medical.htm.

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"The primary mission of the National Registry of Certified Medical Examiners is to improve

highway safety by producing trained, certified medical examiners who can effectively determine if

a commercial motor vehicle driver's health meets Federal Motor Carrier Safety Administration

standards."

FMCSA has begun the rulemaking process for proposing the National

Registry of Certified Medical

Examiners (NRCME) program.

The certified medical examiner would:

• Demonstrate an understanding of FMCSA physical qualification requirements and the demands

of

commercial driving, driver tasks, and the work environment.

• Perform driver certification examinations in accordance with FMCSA physical qualification

requirements and medical guidelines.

To learn more about the National Registry of Medical Examiners, visit

https://nationalregistry.fmcsa.dot.gov.

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The Federal Motor Carrier Safety Regulations identify a person who can be a medical examiner by two

criteria: professional licensure and scope of practice that includes performing physical examinations.

Medical examiner me

ans a person who is licensed, certified, and/or registered, in accordance with

applicable State laws and regulations, to perform physical examinations. The term includes, but is not

limited to, doctors of medicine and osteopathy, advanced practice nurses, physician assistants and

chiropractors.

When the Federal Motor Carrier Safety Administration (FMCSA) completes the notice-and

-comment

rulemaking for the proposed National Registry of Certified Medical Examiners, healthcare professionals

will be required to be trained and certified and listed on a national registry to perform physical

examinations of truck and bus drivers. At this time, FMCSA does not endorse any medical examiner

Page 9 of

260

training, education or certification programs, and healthcare professionals are not required to be listed on

a registry or other database to perform driver physical examinations.

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Medical certification in accordance with Federal Motor Carrier Safety Administration (FMCSA) physical

qualification standards is required when the driver is operating a commercial vehicle in interstate

commerce that:

• Has a combined gross vehicle weight or weight rating of 10,001

lbs. or more.

• Is designed or used to transport 9-15

passengers (including the driver) for compensation.

• Is designed or used to transpor

t 16 or more passengers (including the driver) whether for

compensation or not.

• Transports hazardous materials in quantities that require placarding under the hazardous

materials regulations.

When a driver returns from an illness or injury that interferes

with driving ability, the driver must undergo a

medical examination even if the medical examiner's certificate has not expired.

The medical examiner is responsible for certifying only drivers who meet the physical qualification

st

andards. Certification cannot exceed 2 years, and at the discretion of the FMCSA medical examiner,

may be less than 2 years. The Federal Vision and Diabetes Exemption Programs require annual medical

certification.

The medical examiner's certificate expires at midnight of the day,

month, and year written on the

certificate. There is no grace period on the expiration. The driver must be re-examined and recertified to

continue to drive legally.

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Regulatory requirements take precedence over the Health Insurance Portability and Accountability Act

(HIPAA) of 1996. There are potential subtle interpretations that can cause significant problems for the

medical examiner. What information must or can be turned over to the carrier is a legal issue, and if in

doubt, the examiner should obtain a legal opinion.

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Although the Federal Motor Carrier Safety Regulations do not require the medical examiner to give a

copy of the Medical Examination Report form to the employer, the Federal Motor Carrier Safety

Administration does not prohibit employers from obtaining copies of the Medical Examination Report

form. Medical examiners should have a release form signed by the driver if the employer wishes to obtain

a copy of the Medical Examination Report form.

Employers must comply with applicable State and Federal laws regarding the privacy and maintenance of

em

ployee medical information.

For information about the provisions of the Standards for Privacy of Individually Identifiable Health

In

formation (the Privacy Rule) contact the U.S. Department of Health & Human Services, Office of Civil

Rights at http://www.hhs.gov/ocr/hipaa/. Th

e HIPAA toll-free information line is: 1-866-627-7748.

Page 10

of 260

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49 CFR 391.43(g) addresses the distribution of the medical examiner’s certificate. If the medical examiner

finds that the driver is physically qualified to drive a commercial motor vehicle in accordance with

§391.41(b), the medical examiner shall complete a medical examiner’s certificate and furnish one copy to

the driver and one copy to the motor carrier that employs the driver. A release form is not required. The

motor carrier is required to keep a copy of the certificate in the driver qualification file.

The medical examiner should also keep a copy of the medical examiner's certificate on file. The driver

may

request a replacement copy of the certificate from the medical examiner or get a copy of the

certificate from the motor carrier.

To view 49 C

FR 391.43(g), visit http://www.fmcsa.dot.gov/rules-

regulations/administration/fmcsr/fmcsrruletext.aspx?reg=391.43#49CF

R391.43(g)

Figure 1 - Medical Examiner's Certificate

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The Code of Federal Regulations (CFR) is the codification of the general and permanent rules published

in the Federal Register by the executive departments and agencies of the Federal government. It is

divided into 50 titles that represent broad areas subject to Federal regulation. Title 49 is Transportation.

Each title is divided into chapters, which usually bear the

name of the issuing agency. Chapter III of Title

49 is "Federal Motor Carrier Safety Administration, Department of Transportation."

Page 11 of 260

Each chapter is further subdivided into parts that cover specific regulatory areas. Part 391 is

Qualifications of Drivers and Longer Combination Vehicle (LCV) Driver Instructors. Large parts may be

subdivided into subparts. Subpart E of Part 391 is Physical Qualifications and Examinations.

Parts are organized in sections. Citations for the CFRs include the title, part, and section numbers (e.g.,

49 CFR 391.41). When the title is understood, the citation may just include the part and section (e.g.,

§391.41).

Figure 2 - CFR Citation

Regulations are law and must be followed.

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Standards or Federal Motor Carrier Safety Regulations (FMCSRs) are legal requirements for interstate

commercial vehicles, drivers, and motor carriers.

FMCSA provides medical guidelines or advisory criteria to assist in the evaluation of m

edical fitness to

operate a commercial bus or truck. These guidelines are based on expert review and considered best

practice. The examiner may or may not choose to use these recommended guidelines. When the

certification decision does not conform to the recommendations, the reason(s) for not following the

medical guidelines should be included in the documentation.

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The medical examiner should be familiar with the regulations listed in the following table:

Regulation

Description

49 CFR 391.41

Describes the physical qualification requirements for drivers. The 13 standards

are used to determine driver medical fitness for duty. Four of the standards:

vision, hearing, epilepsy, and diabetes mellitus have objective disqualifiers that

do not depend on medical examiner clinical interpretation. These standards are

the "non-discretionary" standards. For the other nine "discretionary" standards,

the medical examiner makes a clinical judgment in accordance with the physical

qualification requirements for driver certification.

Page 12 of 260

49 CFR 391.43

Describes the responsibilities of the medical examiner, including general

instructions for performing the medical examination, a description of driver tasks

and work environment, medical advisory criteria, the sample Medical Examination

Report form, and the medical examiner's certificate.

49 CFR 391.45

Identifies who must have the commercial motor vehicle (CMV) driver physical

examination.

49 CFR 391.47

Describes the process for conflict resolution when there is a disagreement

between the primary care provider for the driver and the medical examiner for the

motor carrier concerning driver qualifications.

49 CFR 391.49

Describes the Skill Performance Evaluation (SPE) Certification Program, which is

an alternative physical qualification standard for the driver with a fixed

musculoskeletal deficit of an extremity who cannot physically qualify to drive

under §391.41(b)(1) or (b)(2). The driver must be otherwise qualified to drive a

CMV and meet the provisions of the alternate standard.

The first program to address fixed musculoskeletal deficits was created and

administered by the Interstate Commerce Commission (ICC) in 1964 and was

known as the Handicapped Driver Waiver Program. For more information, see

Skill Performance Evaluation Certification Program (SPE) History at

http://www.fmcsa.dot.gov/rules-regulations/topics/medical/spe-history.htm.

49 CFR 391.62

Describes limited exemptions for intra-city zone drivers.

49 CFR 391.64

Describes grandfathering for certain drivers who participated in vision and

diabetes waiver study programs. These drivers may be certified as long as they

continue to meet the provisions outlined in 49 CFR 391.64 and continue to meet

all other qualification standards.

49 CFR 390

Includes general information and definitions.

49 CFR 40

Includes regulations for medical review officers and substance abuse

professionals, including drug and alcohol testing procedures.

Table 1 - Medical Regulations Summary Table

To view the regulations in the Medical Regulations Summary Table, visit: http://www.fmcsa.dot.gov/rules-

regulations/administration/fmcsr/fmcsrguide.aspx?section_type=A.

Page 13 of 260

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An exemption provides temporary regulatory relief from one or more of the FMCSRs for commercial

drivers. Relief from a regulation is for 2 years and may be renewed. Currently, FMCSA has two medical

Driver Exemption Programs:

• Federal Vision Exemption Program (1998).

• Diabetes Exemption Program (September 2003).

The medical examiner cannot issue an exemption. The role of the medical examiner is to determine if the

dr

iver is "otherwise qualified." As part of the application procedure, the driver must obtain a medical

examination, whereby the medical examiner determines whether the driver is "otherwise qualified" if

accompanied by the Federal vision or diabetes exemption. Both Federal exemptions require the driver to

have an annual medical examination for maintenance and renewal of the exemption.

There currently are no FMCSA medical waiver programs.

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The medical examiner should become familiar with frequently used terms in the context of the Federal

Motor Carrier Safety Regulations and the medical examiner role. Select terms from 49 CFR 390.5 and

49 CFR 40 follow.

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Commercial Motor Vehicle:

Commercial motor vehicle means any self-propel

led or towed motor vehicle used on a highway in

interstate commerce to transport passengers or property when the vehicle:

1. Has a gross vehicle weight rating or gross combination weight rating, or gross v

ehicle weight or

gross combination weight, of 4,536 kg (10,001 pounds) or more, whichever is greater; or

2. Is designed or used to transport more than 8 passengers (including the driver) for compensation;

or

3. Is designed or used to transport more than 15 passen

gers, including the driver, and is not used to

transport passengers for compensation; or

4. Is used in transporting material found by the Secretary of Transportation to be hazardous under

49 U

.S.C. 5103 and transported in a quantity requiring placarding under regulations prescribed by

the Secretary under 49 CFR, subtitle B, chapter I, subchapter C.

Driver:

Driver means any person who operates any commercial motor vehicle.

Interstate Commerce:

Interstate commerce means trade, traffic, or transportation in the U

nited States:

1. Between a place in a State and a place outside of such State (including a place outside of the

Uni

ted States);

Page 14 of 260

2. Between two places in a State through another State or a place outside of the United States; or

3. Between two places in a State as par

t of trade, traffic, or transportation originating or terminating

outside the State or the United States.

Intrastate Commerce:

Intrastate commerce means any trade, traffic, or transportation in any State which is not described in the

te

r

m "interstate commerce."

Medical Examiner:

Medical examiner means a person who is licensed, certified, and/or registered, in accordance with

appl

i

cable State laws and regulations, to perform physical examinations. The term includes, but is not

limited to, doctors of medicine and osteopathy, advanced practice nurses, physician assistants and

chiropractors.

Motor Carrier:

Motor carrier means a for-hir

e motor carrier or a private motor carrier. The term includes a motor carrier's

agents, officers, and representatives as well as employees responsible for the hiring, supervising,

training, assigning, or dispatching of drivers and employees concerned with the installation, inspection,

and maintenance of motor vehicle equipment and/or accessories. For purposes of subchapter B, this

definition includes the terms "employer" and "exempt motor carrier."

For additional definitions from 49 C

FR 390.5, visit http://www.fmcsa.dot.gov/rules-

regulations/administration/fmcsr/fmcsrruletext.asp?rule_toc=759&section=390.5&section_toc=1739.

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The Omnibus Transportation Employee Testing Act of 1991 requires drug and alcohol testing of safety-

sensitive transportation employees in aviation, trucking, railroads, mass transit, pipelines, and other

transportation industries. The Department of Transportation (DOT) publishes rules on who must conduct

drug and alcohol tests, how to conduct those tests, and what procedures to use when testing. There are

times when a medical examiner may have interactions with healthcare professionals who perform

services in the drug and alcohol testing program.

Medical Review Off

icer (MRO):

A person who is a licensed physician and who is responsible for receiving and reviewing laboratory

res

ults generated by an employer drug testing program and evaluating medical explanations for certain

drug test results.

Substance Abuse Profess

ional (SAP):

A person who evaluates employees who have violated DOT drug and alcohol regulations and makes

rec

ommendations concerning education, treatment, follow-up testing, and aftercare.

For additional definitions from 49 C

FR 40, visit

http://www.dot.gov/ost/dapc/NEW_DOCS/part40.html?proc.

Page 15 of 260

Part II - The Job of Commercial Driving

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The Federal Motor Carrier Safety Administration (FMCSA) regulates interstate commercial operations,

including the drivers, the trucks and buses the drivers operate, the motor carrier, and the transportation of

hazardous materials in a quantity requiring placards. A safety risk in any one or more of these commercial

operations components can endanger the safety and health of the public.

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Approximately 6 to 7 million commercial motor vehicle (CMV) drivers are required by law to comply with

FMCSA physical qualification standards. Thus, an estimated 3 to 4 million physical examinations must be

performed annually, with the demand increasing every year.

In addition to medical fitness for duty certification, other regulations affecting the CMV driver include drug

and al

cohol testing, record keeping, hours of service, and more.

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CMVs include trucks and buses subject to regulations governing inspection, repair, and maintenance.

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Motor carriers, both for-hire and private, must comply with FCMSA regulations governing their drivers and

minimum levels of financial responsibility.

In the Federal Motor Carrier Safety Regulations (FMCSR), the term "motor carrier" refers to:

• Agents for motor carriers.

• Officers.

• Representatives.

• Employees responsible for the hiring, supervising, training, as

signing, and dispatching of drivers.

• Employees concerned with the installation, inspection, and maintenance of motor vehicle

equipm

ent and accessories.

• Employer.

• Exempt motor carrier.

Motor carriers are responsible for ensuring that the driver meets the gener

al qualification requirements of

49 CFR 391.11. The driver must:

• Be at least 21 years old.

• Speak and read English well enough to:

o Converse with the general public.

o

Understand highway/traffic signals.

o

Respond to official questions.

o

Make legible entrie

s on reports.

• Be capable of safely operating the CMV.

Page 16

of 260

• Have a current Medical Examiner’s Certificate on file.

• Have only one valid CMV operator’s license.

• Have provided the motor carrier with required background and violations information.

• Not be subject to d

isqualification to drive a CMV under the rules in 49 CFR 391.15.

• Have successfully completed a driver’s road test or equivalent.

Commercial driver medical fitness for duty records must include all Federal physical qualification

req

uirements found on the Medical Examination Report form. Truck and bus companies may also have

additional medical requirements, such as a minimum lifting capability. The driver could fail a motor carrier

pre-employment driver certification examination and still meet the Federal physical qualification

requirements for certification and issuance of a Medical Examiner's Certificate.

2+"+ <%:.$"+3'*,

States regulate intrastate commerce and commercial drivers who are not subject to Federal

regulations. They are required, at a minimum, to adopt Federal physical qualification requirements and

may even have additional, different, or more stringent requirements. Medical examiners are responsible

for knowing the driver regulations for the State or States in which they practice.

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49 CFR 391 Qualifications of drivers and longer combination vehicle (LCV) driver instructors establishes

the minimum qualifications for persons who drive a CMV. There are seven subparts. As a medical

examiner, you should be knowledgeable regarding the physical qualification requirements of the driver

specified in Subpart E — Physical qualifications and examinations.

You are responsible for ensuring that only the driver who meets the Federal

physical qualification

requirements is issued a Medical Examiner’s Certificate. When you issue a Medical Examiner’s

Certificate, you are certifying that the driver is medically fit for duty and can perform the driver role that is

described in the Medical Examination Form. You may certify the driver for a maximum of 2 years. You

may also, at any time, certify the driver for less than 2 years when examination indicates more frequent

monitoring is required to ensure medical fitness for duty.

The driver is r

esponsible for maintaining medical certification and carrying the Medical Examiner’s

Certificate while operating a CMV.

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The driver population exhibits characteristics similar to the general population, including an aging work

force. Aging means a higher risk exists for chronic diseases, fixed deficits, gradual or sudden

incapacitation, and the likelihood of comorbidity. All of these can interfere with the ability to drive safely,

thus endangering the safety and health of the driver and the public.

The profile of the average truck or bus driver:

• Male.

• More than 40 years of age.

Page 17 of 260

• Sedentary.

• Overweight.

• Smoker.

• Poor eating habits.

The medical profile:

• Less healthy than the average person.

• More than two medical conditions.

• Cardiovascular dise

a

se prevalent.

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Many factors contribute to making commercial driving a stressful occupation.

• Types of routes — Tur

n-around or short relay routes allow the driver to return home each

evening. A long relay route requires driving 9 to 11 hours, followed by at least a 10-hour, off-duty

period. Several days may elapse before the driver returns home. With a straight through haul or

cross-country route, the driver may spend a month on the road, dispatched from one load to the

next. The driver usually sleeps in the truck and returns home for only 4 or 5 days before leaving

for another extended period on the road. In team operation, drivers share the driving by

alternating 5-hour driving periods with 5-hour rest periods.

• Schedules — Abr

upt schedule changes and rotating work schedules may result in irregular sleep

patterns and a driver beginning a trip already fatigued. Tight pickup-and-delivery schedules

require both day and night driving. Failure to meet schedules may result in a financial loss for the

driver. Long hours and extended time away from family and friends may result in a lack of social

support.

• Environment — The dr

iver may be exposed to excessive vehicle noise, vibration, and extremes

in temperature. The driver may encounter adverse road, weather, and traffic conditions that

cause unavoidable delays.

• Types of cargo — The

driver of a bus is responsible for passenger safety. Transporting

passengers also demands effective social skills. Loss of or shifting cargo while driving can result

in serious accidents. Transporting hazardous materials, including explosives, flammables, and

toxics, increases the risk of injury and property damage extending beyond the accident site.

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• Stay alert when driving — This demands sustained mental alertness and physical endurance

that is not compromised by fatigue or sudden, incapacitating symptoms. Required cognitive skills

include problem solving, communication, judgment, and appropriate behavior in both normal and

emergency situations. Driving requires the ability to judge the maximum speed at which vehicle

control can be maintained under changing traffic, road, and weather conditions.

Page 18 of 260

• Use side mirrors — Mirrors on both sides of the vehicle are

used to monitor traffic that can move into the blind spot of the

driver. Mirrors are also used in backing up trucks to loading and

unloading areas. Sufficient lateral cervical mobility is needed for

effective use of side mirrors.

• Control steering wheel — Ste

ering wheels of large trucks and

buses are oversized. The act of steering can be simulated by

offering resistance, while having the driver imitate the motion

pattern necessary to turn a 24-inch steering wheel.

• Manipulate dashboard switches and controls — Large

trucks

and buses are complex vehicles with multiple dashboards,

switches, and knobs. Use of these components requires

adequate reach, prehension, and touch sensation in hands and

fingers.

• Shift gears — The

manual

transmission of a large truck may

have more than 20 gears. This requires the driver to repeatedly

perform reciprocal movements of both legs coordinated with right

arm and hand movements.

• Enter and exit

vehicle —

The driver may have to enter and

exit the vehicle similar to the same

way an individual climbs a ladder:

by maintaining three points of

contact for safety. Full overhead extension may be required to

rea

ch the hand holds. Hip angle and knee flexion may both have

to exceed 90°.

• Coupling and uncoupling the trailers — Mul

tiple sub-tasks are

performed in the process of coupling and uncoupling the trailer, including raising and lowering the

trailer supports, connecting air lines and electrical cables, and checking the height of the trailer

kingpin. Physical demands include grip strength, upper body strength, range of motion, balance,

and flexibility.

Page 19 of 260

• Load, secure, and unload cargo — Federal Motor Carrier Safety Administration (FMCSA)

guidelines do not specify the number of pounds a driver must be able to lift. However, the Centers

for Disease Control and Prevention (CDC) table of General Physical Activities Defined by Level of

Intensity lists "loading and unloading a truck" as an example of a vigorous activity that requires

the individual to exert greater than 6.0

me

tabolic equivalents (MET) in

performance of the activity.

• Perform vehicle checks — Gr

ip

strength, upper and lower body strength,

range of motion, balance, and flexibility

are required to inspect the engine,

brakes, and cargo. Vision and hearing

are used to identify and interpret

changes in vehicle performance.

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The Federal Motor Carrier Safety Administration (FMCSA) Office

of Analysis, Research, and Technology (ART) provides the

transportation industry and the public with analytical reports on

trends, costs, fatalities, and injuries in large truck and bus crashes.

ART research and data help identify factors that contribute to

crashes. FMCSA uses this information to develop effective

countermeasures that will reduce the occurrence and severity of

crashes.

Page 20

of 260

ART prepares all economic and environmental analyses for FMCSA rulemakings to ensure that changes

to motor carrier regulations are based on sound data and analysis.

Statistics, facts, publications, and reports resulting from ART studies can be accessed on the FMCSA

Web site at ht

tp://www.fmcsa.dot.gov/facts-research/art.aspx.

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FMCSA is dedicated to lowering the rate of crashes, injuries, and fatalities involving large trucks and

buses. When a fatal crash involves at least one large truck, regardless of the cause, the occupants of

passenger vehicles are more likely to sustain serious injury or die than the occupants of the large truck.

Why are the death rates of occupants in passenger vehicles so high? The answer is found in basic

physics: injury severity equals relative velocity change. The greater the mass, the less relative velocity

change. The crash of a vehicle having twice the mass with a lighter vehicle equals a six-fold risk of death

Page 21 of 260

to persons in the lighter vehicle. A sport utility vehicle (SUV) weighs approximately 4,000 pounds. A

loaded semi-truck weighs roughly 80,000 pounds. The truck has 20 times the mass of the SUV.

In addition to the grievous toll in human life and survivor suffering, the economic cost of these crashes is

exceedingly high.

Page 22 of 260

Part III - Medical Examination Guidelines

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49 CFR 391.43 Medical examination; certificate of physical examination describes your responsibilities as

a Federal Motor Carrier Safety Administration (FMCSA) medical examiner: determine medical fitness for

duty and issue Medical Examiner's Certificates to commercial motor vehicle (CMV) drivers who meet the

physical qualification standards.

Visit the FMCSA Medical Program Page Link to Responsibilities of Medical Examiners at

http://www.fmcsa.dot.gov/rules-regul

ations/topics/medical/medical.htm. You can access 391.43 by going

to the FMCSA Web site, entering "391.43" in the "RULES & REGULATIONS" text box, and selecting

"Go."

From the same area of the Web site, you ca

n also access 391.43 by selecting the "Medical Program" link

and then the "Responsibilities of Medical Examiners" link.

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FMCSA describes the periodic physical qualification examination of the interstate CMV driver to be a

"medical fitness for duty" examination. The purpose of the physical examination is to detect the presence

of any physical, mental, or organic conditions of such character and extent as to affect the ability of the

driver to operate a CMV safely.

As a medical examiner, your fundamental obligation is to establish whether a driver has a disease,

disorder

, or injury resulting in a higher than acceptable likelihood for gradual or sudden incapacitation or

sudden death, thus endangering public safety.

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The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely. This examination is for public safety determination and is

considered by the Federal Motor Carrier Safety Administration (FMCSA) to be a “medical fitness for duty"

examination.

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As a medical examiner, your fundamental obligation during the physical assessment is to establish

whether a driver has a disease or disorder that interferes with the ability to safely operate a CMV,

increases the risk for sudden death, or increases the risk for the onset of gradual or sudden

incapacitation, thus endangering public safety.

Risk is the probability of an event occurring within a certain period of time. Determining "acceptable risk"

is bot

h a medical and societal decision.

Page 23 of 260

Does the Driver Pose a Risk to Public Safety?

As a medical examiner, any time you answer “yes“ to this question, you should not certify the

dri

ver as medically fit for duty.

Figure 3 - Right to Work vs. Public Safety

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As you conduct the physical examination to determine if the driver is medically fit to perform the job of

commercial driving, you must consider:

• Physical conditio

n

o Symptoms — Do

es a benign underlying condition with an excellent prognosis have

symptoms that interfere with the ability to drive (e.g., a benign supraventricular

arrhythmia that causes syncope)?

o Incapacitation — Is

the onset of incapacitating symptoms so rapid that symptoms

interfere with safe driving, or can the driver stop the vehicle safely before becoming

incapacitated? Is the onset of incapacitating symptoms so gradual that the driver is

unaware of diminished capabilities, thus adversely impacting safe driving?

• Mental condition

o Cognitive — Ca

n the driver process environmental cues rapidly and make appropriate

responses, independently solve problems, and function in a dynamic environment?

o Behavior — Ar

e the driver interactions appropriate, responsible, and nonviolent?

• Medical treatment

o Effects — Do

es treatment allow the driver to perform tasks safer than without treatment?

o Side effects — Do

side effects interfere with safe driving (e.g., drowsiness, dizziness,

orthostatic hypotension, blurred vision, and changes in mental status)?

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As the medical examiner, you are examining for medical fitness for duty, not diagnosing and treating

personal medical conditions. Nonetheless, you have a responsibility to educate and refer the driver for

Page 24 of 260

further evaluation if you suspect an undiagnosed or worsening medical problem. Keep the following in

mind—

DO:

• Comply with FMCSA regulations.

• Seek further testing/evaluations for those medical conditions of which you are unsure.

• Refer the driver to his/her personal health-ca

r

e provider for diagnosis and treatment of potential

medical conditions discovered during your examination.

• Promote public safety by educating the driver about:

o Si

de effects caused by the use of prescription and/or over-th

e-counter medications.

o Medication warning labels and how to read them.

o

The im

portance of seeking appropriate intervention for non-disqualifying conditions,

especially those that, if neglected, could result in serious illness and possible future

disqualification.

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As a medical examiner, you must perform the driver physical examination and record the findings in

accordance with the instructions on the Medical Examination Report form. You may use an equivalent

medical examination report form, as long as all the elements of the Medical Examination Report form

posted in 49 CFR 391.41 are included.

Driver certification is determined based on whether or not the driver meets the requirements of the

Fed

eral Motor Carrier Safety Administration (FMCSA) physical qualification standards cited in 49 CFR

391.41.

The purpose of this overview is to familiarize you with the sections and data elements on the Medical

Exa

mination Report form, including, but not limited to:

• Organization of the form.

• Required signatures.

• Minimum documentation.

Part IV — Phy

sical Qualification Standards elaborates on clinical assessment of driver medical fitness for

duty.

You are encouraged to have a copy of the Medical Examination Report form for reference as you review

the

remaining topics. Visit http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Rep

ort.pdf to

access a copy of the Medical Examination Report form.

Page 25 of 260

Driver Information The

Driver completes section 1:

Figure 4 - Medical Examination Report Form: Driver's Information

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The driver completes this section, but you, as the medical examiner, must review the data to be sure

information is legible and the section is completed.

• Driver Name (Last, First, Middle) - Verif

y that the order is correct.

• Social Security Number (SSN) - Verif

y the identification of the driver.

• Birthdate (Month, Day, Year) - Verif

y that the order is correct.

• Age - Verify that the birthdate agrees

with the age given.

NOTE: The motor carrier is responsible for ensuring that the driver meets the 21 years of age requirement

before driving an interstate commercial motor vehicle (CMV). You can administer the driver physical to

anyone who requests the examination.

• Sex (Gender) - Self-explanatory.

• Type of Certificate - A com

plete physical examination is required for both a "New

Certification" and "Recertification."

"Follow-up" is used if further information is needed before you can make your driver certification

determination. It is a continuation of your original new or recertification examination. You need not

perform the entire physical examination again.

• Date of Exam - The medical examiner's certificate expiration date is calculated from the

date of the "New Certification" or "Recertification" examination, not the date of any

subsequent "Follow-up" examination.

• Address - Self-expl

anatory.

• Telephone Numbers - Self-expl

anatory.

• Driver License No., License Class, and State of Issue - Self-expl

anatory.

As a medical examiner, you are responsible for determining medical fitness for duty and driver

certi

fication status.

Page 26 of 260

The motor carrier is responsible for ensuring that the driver meets the commercial driver's license (CDL)

requirements before driving an interstate CMV.

Health&History

The Driver completes and signs section 2, and the Medical Examiner reviews and adds comments:

Figure 5 - Medical Examination Report Form: Health History

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The driver is instructed to indicate either an affirmative or negative history for each statement in the health

history by checking either the "Yes" or "No" box.

The driver is also instructed to provide additional information for "Yes" responses, including:

• Onset date.

•

Diagnosis.

• Treating provider contact information.

• Any limitations resulting from a current or past medical condition.

• Medications used regularly or recently, including prescriptions, over-th

e-co

unter, and herbal

supplements.

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Verify that the Driver signs Medical Examination Report Form:

Figure 6 - Medical Examination Report Form: Driver Signature

Page 27 of 260

By signing the Medical Examination Report form, the driver:

• Certifies that information is “com

plete and true.”

• Acknowledges that providing inaccurate or false information or omitting information could:

o In

validate the examination and any certificate issued based on it.

o Res

ult in the levy of a civil penalty against the driver under 49 U.S.C. 521(b)(2

)(B).

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The purpose of the health history is to obtain information relevant to detecting the presence of physical,

mental, or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely.

Regulations — You must review and discuss with the driver any "Yes" answers

For each "Yes" answer:

• Ask about history, diagnosis, treatment, and response to treatment.

• Explore underlying cause, preci

pitating events, and other pertinent facts.

• Obtain additional tests or consultations, as necessary, to adequately assess the medical fitness

of the

driver.

• Review and discuss driver response to treatment and medications currently or recently used,

includi

ng over-the-counter medications, and discuss any potential effects and side effects that

may interfere with driving. As needed, you should also educate the driver regarding drug

interactions with other prescription and nonprescription drugs and alcohol.

• Write all information on the Medical Examination Report form.

For information on a specific medical condition, see Part IV - Ph

ys

ical Qualification Standards of this

handbook.

Recommendations — Questions that you may ask include:

Does the driver have:

• Symptoms that interfere with safe driving because of:

o Fr

equency?

o Dur

ation?

o Sev

erity?

o Rap

id onset?

• Li

mitations that interfere with safe driving because of:

o De

gree of limitation present?

o Lik

elihood of progressive limitation?

• Me

dications that when used have effects and side effects that interfere with driving ability, such

as:

o Vis

ual disturbances.

o Dro

wsiness.

o Hyp

otension.

o Beh

avioral changes.

Pag

e 28 of 260

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In addition to the guidance provided in the section above, directions specific to each category in Column 1

for each "Yes" answer are listed below. Feel free to ask other questions to help you gather sufficient

information to make your qualification/disqualification decision.

Any illness or injury in the last 5 years

A driver must report any condition for which he/she is currently under treatment. The driver is also

asked

to report any illness/injury he/she has sustained within the last 5 years, whether or not currently

under treatment.

For information on specific medical conditions, see Part IV of this handbook.

Head/brain injuries, disorders, or illnesses

Ask questions that help you determine if the driver has recurring episodes of illness or any residual

physical, cognitive, or behavioral effects that interfere with the ability to safely operate a CMV.

Seizures, epilepsy

Ask questions to ascertain whether the d

river has a diagnosis of epilepsy (two or more unprovoked

seizures), or whether the driver has had one seizure. Gather information regarding type of seizure,

duration, frequency of seizure activity, and date of last seizure.

REMEMBER: Acc

ording to regulation, a driver with an established medical history or clinical

diagnosis of epilepsy does not meet qualification standards and cannot be certified.

Eye disorders or impaired vision (except corrective lenses)

Ask about changes in vision, diagnosis of eye disorder, and diagnoses commonly associated with

secon

dary eye changes that interfere with driving. Complaints of glare or near-crashes are driver

responses that may be the first warning signs of an eye disorder that interferes with safe driving.

REMEMBER: Th

e requirements for vision screening are regulatory.

Ear disorders, loss of hearing or balance

Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. Loss of

balance while performing nondriving tasks can lead to serious injury of the driver.

REMEMBER: The

requirements for screening for hearing loss are regulatory.

Heart disease or acute myocardial infarction, other cardiovascular conditions

Ask about history and symptoms of cardiovascular disease (CVD), syncope, dyspnea, congestive

heart failure, angina, etc.

NOTE: If th

e d

river reports symptoms consistent with undiagnosed CVD, you should refer the driver

to a specialist for further evaluation prior to certification. If a driver reports current CVD, consult with

the driver health care provider and obtain documentation prior to certification.

Heart surgery

Ask about history of heart surgery, bypass, valve replacement, pacemaker, angioplasty, and whether

th

e d

river has an implantable cardioverter defibrillator (ICD). Obtain heart surgery information,

including such pertinent operative reports as copies of the original cardiac catheterization report,

Page 29 of 260

stress tests, worksheets, and original tracings, as needed, to adequately assess medical fitness for

duty.

NOTE: If a

driver gives a "Yes" answer to the question regarding heart surgery, obtain documentation

fr

om the cardiologist before certifying. Also, FMCSA medical guidelines recommend not to certify the

driver who has an ICD, due to risk of syncope and gradual or sudden incapacitation while driving a

CMV. This includes a dual pacemaker/ICD, even if the ICD has not been activated.

High blood pressure

Ask about the history, diagnosis, and treatment of hypertension. In addition, talk with the driver about

his/her response to prescribed medications.

Hypertension alone is unlikely to cause sudden collapse. The likelihood inc

reases, however, when

there is target organ damage, particularly cerebral vascular disease. Recommending specific therapy

is beyond the scope of the physical examination. As a medical examiner, though, you are concerned

with the blood pressure response to treatment, and whether the driver is free of any effects or side

effects that could impair job performance.

Muscular disease

Ask the driver about history, diagnosis, and treatment of musculoskeletal conditions, such as

rhe

umatic, arthritic, orthopedic, and neuromuscular diseases. Does the diagnosis indicate that the

driver is at risk for sudden, incapacitating episodes of muscle weakness, ataxia, paresthesia,

hypotonia, or pain? Does the diagnosis indicate a degenerative process that over time will restrict

movements and eventually interfere with the ability to safely operate a CMV?

NOTE: In addition to driving, CMV driver duties include such rigorous activity as coupling and

unc

oupling trailers, loading and unloading trailers, inspecting the vehicle, lifting, installing tire chains,

climbing ladders, getting in and out of the cab, etc. Musculoskeletal diseases may adversely impact

the CMV driver’s muscle strength and agility needed to perform these nondriving tasks.

Shortness of breath (SOB)

Ask what acti

vities precipitate the episodes, nature, and characteristics of SOB. Does the driver

experience SOB only with exertion or also when at rest?

NOTE: Ac

cording to guidelines, many drivers may experience SOB while performing the nondriving

as

pects of their work (e.g., loading and unloading, etc.). However, most commercial drivers are not

short of breath while driving their vehicles. SOB while driving should trigger a more detailed

evaluation of the driver that can include consulting with an appropriate medical specialist.

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In addition to the guidance provided in the section above, directions specific to each category in Column 2

are listed below for each "Yes" answer. Feel free to ask other questions to help you gather sufficient

information to make your qualification/disqualification decision.

Lung disease, emphysema, asthma, chronic bronchitis

Ask about emergency room visits, hospitalizations, supplemental use of oxygen, use of inhalers and

other medications, risk of exposure to allergens, etc.

NOTE: Si

nce a driver must be alert at all times, any change in mental state is in direct conflict with

hi

ghway safety. Even the slightest impairment in respiratory function under emergency conditions

(when greater oxygen supply is necessary for performance) may be detrimental to safe driving.

Page 30 of 260

Kidney disease, dialysis

Ask about the degree and stability of renal impairment, ability to maintain treatment schedules, and the

presence and status of any co-existing diseases.

REMEMBER: If the driver is on dialysis, he/she cannot drive.

Digestive problems

Refer to the guidance found in Regulations - You

must review and discuss with the driver any "Yes"

answers.

Diabetes or elevated blood glucose controlled by diet, pills, or insulin

Ask about treatment, whether by diet, oral medications, Byetta, or insulin.

REMEMBER: D

r

ivers with insulin-treated diabetes mellitus who are otherwise qualified may apply for

a Federal exemption. To do so, the medical examiner must complete the examination and check the

following boxes:

• Meets standards but periodic monitoring required due to (write in: insulin treatment).

• One year.

• Accompanied by (write in: Federal Diabetes

) waiver/exemption (circle: exemption).

Nervous or psychiatric disorders (e.g., severe depression)

Refer to the guidance found in Regulations - You

must review and discuss with the driver any "Yes"

answers.

Loss of or altered consciousness

Loss of consciousness while driving endangers the driver and the public. Your discussion with the

dr

i

ver should include cause, duration, initial treatment, and any evidence of recurrence or prior

episodes of loss of or altered consciousness. You may, on a case-by-case basis, obtain additional

tests and/or consultation to adequately assess driver medical fitness for duty.

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In addition to the guidance provided in the section above, directions specific to each category in Column 3

are listed below for each "Yes" answer. Feel free to ask other questions to help you gather sufficient

information to make your qualification/disqualification decision.

Fainting, dizziness

Note whether the driver checked “Yes” due to fainting or dizziness. Ask

about episode

characteristics, including frequency, factors leading to and surrounding an episode, and any

associated neurologic symptoms (e.g., headache, nausea, loss of consciousness, paresthesia).

Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

Ask the driver about sleep disorders. Also ask about such symptoms as daytime sleepiness, loud

sno

ring, or pauses in breathing while asleep. When indicated, you should screen for sleep disorders.

Page 31 of 260

Stroke or paralysis

Note any residual paresthesia, sensory deficit, or weakness as a result of stroke and consider both

tim

e and risk for seizure.

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

toe

Determine whether the missing limb affects driver power grasping, prehension, or ability to perform

norm

al tasks, such as braking, clutching, accelerating, etc.

NOTE: The Skilled Performance Evaluation (SPE) is designed for fixed deficits of the ext

remities and

cannot be used for deficits caused by progressive disorders.

Spinal injury or disease

Refer to the guidance found in Regulations - You

must review and discuss with the driver any "Yes"

answers

.

Chronic low back pain

Ask about the degree of pain. How does the pain affect the ability of the driver to perform driving and

nondri

ving tasks? What does the driver do to alleviate pain? Does the treatment interfere with safe

driving?

Regular, frequent alcohol use

Ask about driv

e

r consumption of alcohol, including quantity and frequency, or use such tools as the

CAGE questionnaire to screen for possible alcohol-use problems. You should refer the driver who

shows signs of a current alcoholic illness to a specialist.

Narcotic or habi

t-forming drug use

Explore the use of the medication, whether or not it is prescribed, and the medication’s effect on

dri

ver reaction time, ability to focus, and concentration. Ask whether the medication causes

drowsiness, fatigue, or sleepiness.

NOTE: The medical examiner has the authority to disqualify a driver if he/she believes that the

me

dication the driver is taking adversely impacts the ability to safely operate a CMV.

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At a minimum, your comments should include:

• Nature of a positive history and the effect on driving ability.

• Discussion about medication and/or treatment effects and side effects that might interfere with

dri

ving ability.

Include a copy of any supplementary medical reports obtained to complete the health history.

Page 32 of 260

Vision

The Medical Examiner completes section 3:

Figure 7 - Medical Examination Report Form: Vision

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To meet the Federal vision standard, the driver must meet the qualification requirements for vision with

both eyes.

Regulations — driver must have:

• Distant visual acuity of at least 20/40 (Snellen) in each eye, with or without corrective lenses.

• Distant binocular visual acuity of at least 20/40 (Snellen) in bot

h eyes, with or without corrective

lenses.

• Field of vision of at least 70° in the horizontal meridian in each eye.

• Ability to recognize and distinguish among the colors of traffic signals and devices showing the

sta

ndard red, amber, and green.

Administer Vision Screening Tests

• Use the Snellen chart for testing or give results in Snellen-comparable values.

• Have drivers who wear corrective lenses for driving wear corrective lenses for testing.

• Evaluate drivers who wear contact lenses for good toleran

ce and adaptation to contact lens

usage.

• Assess the ability to recognize and distinguish among red, amber, and green traffic signals (true

col

or perception deficiencies are rarely disqualifying).

• If needed, request a vision examination by a specialist usin

g advanced vision testing equipment

to evaluate driver vision adequately.

NOTE: Trained assistive personnel may perform vision screening tests and record results. However,

th

e Medical Examiner must sign the Medical Examination Report form. By signing the Medical

Examination Report form, you are taking responsibility for and attesting to the validity of all

documented test results.

Disqualifying Vision

• Monocular vision.

Page 33 of 260

• Use of contact lenses when one lens corrects distant visual acuity and the other lens corrects

near visual acuity.

• Use of telescopic lenses.

• Failure to meet any part of the vision testing criteria with one eye or both eyes.

NOTE: So

me drivers with monocular vision may be able to be certified if otherwise medically fit for

duty

and are granted a Federal vision exemption certificate.

Specialist Vision Certification

The vision testing and certification may be completed by an ophthalmologist or optometrist. A specialist

vision examination may be:

• A requirement for obtaining and renewing a medical exem

ption.

• Necessary to obtain adequate evaluation of vision with specialized diagnostic equipment.

When the vision test is done by an ophthalmologist or optometrist, that provider must fill in the date,

nam

e, t

elephone number, license number, and State of issue, and sign the examination form.

Additionally, ensure that any attached specialist report includes all required examination and provider

information listed on the Medical Examination Report form.

NOTE: Vision is the only portion of the driver physica

l examination that can be performed and certified by

a provider other than a medical examiner.

Hearing

The Medical Examiner completes section 4:

Figure 8 - Medical Examination Report Form: Hearing

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To meet the Federal hearing standard, the driver must successfully complete one hearing test with one

ear.

Regulations — driver must:

• First perceive a forced, whispered voice in one ear at not less than five feet,

OR

• Not have an average hearing

loss in one ear greater than 40 decibels (dB) at 500 hertz (Hz),

1,000 Hz, and 2,000 Hz.

Administer Hearing Test or Tests

• Administer either hearing test first (see Part IV of this handbook for more information about

Hearing Tests):

o Forced whisper test.

o Aud

iometric test.

Pag

e 34 of 260

• Complete the test in both ears.

• If the driver passes the

initial hearing test:

o Do not adm

inister the other test.

o Rationale: test results show that hearing meets the standard.

•

If the driver fail

s the initial hearing test:

o Do admi

nister the other hearing test.

o Rationale: test results from only one test are insufficient to determine whether or not

hear

ing meets the standard.

Hearing Aid

A driver may use a hearing aid to meet the standard.

NOTE: The driver will usually have to go to an audiologist or hearing aid center for testing with

appr

opriate equipment because the audiometer used in most non-ear-specialty practices is not designed

to test a person who is wearing a hearing aid.

Record use of a hearing aid:

•

If the driver uses a hearing aid while testing, mark the “Check if hearing aid used for tests” box.

• If the driver must use a hearing aid to meet standard, mark the “Check if hearing aid required to

mee

t standard” box.

NOTE: A driver who must use a hearing aid to qualify is required to use a hearing aid while

dr

iving a commercial motor vehicle (CMV).

Record Hearing Tests Results

• Forced whisper test — Record the distance, in feet, at which a whispered voice is first heard.

• Audiometric test — Re

cord hearing loss in dB for 500 Hz, 1,000 Hz, and 2,000 Hz according to

the American National Standards Institute (ANSI).

NOTE: Convert International Organization for Standardization (ISO) audiometric test results to ANSI by:

o

Subtracting 14

dB from ISO for 500 Hz.

o Subtracting 10 dB from ISO for 1,000 Hz.

o

Subtracting 8.5 dB from ISO for 2,000 Hz.

NO

TE: Trained assistive personnel may perform hearing tests and record results. However, the Medical

Ex

aminer must sign the Medical Examination Report form. By signing the Medical Examination Report

form, you are taking responsibility for and attesting to the validity of all documented test results.

L"0*$%-)K L"0*$%-)<"(&)NO0+P/"

In the example above, the examiner has documented the test results for both hearing tests. The forced

whisper test was administered first, and hearing measured by the test failed to meet the minimum five

feet requirement in both ears. Therefore, the medical examiner also administered an audiometric test,

resulting in:

• Right ear 30 + 33 + 35 = 98/3 = 32.6 = PASS

•

Left ear 40 + 43 + 50 = 133/3 = 44.3 = FAIL

The hearing standard is met because the average hearing loss in the right ear is less than 40 dB when

me

a

sured with an audiometer.

Page 35 of 260

This driver passed one hearing test in one ear.

Blood&Pressure/Pulse

The Medical Examiner completes section 5:

Figure 9 - Medical Examination Report Form: Blood Pressure/Pulse Rate

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Regulations — You must measure:

W/''> X*"((.*" RW X T

• Only BP readings taken during the driver physical or follow-up examinations may be used for

certification decisions.

• BP greater than 139/89 must be confirmed with a second measurement taken later during the

exam

ination.

• Record addit

ional BP measurement in your comments on the Medical Examination Report form.

X./("

• Document pulse rhythm by marking the “Regular” or “Irregular” box.

• Record pulse rate.

• Record additional pulse characteristics in your comments on the Medical Examination Report

for

m.

NOTE: Trained assistive personnel may take and record the BP and pulse. When BP, pulse rate, or both

ar

e significant factors in your decision not to certify a driver, it is prudent for you to measure the readings

yourself. However, the Medical Examiner must sign the Medical Examination Report form. By signing the

Medical Examination Report form, you are taking responsibility for and attesting to the validity of all

documented test results.

Blood Pressure/Pulse Rate — Stages of Hypertension Guidelines Table

The instructions for medical examiners found in 49 CFR 391.43 Blood pressure (BP) stipulate that more

frequent monitoring is appropriate when a driver has hypertension at examination time or is being

medicated for hypertension. The Blood Pressure/Pulse Rate section of the Medical Examination Report

form has a table that summarizes the medical guidelines for BP measurements and is equivalent to three

stages of hypertension.

A one-time, three-mo

nth medical certificate is granted in two cases: where the driver has a BP that is

equivalent to Stage 2 hypertension, or a driver that was certified with Stage 1 hypertension has not

achieved a BP less than or equal to 140/90 at recertification. This three-month certificate is a one-time

issuance for the recertification period and is not intended to mean once in the driver’s lifetime.

Page 36 of 260

NOTE: These are recommendations. The medical examiner may use his/her clinical expertise and results of

the individual driver examination to determine the length of time between recertification examinations.

Figure 10 - Medical Examination Report Form: Blood Pressure/Pulse Rate Recommendation Table

The following table corresponds to the first two columns of the recommendation table in the Medical

Examination Report form. Column one has the blood pressure readings, and column two has the

category classification.

Reading

Category

140-159/90-99

Stage 1 hypertension

160-179/100-109

Stage 2 hypertension

greater than or equal to 180/110

Stage 3 hypertension

Table 2 - Blood Pressure/Pulse Rate Recommendation Table Columns 1 and 2

When a BP reading is a value where the individual systolic and diastolic readings are in different stages,

you should classify the reading by the higher stage. For example, 168/94 and 148/104 are both examples

of Stage 2 hypertension.

The next table corresponds to columns three and four of the recommendation table in the Medical

Exam

ination Report form. Use the Expiration Date and Recertification columns to assist you in

determining driver certification decisions.

Expiration Date

Recertification

1 year

1 year if less than or equal to 140/90

One-time certificate for 3 months

1 year from date of examination if less than

or equal to 140/90

6 months from date of examination if less

than or equal to 140/90

6 months if less than or equal to 140/90

Table 3 - Blood Pressure/Pulse Rate Recommendation Table Columns 3 and 4

A driver with Stage 3 hypertension (greater than or equal to 180/110) is at an unacceptable risk for an

acute hypertensive event and should be disqualified. You may reconsider the driver for certification

following effective treatment for hypertension evidenced by BP stabilized at less than or equal to 140/90.

Page 37 of 260

The 6-month expiration and recertification dates apply to the driver with a known history of Stage 3

hypertension, who has an acceptable BP at examination time, and who tolerates treatment with no side

effects affecting safe operation of a commercial motor vehicle (CMV).

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The Medical Examiner Completes section 6:

Table 4 - Medical Examination Report Form: Laboratory and Other Test Findings

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Test for:

• Specific gravity.

• Protein (proteinuria).

• Blood (hematuria).

• Glucose (glycosuria).

NOTE: Trained assistive personnel may obtain urine specimens and record test results. However, the

Me

dical Examiner must sign the Medical Examination Report form. By signing the Medical Examination

Report form, you are taking responsibility for and attesting to the validity of all documented test results.

-773+3'*"$ !%,+, "*7F'9 >@"$."+3'* (9'4 " 2A%63"$3,+

Abnormal dip stick readings may indicate a need for further testing. As a medical examiner, you should

evaluate the test results and other physical findings to determine the next step. For example, glycosuria

may prompt you to obtain a blood glucose test. If the urinalysis, combined with other medical findings,

indicates the potential for renal dysfunction, you should obtain additional tests and/or consultation to

adequately assess driver medical fitness for duty.

Document all additional test results and include the results in your comments, including whether or not

the

health of the driver affects the ability to safely operate a commercial motor vehicle (CMV). Attach any

additional medical reports obtained to the Medical Examination Report form.

NOTE: Testing for controlled substances is not a part of the physical qualifications for the driver

ex

amination process. Testing for controlled substances falls under a different regulation. However, if you

suspect a need for drug/alcohol testing, contact the Federal Motor Carrier Safety Administration

(FMCSA), or the motor carrier directly, for information on controlled substances and alcohol testing under

Part 382 of the Federal Motor Carrier Safety Regulations (FMCSR). Specific questions may be directed to

the FMCSA Field Office in your State or call FMCSA at 1-800-832-5660.

Page 38 of 260

8/=,36"$ >?"43*"+3'*

The Medical Examiner completes section 7:

Figure 11 - Medical Examination Report Form: Physical Evaluation

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<%:.$"+3'*, C X'. 4.,+ 4%",.9% "*7 9%6'97&793@%9 /%3:/+ ^3*6/%,_ "*7&V%3:/+ ^A'.*7,_

The physical qualification standards do not include any maximum or minimum height and weight

requirements. You should consider height and weight factors as part of the overall driver medical fitness

for duty.

NOTE: Tr

ained assistive personnel may measure height and weight. However, the Medical Examiner

must sign the Medical Examination Report form. By signing the Medical Examination Report form, you

are taking responsibility for and attesting to the validity of all documented test results.

X;M($B0/ NO0+$%0&$'% K ?">$B0/ NO0+$%"* ,"(P'%($Q$/$&$"(

The general purpose of the physical examination is to detect the presence of physical, mental, or organic

conditions of such character and extent as to affect the driver ability to operate a commercial motor

vehicle (CMV) safely. This examination is for public safety determination and is considered by the Federal

Motor Carrier Safety Administration (FMCSA) to be a "medical fitness for duty" examination.

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The physical examination should be conducted carefully and must, at a minimum, be as thorough as the

examination of body systems outlined in the Medical Examination Report form. For each body system,

mark "Yes" if abnormalities are detected, or "No" if the body system is normal.

You must document abnormal findings on the Medical Examination Report form, even if not disqualifying.

Page 39 of 260

Start your comments using the number to indicate the body system (e.g., 2 for eyes or 8 for vascular

system). Your comments should:

• Indicate whether or not the abnormality affects driving ability.

• Indicate if additional evaluation is needed to determine medical fitness for duty.

• Include a copy of any supplementary medical evaluation obtained to adequately assess driver

heal

t

h.

• Document your discussion with the driver, which may include advice to seek additional evaluation

of a

condition that is not disqualifying but could, if neglected, worsen and affect driving ability.

• Indicate whether or not the body has compensated for an organic disease adequately to meet

physical qualification requirements.

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1. General Appearance

Observe and note on the Medical Examination Report form any abnormalities with post

ure, limps, or

tremors. Also observe and note driver affect and overall appearance. Note driver demeanor and whether

responses to questions indicate potential adverse impact on safe driving.

Is the driver markedly overweight? If yes, what are the clinica

l and safety implications when integrated

with all other findings?

Are there signs of current alcohol or drug abuse? If yes, refer the driver to a specialist for evaluation. After

succe

ssful counseling and/or treatment, a driver may be considered for certification, as long as no

residual limitations exist that could interfere with the ability to safely operate a CMV.

2. Eyes

At a minimum, you must check for pupillary equality, reaction to light and accommodation, ocular motility,

ocul

ar muscle imbalance, extraocular movement, nystagmus, and exophthalmos.

Does your examination find any abnormality that interferes with driving ability? Is an eye abnormality an

ind

icator that additional evaluation, perhaps by a specialist, is needed to assess the nature and severity

of the underlying condition?

NOTE: Special diagnostic equipment may be needed to adequately assess a driver with a known

di

agnosis or who is at risk for retinopathy, cataracts, aphakia, glaucoma or macular degeneration.

Referral to a vision specialist may be required.

3. Ears

You should check for

evidence of any aural disease or condition. At a minimum, you must check for

scarring of the tympanic membrane, occlusion of the external canal, and perforated eardrums.

Does your examination of the ear find abnormalities that might account for hearing l

oss or a disturbance

in balance? Should the driver consult with a primary care provider or hearing specialist for possible

treatment that might improve hearing test results?

The presence of some hearing disorders, such as Meniere's disease, may interfere

significantly with

driving ability and the performance of other CMV driver tasks. In this case, guidelines recommend not to

certify the driver.

Page 40 of 260

4. Mouth and Throat

Does the condition or treatment require long-ter

m follow-up and monitoring to ensure that the disease is

stabilized, and the treatment is effective and well tolerated?

5. Heart

You must examine the heart for murmurs, extra sounds, enlargement, and a pacemaker or implantable

ca

r

dioverter defibrillator. Check the lower extremities for pitting edema and other signs of cardiac disease.

Does your examination find any abnormalities that indicate the driver may have a current cardiovascular

dis

ease accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive

cardiac failure?

Can the condition be corrected surgically or managed well by pharmacological treatments? Is the disease

progr

essive?

Does the condition or treatment require long-ter

m follow-up and monitoring to ensure that the disease is

stabilized and treatment is effective and well-tolerated?

NOTE: There are no work restrictions permitted. The commercial driver must be able to perform all job-

re

lated tasks, including lifting, to be certified.

6. Lungs and Chest, Not Including Breast Examination

You must examine the lungs and c

hest for abnormal chest wall expansion, respiratory rate, and breath

sounds including wheezes or alveolar rales. You must check for impaired respiratory function and

cyanosis. Be sure to examine the extremities to check for clubbing of the fingers and other signs of

pulmonary disease.

Does your examination detect a respiratory dysfunction that in any way could interfere with the ability of

the

driver to safely operate a CMV? The driver may need to have additional pulmonary function tests

and/or have a specialist evaluation to adequately assess respiratory function.

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7. Abdomen and Viscera

You must check for enlarged liver and spleen, masses, bruits, hernia, and significant abdominal wall

mus

cle weakness. Check for tenderness and auscultate for bowel sounds.

Does an abnormal finding suggest a condition that might interfere with safe CMV operation? You should

not m

ake a certification decision until the etiology is confirmed, and treatment has been shown to be

adequate/effective and safe.

8. Vascular System

You must check for abnormal pulse and amplitude, carotid or arterial bruits, and varicose veins. Check for

pedal

pul

ses.

The diagnosis of arterial disease should prompt you to evaluate for the presence of other cardiov

ascular

diseases. Adequate evaluation may require additional testing and/or specialist examination.

9. Genitourinary System

Page 41 of 260

You must check for hernias. You should evaluate any hernia that causes the driver discomfort to

determine the extent to which the condition might interfere with the ability of the driver to operate a CMV

safely. Obtain further testing and evaluation as required.

An abnormal urinalysis indicates further testing to rule out underlying medical problems.

NOTE: Yo

u cannot certify a driver who has not provided a urine specimen.

10. Extremities-Li

mb Impaired. Driver may be subject to Skill Performance Evaluation (SPE)

certificate if otherwise qualified.

Check for fixed deficits of the extremities caused by loss, impairment, or deformity of an arm

, hand,

finger, leg, foot, or toe. Does the driver have a perceptible limp?

Does the driver have sufficient grasp and prehension in the upper limbs to maintain steering wheel grip?

Do

es the driver have sufficient mobility and strength in lower limbs to operate pedals properly?

Does the driver have signs of progressive musculoskeletal conditions, such as atrophy, weakness, or

hy

potonia?

Does the driver have clubbing or edema that may indicate the presence of an underlying heart, lung, or

va

scular condition?

NOTE: If y

ou find a driver is medically qualified EXCEPT FOR a fixed deficit of an extremity caused by

the loss or functional impairment of a limb, you can qualify the driver, subject to obtaining an SPE

certificate. The SPE program is intended only for individuals with fixed deficits of the extremities (not for

individuals with progressive diseases).

11. Spine, Other Musculoskeletal

You must check the entire musculoskeletal system for previous surgery, deformities, limitations of motion,

and

tenderness. Does the driver have a diagnosis or signs of a condition known to be associated with

acute episodes of transient muscle weakness, poor muscular coordination, abnormal sensations,

decreased muscular tone, and/or pain? What is the:

• Nature and severity of the condi

tion?

• Degree of limitation present?

• Likelihood of progressive limitation?

• Likelihood of gradual or sudden incapacitation?

12. Neurological

You must examine the driver for impaired equilibrium, coordination, and speech pattern. Does the driver

hav

e ataxia? Are deep tendon reflexes asymmetric? Are patellar reflexes normal? Is Babinski's reflex

negative or normal? Are there any sensory or positional abnormalities?

Does an abnormal finding suggest a condition that might interfere with safe CMV operation? You should

not

make a certification decision until the etiology is confirmed, and treatment has been shown to be

adequate/effective and safe.

Page 42

of 260

I%+%943*%&)%9+3(36"+3'*&2+"+.,

!"&"*+$%" 3"*&$#$B0&$'% D&0&.( K ?">$B0/ NO0+$%"* ,"(P'%($Q$/$&M

The Federal Motor Carrier Safety Administration (FMCSA) relies on you, the medical examiner, to assess

and determine if the commercial motor vehicle (CMV) driver meets the physical qualification requirements

cited in 49 CFR 391.41. In some cases, you will also consider any reports and recommendations from the

primary care provider and/or specialists treating the driver to supplement your examination and ensure

adequate medical assessment.

As a medical examiner, you are responsible for making the certification decision and signing the M

edical

Examination Report form. You issue a Medical Examiner's Certificate to the drivers you determine to be

medically fit for duty.

Your certification decision is limited to the certification and disqualification options printed on the Medical

Exa

mination Report form. The maximum time for which you can certify a driver is 2 years. You can,

however, certify for a period of time less than 2 years.

3"*&$#$B0&$'% D&0&.(

When you determine that a driver is medically fit to drive and also able to perform non-driving

responsibilities, you will certify the driver and issue a Medical Examiner's Certificate.

When you determine that a driver has a health history or condition that does not meet physical

quali

fication standards, you must not certify the driver. However, you should complete the examination to

determine if the driver has more than one disqualifying condition. Some conditions are reversible, and the

driver may take actions that will enable him/her to meet qualification requirements if treatment is

successful.

!$(B.(($'% ,"-0*>$%- 3"*&$#$B0&$'% !"B$($'%

You must discuss your certification decision with the driver.

Ensure that the driver understands the certification decision. When you:

Certify — dis

cussion may include:

• Reason for periodic monitoring and s

hortened examination interval.

• Additional requirements associated with certification.

• Medical Examiner's Certificate expiration information:

o Occurs at midnight on the expiration date.

o

Has no grace period.

Di

squalify — dis

cussion may include:

• Reason for disqualification.

•

Steps that can be taken to meet certification standards.

• Temporary disqualification.

o Reason (condition or medication).

o

Length of waiting period.

o

Conditions that could restart the waiting period.

o

List of any documentation the driver is

to provide to the medical examiner.

Page 43 of 260

NOTE: A driver is certified from the date of examination. If only the disqualifying condition, e.g., blood

pressure, is evaluated at the next examination following temporary disqualification, the date of the initial

examination is used to calculate the certification period. If the examiner performs a complete physical

examination, then the certification period is calculated from the date of this examination.

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<%:.$"+3'*, C X'. 4.,+ 7'6.4%*+ +/% 793@%9 A/=,36"$ %?"43*"+3'*

You must record the results of every driver physical examination, substantially in accordance with the

Medical Examination Report form and the instructions cited in 49 CFR 391.43.

1%736"$ >?"43*"+3'* <%A'9+ 0'94

• You are to retain the driver medical records for a minimum of 3 years.

• You will need to provide a copy to the driver who is applying for, or renewing, a:

o Skill Performance Evaluation (SPE) certificate.

o

Diabetes exemption certificate.

o

Vision exemption certificate.

1%736"$ >?"43*%9T, )%9+3(36"+%

• Provide the original to the driver you examined and found medically fit for duty.

• You must retain a copy of the driver medical records, including the certificate, for a minimum of 3

yea

rs.

• You may provide a copy to a prospective or current employer upon request.

•

The driver must carry the Medical Examiner's Certificate while operating a CMV. The certificate

may

be:

o The original certificate.

o

A copy of the original certificate.

o

A reduced-si

ze copy of the original certificate (e.g., wallet size).

)%9+3(=

As a medical examiner, you determine when a driver meets physical qualification requirements. The only

requirements you can stipulate when certifying a driver are those in the "Note certification status here"

section of Medical Examination Report form and on the Medical Examiner's Certificate. You also

determine when the driver must repeat the physical examination for continuous certification. Although you

cannot exceed the maximum certification period, you are never required to certify a driver for a

certification interval longer than what you deem necessary to adequately monitor driver medical fitness for

duty.

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].0/$#M #'* U9^"0*

3"*&$#$B0&"

Page 44 of 260

Figure 12 - Medical Examination Report: 2 Year Certification

When your examination finds that the driver meets all physical qualification standards, you can certify the

driver for the maximum 2 years.

• Mark the “Meets standards in 49 CFR 391.41; qualifies for 2 year certificate” box.

• Verify that the expiration date is 2 years from the date of the physical examination.

].0/$#M K :$&; X"*$'>$B ?'%$&'*$%- R/"(( &;0% U M"0*(T

Figure 13 - Medical Examination Report: Certification with Periodic Monitoring

You will certify for less than 2 years when a need exists to monitor the medical fitness for duty of the

driver more frequently. Some of the Federal Motor Carrier Safety Administration (FMCSA) medical

guidelines include recommendations for maximum certification intervals 1 year or less. Recommended

maximum certification periods are considered best practices. You are never required to certify a driver for

a certification interval longer than what you deem necessary to adequately monitor driver medical fitness

for duty.

• Mark the “Meets standards, but periodic monitoring required due to ______” box.

• Note the reason for periodic monitoring.

• Indicate the length of cert

ification by checking 3 or 6 months, 1 year, or Other and write in the

time frame (e.g., 1 month).

• Calculate the expiration date from the date of the initial physical examination, not a follow-up

examination date.

Page 45

of 260

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].0/$#M ` :$&

; ,"_.$*"+"%& &' :"0* 3'**"B&$A" D"%('*M X"*B"P&$'% !"A$B"

Figure 14 – Medical Examination Report: Certification with Requirement to Wear Corrective Sensory

Perception Device

As a medical examiner, you must specify, as a requirement for certification, that a driver wear corrective

lenses and/or a hearing aid when that driver has to use one or both to meet the vision and/or hearing

physical qualification requirements.

• Mark the “Wearing corrective lenses” and/or “Wearing hearing aid” option to indicate that the

dri

ver must wear the sensory perception correction device while driving.

• You can combine a req

uirement to wear a sensory perception correction device with a 2-year

certification, periodic monitoring certification, and/or any of the other four listed options.

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// X"*#'*+0%B" NA0/.0&$'% RDXNT 3"*&$#$B0&"

Figure 15 - Medical Examination Report: Certification When Driver Must Meet Alternate Standard

Page 46 of 260

By marking the SPE option, you certify that the driver:

• Fails to meet one or more of the limb requirements of 49 CFR 391.41(b)(1) or (2).

• Meets all other physical requirements cited in 49 CFR 391.41(b).

• Must have both a valid SPE certificate and Medical Examiner's Certifi

cate to drive.

As a medical examiner, you start the SPE program application process by first determining if the driver is

other

wise medically qualified. The SPE certificate is issued for 2 years. A copy of the Medical

Examination Report form is required with initial and renewal SPE applications.

NOTE: The driver with an SPE certificate meets an alternative qualification standard for 49 CFR

391.

41(b)(1) or (2).

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].0/$#M ` :$&

; 0 4">"*0/ NO"+P&$'%

Figure 16 - Medical Examination Report: Certification with Federal Exemption

There are two Federal medical exemption programs for drivers:

• The Diabetes Exemption Program allows some drivers wit

h diabetes mellitus who use insulin

replacement therapy to drive a commercial motor vehicle (CMV).

• The Vision Exemption Program allows some drivers with monocular vision to drive a CMV.

To learn more about the Federal medical exemption programs, visit http://www.fmcsa.dot.gov/rules-

regulations/topics/medical/exemptions.htm.

As

a medical examiner, you start the exemption program application process by first determining i

f the

driver is otherwise medically qualified except for monocular vision or the use of insulin. A copy of the

Medical Examination Report form is required with both the initial and renewal Federal exemption

applications.

By marking “Accompanied by a _______ w

aiver/exemption,” circling "exemption," and writing in the

Federal program name, you certify that the driver:

• Fails to meet the insulin use requirement of 49 CFR 391.41(b)(3) or the monocular vision

req

uirement of 49 CFR 391.41(b)(10).

• Meets all other physical requirements cited in 49 CFR 391.41(b).

• Must also have a valid Federal medical exemption certificate to drive.

Page 47 of 260

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• Applies to a small number of individuals who participated in the FMCSA studies conducted prior

to the implementation of the medical exemption programs.

• By checking the “By Operation of 49 CFR 391.64,” option, you certify that the driver:

o Presented documentation of participation in a study.

o

Continues to meet 49 CFR 391.64 requirements.

o

Is otherwise

medically fit for duty.

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• Intracity zones are geographical areas defined in the regulations.

• By checking the “Driving within an exempt intracity zone (See 49 CFR 391.62)” option, you certify

tha

t the driver:

o Is otherwise medically fit for duty except for the exempted condition.

o

The exempted condition remains stable.

o

Remains in medical compliance with the requirements of section 391.62.

I3,\."$3(=

As a medical examiner, you must disqualify the driver who does not meet one or more of 49 CFR 391.41

physical qualification standards. You should complete the physical examination of the driver and discuss

with him/her the reason(s) for disqualification and any steps that can be taken to meet certification

standards.

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As a medical examiner, you must disqualify the driver who:

• Fails to meet a physical qualification requirement cited in the standards (e.g., vision tes

t result,

hearing loss test result, epilepsy, or insulin use).

• You believe has a medical condition that endangers the health and safety of the driver and the

public.

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Figure 17 - Medical Examination Form: Disqualify

Page 48 of 260

Document the decision to disqualify on the Medical Examination Report form.

• Mark the "Does not meet standards" box.

• Note the reason for disqualification.

• Document the discussion with the driver explaining the rationale for the dec

ision to disqualify.

NOTE: DO

NOT issue a medical examiner's certificate.

Before a disqualified driver can return to commercial motor vehicle (CMV) driving, a medical examiner

mu

st find the driver to be medically fit for duty.

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Figure 18 - Medical Examination Form: Disqualify Temporarily

When the disqualifying condition or treatment has a clinical course likely to restore driver medical fitness

for duty, you may complete the:

• “Temporarily disqualified due to

(condition or medication):_____________” line.

• “Return to medical examiner's office for follow up on __________________” line.

When a recommended waiting period is applicable, the date:

• Should be greater than or equal to the waiting period.

• Should be gre

ater than or equal to the longest waiting period when the driver has multiple

medical conditions.

NOTE: DO

NOT issue a medical examiner's certificate.

REMEMBER:

The driver is disqualified and not allowed to operate a CMV until a medical examiner finds

the driver to be medically fit for duty.

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When you find that the driver examined is medically qualified to operate a commercial motor vehicle

(CMV) in accordance with 49 CFR 391.41(b), you should complete a certificate as prescribed in 49 CFR

391.43(h) and furnish the original to the person who was examined. You may provide a copy to a

prospective or current employer requesting one.

H,,.% 1%736"$&>?"43* %9 T, )%9+3(36"+%

When you find that the driver examined is medically qualified to operate a commercial motor vehicle

(CMV) in accordance with 49 CFR 391.41(b), you should complete a certificate as prescribed in 49 CFR

Page 49

of 260

391.43(h) and furnish the original to the person who was examined. You may provide a copy to a

prospective or current employer requesting one.

Figure 19 - Medical Examiner's Certificate

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1. Ensure that the name of the driver matches the name on the Medical Examination Report form.

2. Mark any certification requirement that applies:

o we

aring corrective lenses

o we

aring hearing aid

o ac

companied by a ____________ waiver or exemption

o dr

iving within an exempt intracity zone (49 CFR 391.62)

o ac

companied by a Skill Performance Evaluation (SPE) Certificate qualified by operation

of 49 CFR 391.64

3. Write “Federal vision” or “Federal diabetes” when ex

emption certificate is required.

4. Sign the certificate and complete medical examiner information.

5. Write the date of the medical examination.

6. Have the driver sign the certificate and compare this with the information provided by the driver.

7. Verify that the

expiration date does not exceed the certification interval (maximum certification period

is 2 years).

Page 50

of 260

Part IV - Physical Qualification Standards and Advisory Criteria

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^1%736"$ G.37%$3*%,_

As a medical examiner, it is important for you to distinguish between medical standards and medical

guidelines. Regulations/standards are laws and must be followed. Whereas guidelines, such as advisory

criteria and medical conference reports, are recommendations. While not law, the guidelines are intended

as best practices for medical examiners.

Guidelines have been issued by the Federal Motor Carrier Safety Administration (FMCSA) to provide you

wit

h additional information and are based on medical literature. If you choose not to follow the guidelines,

the reason(s) for the variation should be documented. You are responsible for determining if the

commercial motor vehicle (CMV) driver is medically qualified and is safe to drive under the Federal Motor

Carrier Safety Regulations (FMCSRs).

The physical qualification regulations for CMV drivers in interstate commerce are found at

http://www.fmcsa.dot.gov/rules-

regulations/administration/fmcsr/fmcsrruletext.asp?section=391.41#r49CFR391.41-b (Section 391.41(b)

of

the FMCSRs).

The advisory criteria under 391.41 are recommendations to help you as a medical examiner perform

med

ical examinations and determine the medical fitness for duty of a driver. They are accessible on the

FMCSA Web site at

http://www.fmcsa.dot.gov/rules-reg

ulations/administration/medical.htm.

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FMCSA has an ongoing process for reviewing all Federal medical standards and guidelines used to

determine driver medical fitness for duty.

To ensure that these regulations and guidelines ar

e evidence-based, FMCSA uses a number of methods

for gathering medical data, including, but not limited to:

• Agency expert analyses of Federal data and other relevant international, national, and State data.

• Interagency, national, and international regulat

ory analyses.

• Evidence reports.

• Medical Expert Panels (MEPs).

• Medical Review Board (MRB), a committee established in accordance with the Federal Advisory

Com

mittee Act.

First, FMCSA formulates questions relating to a specific medical condition and the ass

ociated impact on

driving. FMCSA then gathers information through a systematic review of the available scientific literature.

The findings are summarized in evidence reports that reflect current diagnostic and therapeutic medical

advances.

For some topics

, FMCSA convenes an MEP. The members of the MEP vary according to the specific

topic and panel expertise. The task of the MEP is to provide an opinion for consideration by FMCSA.

Evidence reports, executive summaries, and MEP opinions are posted on the FMC

SA Web site at

http://www.fmcsa.dot.gov/rules-reg

ulations/topics/mep/mep-reports.htm.

Page 51 of 260

The MRB meets three to four times each year on specific topics. The MRB independently reviews

evidence reports and if an MEP was convened, also reviews the MEP opinion. The MRB deliberates and

proposes recommendations for consideration by FMCSA.

FMCSA considers the evidence reports, the MEP opinion, and the recommendations from the MRB when

re

viewing medical standards and guidelines. FMCSA also considers other factors such as feasibility and

impact. FMCSA posts information regarding proposed changes to the current standards and guidelines

on the FMCSA Medical Program Web page at http://www.fmcsa.dot.gov/rules-

regulations/topics/medical/medical.htm. P

roposed changes to guidelines will accompany the standards as

guidance and are subject to public notice-and-comment rulemaking.

This Medical Examiner Handbook will be updated as new standards and guidelines are approved by

FM

CSA.

-#'.+ OP )0< QPRSOR

49 CFR 391.41 Physical qualifications for drivers describes the medical fitness for duty qualification

standards that an individual must meet in order to be qualified to operate an interstate commercial motor

vehicle (CMV).

You can access 391.41 on the FMCSA Web site at http://www.fmcsa.dot.gov/ by entering "391.41" in the

"R

ULES & REGULATIONS" text box, and selecting "Go." From the same area of the Web site, you can

also access 391.41 by selecting the "Medical Program" link and then the "Physical Qualifications" link.

The driver medical qualification standards describe requirements that are critical to evaluation of medical

fi

tness for duty in commercial drivers. Your knowledge of the physical and mental demands of commercial

driving and your medical judgment determine whether a particular condition interferes with driver ability of

the person to operate a CMV safely.

J3,3'*

Adequate central and peripheral vision are necessary for safe driving.

The driver must perceive the relative distanc

e of objects, and react appropriately to vehicles in adjacent

lanes or reflected in the mirrors, to pass, make lane changes, and avoid other vehicles on the road.

The visual demands of driving are magnified by vehicles that have larger blind spots, lo

nger turning

radiuses, and increased stopping times.

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"A person is physically qualified to drive a commercial motor vehicle if that person —

Has distant visual acuity of at least 20/40

(Snellen) in each eye without corrective lenses or visual acuity

separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least

20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70º in the

horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices

showing standard red, green, and amber."

• The required tests measure visual acuity, peripheral horizontal visual fields, and colo

r.

• Visual acuity is measured in each eye individually and both eyes together.

Page 52

of 260

• Distant visual acuity of at least 20/40 (Snellen) in each eye, with or without corrective lenses.

• Distant binocular visual acuity of at least 20/40 (Snellen) in both eyes, with

or without corrective

lenses.

• Field of vision of at least 70° in the horizontal meridian in each eye.

• Color vision must be sufficient to recognize traffic signals and devices showing the standard red,

am

ber, and green traffic signal colors.

• When correctiv

e lenses are used to meet vision qualification requirements, the corrective lenses

must be used while driving.

• A medical examiner, ophthalmologist, or optometrist may perform and certify vision test results.

The medical examiner determines driver certification status.

• Monocular vision is disqualifying.

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Here are the vision questions that are asked in the health history. Yes responses require clarification and

documentation.

• Eye disorders?

• Impaired vision (do not include corrective lenses)?

He

re are important vision questions to ask.

• Symptoms related to or caused by eye diseases?

• Use of ophthalmic preparations that have side effects that can affect safe driving?

X;M($B0/ NO0+$%0&$'%

Examine the eyes for:

• Pupillary equality.

• Reaction to light and accommodation.

• Ocular motility.

• Ocular muscle imbalance.

• Extraocular movements.

• Nystagmus.

• Exophthalmos.

Note abnormal findings. Discuss the value of regular vision examinations in early detection of eye

di

seases.

Ask about:

• Retinopathy.

• Cataracts.

• Aphakia.

Page 53

of 260

• Glaucoma.

• Macular degeneration.

Medical examiners cannot diagnose these diseases or conditions because most do not have the

equipment neces

sary to diagnose them.

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Required vision screening tests include central visual acuity, peripheral vision, and color vision.

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The Snellen chart or the Titmus Vision Tester measures static central vision acuity. The requirement for

central distant visual acuity is at least 20/40 in each eye and distant binocular visual acuity of at least

20/40. Test results must be recorded in Snellen-comparable values.

Eyeglasses or contact lenses may be worn to meet distant visual acuity requirements. When corrective

lenses

are worn to meet vision qualification requirements, corrective lenses must be worn while driving.

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The Snellen chart is widely used for measuring central visual

acuity.

• The Snellen wall chart should be 20 feet away from

the

driver.

o Measure distance.

o Mark t

esting location.

• The c

hart should be illuminated with white light.

• The driver may wear corrective lenses during the

exami

nation.

• When the driver is read

ing larger lines easily, the

medical examiner may ask the driver to skip

to smaller lines.

Figure 20 - Snellen Chart

Snellen chart is illustrative only and

not suitable for vision testing

Page 54 of 260

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The Snellen eye test results use 20 feet as the norm, represented by the numerator in the Snellen test

result. The number of the last line of type the driver read accurately is recorded as the denominator in the

Snellen test result.

The minimum qualification requirement is distant visual acuity of at least 20/40 in each eye and distant

Figure 22- Visual Acuity Test Results

binocular acuity of at least 20/40.

If a test other than the Snellen is used to test visual acuity, the

test results should be recorded in Snellen-equivalent values.

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There are versions of the Snellen chart that compensate for

failure to read letters because of limited English reading skill,

not because of poor eyesight. One example is the "Snellen Eye

Chart - Illiterate" that requires the individual to indicate the

orientation of the letter "E" on the chart.

8%93A/%9"$ @3,3'*

Figure 21 - Snellen Eye Chart –

Illiterate

The requirement for peripheral vision is at least 70° in the

horizontal meridian for each eye. In the clinical setting, some

Snellen chart is illustrative only and

form of confrontational testing is often used to evaluate

not suitable for vision testing

peripheral vision. When test results are inconclusive, the

evaluation should be performed by a specialist with equipment capable of precise measurements.

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The driver must have at least 70° in the horizontal meridian for each eye. Some form of confrontational

testing that tests vision of selected horizontal points is generally used in the clinical setting.

A "Protocol for S

creening the Visual Field Using a Confrontation Method" is found in Appendix E of the

Visual Requirements and Commercial Drivers report.

Page 55 of 260

<3:/+ %=% %?"43*"+3'*

1. Stand or sit approximately two feet in front of the driver so that your

eyes are at about the same level as the eyes of the driver.

2. Instruct the driver to use the palm of the left hand to cover the left

eye.

3. Ask the driver to fixate on your left eye.

4. Extend your arms forward and position your hands halfway between

you

rself and the driver. Position your right hand one foot to the right

of the straight-ahead axis and six inches above the horizontal plane.

Position your left hand one-and-a-half feet to the left of the straight-

ahead axis and six inches above the horizontal plane.

5. Ask the driver to c

onfirm when a moving finger is detected. Repeat the procedure with your hands

positioned six inches below the horizontal meridian.

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Repeat the procedure for the left eye (steps 2 through 5), making sure the driver fixates on your right eye

and the hand placement is appropriately reversed.

When test results are inconclusive, obtain specialist evaluation for precise measurement of peripheral

vis

ion.

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The color vision requirement is met by the ability to recognize and distinguish among red, amber, and

green, the standard colors of traffic control signals and devices. True color perception is not required.

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Eye trauma and ophthalmic disease can adversely impact visual performance and interfere with safe

driving. Some ophthalmic diseases are seen more frequently with increased age or are secondary to

other diseases such as diabetes mellitus or atherosclerosis.

The clinical setting may not provide the necessary equipment to evaluate ophthal

mic diseases

adequately. The medical examiner determines if the vision symptoms and signs or underlying disease

require evaluation by an ophthalmologist or optometrist. The medical examiner then considers the

documented results and the specialist opinion when determining if the vision meets qualification

requirements.

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The qualified driver meets all of the following requirements:

•

Distant acuity of at least 20/40 in each eye,

• Binocular acuity of at least 20/40,

• Horizontal field of vision of at least 70° measured in each eye, and

• The ability to recognize and distinguish among traffic control signals and devices showing standard

red, amber, and green colors.

The medical examiner may certify the driver for up to 2 years.

The driver who wears corrective lenses to meet the vision qualification requirements must wear corrective

len

ses while driving. The medical examiner marks the "wearing corrective lenses" checkbox on both the

Medical Examination Report form and the medical examiner's certificate. The examiner should advise the

Page 56 of 260

driver to carry a spare set of eyeglasses. The driver avoids both stress and delay when lost or damaged

eyeglasses or uncomfortable contact lenses can be replaced immediately.

?'%'B./0* A$($'%

Monocular vision occurs when the vision requirements are met in only one eye, with or without the aid of

corrective lenses, regardless of cause or degree of vision loss in the other eye. In low illumination or

glare, monocular vision causes deficiencies in contrast recognition and depth perception compared to

binocular vision. Monocular vision is disqualifying.

The medical examiner should complete the certification examination of the driver with monocular vision

and det

ermine if the driver is otherwise qualified. The driver with monocular vision who is otherwise

qualified may want to apply for a Federal vision exemption.

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At the annual recertification examination, the driver presents a valid vision exemption and a copy of the

specialist eye examination report before receiving the medical examiner's certificate. Certify the driver for

up to 1 year. Mark the "accompanied by" exemption checkbox and write "vision" to identify the type of

Federal exemption.

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The driver applying for a vision exemption should include a copy of the Medical Examination Report form

and the medical examiner's certificate with the application to the Federal Vision Exemption Program.

Certify the driver for up to 1 year. Mark the "accompanied by" exemption checkbox and write "vision" to

ide

ntify the type of Federal exemption. Provide the driver with a copy of the Medical Examination Report.

The medical examiner does not issue a Federal vision exemption. Both the medical examiner's certificate

and F

ederal vision exemption are required before the driver with monocular vision can legally drive a

commercial vehicle in interstate commerce.

See the Fe

deral Vision Exemption Program section of this handbook.

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Determine if the treatment is having the desired effect of preserving vision that meets qualification

requirements without any visual and/or systemic side effects that interfere with safe driving (e.g., stinging,

blurring, decreased night vision, sensitivity to glare, headache, or allergic reaction).

Categories include:

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Classifications of agents used to treat age-related macular degeneration include:

• Antioxidants and zinc.

• Vascular endothelial growth factor (VEGF) inhibitors.

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Classifications of anti-allergy agents used to treat allergic conjunctivitis include:

• Oral and topical antihistamines.

• Topical decongestants.

• Antihistamine/decongestant combinations.

Page 57 of 260

• Mast cell stabilizers.

• Topical nonsteroidal anti-in

flammatory.

-*+3:$".6'4" -:%*+,

Classifications of agents used to treat glaucoma include:

• Prostaglandin anal

ogs.

• Beta adrenergic blocking agents.

• Carbonic anhydrase inhibitors.

• Alpha agonists.

• Cholinergic agonists.

• Osmotic agents.

• Combinations.

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Classifications of anti-infective agents used to treat bacterial conjunctivitis include oral and topical

antibiotics.

I9= >=%,

Classifications of agents used to treat dry eyes include:

• Lubricants.

• Nonsteroidal anti-in

flammatory.

• Topical cyclosporine.

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)"+"9"6+,

Cataracts are a common cause of visual disturbances in the adult population. The slow, progressive

opacification of the crystalline lens of the eye distorts the optical passage of light to the retina resulting in

diminished visual acuity. Cataract formation can be accelerated by a number of conditions, including

injury, exposure to radiation, gout, certain medications (steroids), and the presence of diabetes mellitus.

Glare, particularly during night driving in the face of oncoming headlights, may be an early symptom of

ca

taracts. Glare, diminished overall acuity, contrast, and color resolution are compounded by the light-

scattering effect of the cataracts.

Treatment for cataracts is surgical removal and placement of an intraocular lens.

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Glaucoma can cause deficits in peripheral vision. The abnormal regulation of intraocular pressure can

result in gradual progressive atrophy of optic nerve cells. The development of chronic elevated intraocular

pressure is generally painless, and the gradual loss of peripheral visual field can progress significantly

before symptoms are noticed.

Glaucoma may also affect a number of subtler visual functions, such as redirection of visual attention,

ni

ght vision, and color vision. With glaucomatous damage, Snellen acuity test results may not be affected,

but peripheral field test results may show deficits. Specialist examination may result in early detection and

treatment before the occurrence of possibly disqualifying vision loss.

Page 58

of 260

Vision loss caused by glaucoma cannot be restored.

A therapeutic goal is to

lower intraocular pressure to a level that preserves the existing neuronal cells and

prevents further loss of the peripheral visual field deficit. Strict and ongoing compliance with prescribed

ophthalmic preparations is required for successful treatment; however, antiglaucoma agents may have

side effects that impact vision and interfere with safe driving.

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Macular degeneration is a leading cause of untreatable legal blindness in the United States. Macular

degeneration describes many ophthalmic diseases that impact the macula function and interfere with

detailed, central vision. These diseases increase in prevalence with age, affecting some 30% of all

Americans by age 70. For the majority of cases, macular degeneration is a slow process resulting in

subtle visual defects; however, approximately 10% of cases are a "malignant" form of the disease and

cause rapid loss of central vision.

Peripheral vision is generally spared in macular degeneration. Therapeutic options are limited.

Macular degener

ation causes noticeable signs and symptoms. Visual acuity drops, recovery from bright

lights is lengthened, and eventually a partial or total scotoma develops in the direction of attempted gaze.

Snellen-type acuity testing will detect diminishing central acuity.

Telescopic lenses redirect unaffected peripheral vision to compensate for lost central acuity, resulting in a

re

duced peripheral field of vision. The use of telescopic lenses is not acceptable for commercial driving.

<%+3*'A"+/=

Noninflammatory damage to the retina of the eye has many causes. The most common cause of

retinopathy is diabetes mellitus. Background retinopathy with microaneurysms and intraretinal

hemorrhages is common after 5-7 years with diabetes mellitus. In many cases, the retinopathy does not

progress beyond this stage; however, fluid leakage near the macula (diabetic macular edema) can create

partial scotomas in central vision or cause gross hemorrhage in the eye which can obscure vision and

eventually lead to retinal detachment and blindness. Subtler visual modalities such as contrast sensitivity,

flicker fusion frequency, and color discrimination may also be affected.

Strict control of blood glucose, as well as medical control of comorbid diseases (e.g., hypertension, renal

dise

ase, cardiac disease), may prevent or delay development of retinopathy.

Medical guidelines for the driver with diabetes mellitus include:

• Annual medical examination.

• Annual ophthalmologist or optometrist eye evaluation.

• Disqualification for a diagnosis of

unstable proliferative retinopathy.

Other diseases can cause retinopathy. Carcinoma-as

sociated retinopathy is characterized by rapid onset

of blindness caused by retinal degeneration, usually of photoreceptors. Proliferative retinopathy can be a

complication of sickle cell disease and sickle cell-thalassemia disease. A rare but characteristic finding of

systemic lupus erythematosus is retinal exudates, usually near the disk.

W%"93*:

Hearing plays a role in safe driving. Hearing warning sounds, such as horns, train signals, and sirens may

allow the driver to react to a potential hazard before it is visible. An auditory alarm or changes in the usual

sound of the engine or vehicle carriage may be the first indication that the vehicle may require

maintenance.

Page 59

of 260

Hearing loss can interfere with communication between the driver and other people such as dispatchers,

loading dock personnel, passengers, and law enforcement officers.

Balance is required for safe driving and task performance (e.g., vehicle inspections, secu

ring loads) and

when getting into, and out of, trucks and buses.

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"A person is physically qualified to drive a commercial motor vehicle if that person —

First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of

a hear

ing aid or, if tested by use of an audiometric device, does not have an average hearing loss in the

better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when

the audiometric device is calibrated to American National Standard (formerly ASA Standard) Z24.5–

1951."

The required tests screen for hearing loss in the range of normal conversational tones. Two tests are

used

to screen hearing: a forced whisper test AND/OR an audiometric test.

• Either test may be administered first.

• Test both ears.

• Administration of the second test may be omitted when the test results of the initial test meet the

heari

ng requirement for that test.

Hearing requirements are:

• First perceive a forced whispered voice, in one ear, at not less than five feet.

•

OR

• Have an average hearing loss, in one ear, less than or equal to 40 decibels (dB).

• When a hearing aid is used to meet the hearing qualification requirement, the hearing aid must

b

e

used while driving.

• Disqualify when both the forced whisper test AND the audiometric test are failed.

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Here are the hearing questions that are asked in the health history. Yes responses require clarification

and documentation.

• Ear disorders?

• Loss of hearing?

•

Los

s of balance?

Here are important questions to ask.

•

Symptoms related to or caused by ear disease?

• Use of otic preparations?

Pa

ge 60 of 260

X;M($B0/ NO0+$%0&$'%

Examine the ears for:

• Scarring of the tympanic membranes.

• Occlusion of the external ear canal.

• Perforated eardrums.

Note and discuss abnormal findings, including the impact on driving and certification. Hearing loss can be

a s

ymptom of a disease rather than a discrete disorder. In some cases, hearing loss may be treated and

reversed.

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The forced whisper test and audiometry are used to determine certification. These tests measure hearing

loss using the frequencies found in normal conversation. Either test can be administered first.

Administration of both tests is required only when the initial test results for both ears fail to meet the

hearing requirement.

A hearing aid may be used during forced whisper testing. When a driver who wears

a hearing aid is

unable to pass a forced whisper test, referral to an audiologist, otolaryngologist, or hearing aid center is

required.

0'96%7 V/3,A%9 +%,+

• First perceives a forced whispered voice.

• In one ear.

• At not less than five feet.

A hearing aid may be worn while testing. When a hearing aid is used to qualify, the hearing aid must be

wor

n while driving.

The testing area should be free from noise that could interfere with a valid test. Measure and mark the

fiv

e-foot passing distance.

,$-;& N0* NO0+$%0&$'%\

1. Have the driver cover the left ear.

2. Stand to the side or behind the driver to eliminate visual cues.

3.

From the measured five-foo

t distance from the right ear, exhale fully and then whisper a sequence of

words, numbers, or letters. (Avoid using only s-sounding words.)

4. Ask the driver to repeat the w

hispered sequence.

5. To pass, the driver must respond correctly.

Z"#& N0* NO0+$%0&$'%\

Repeat the procedure for the left ear, making sure that the right ear is covered and that you are

positioned the measured five-foot distance from the left ear.

Complete the forced whisper test for both ears, whether or not the initial test result meets the hearing

re

quirement.

Page 61 of 260

-.73'4%+936 !%,+

The hearing qualification requirement for the Audiometric test:

• Has an average hearing loss (average of test results for 500 hertz (Hz), 1,000 Hz, and 2,000 Hz).

• In one ear.

• Less than or equal to 40 dB.

The hearing requirement for an audiometric test is based on hearing loss only at the 500 Hz, 1,000 Hz,

and

2,

000 Hz frequencies that are typical of normal conversation.

The test results are for an audiometer calibrated to the American National Standards Institute (ANSI)

Z24

.5-1951 standard. When an audiometer that is calibrated to a different standard is used, the test

results must be converted to the ANSI standard. To convert International Organization for Standardization

(ISO) test results to the ANSI standard, subtract from the ISO test results: 14 dB for 500 Hz, 10 dB for

1,000 Hz, and 8.5 dB for 2,000 Hz.

The area sel

ected for testing should be free from noise that could interfere with a valid test.

1. Record hearing test results for each ear at 500 Hz, 1,000 Hz, and 2,000 Hz (ANSI standard).

2. Average the readings for each ear by adding the test results and dividing by 3.

3. To pass, one ear must show an average hearing loss that is less than or equal to 40 dB.

L"0*$%- 0$>

When a hearing aid is to be worn during audiometric testing, an audiologist or

hearing aid center should perform the test using appropriate audiometric

equipment.

C>>$&$'%0/ NA0/.0&$'% 0%>Y'* C%B$//0*M)<"(&(

Ear trauma and otic disease can adversely impact hearing and/or balance and interfere with safe driving

and performance of related tasks. When findings are inconclusive regarding medical fitness for duty,

ancillary tests and/or additional evaluation by a specialist, usually an audiologist or otolaryngologist, may

be required to obtain sufficient medical information to determine certification status.

)%9+3(36"+3'* "*7&I'6.4%*+"+3'*

The qualified driver, with or without the use of a hearing aid:

• First perceives a forced whispered voice, in one ear, at not less than five feet.

OR

•

Has an average hearing loss, in one ear, less than or equal to 40 dB

at 500 Hz, 1,000 Hz, and

2,000 Hz.

The medical examiner may certify the driver for up to 2 years.

The driver who uses a hearing aid to qualify must wear a hearing aid while driving. The medical examiner

mar

ks the "wearing hearing aid" checkbox on both the Medical Examination Report form and the medical

examiner's certificate. The examiner should advise the driver to carry a spare power source for the

hearing aid.

Page 62 of 260

-7@3,'9= )93+%93"FG.37"*6%

F&$B X*"P0*0&$'%(

Determine if the treatment is having the desired effect of preserving hearing, reducing inflammatory

disorders causing pain, and/or controlling dizziness causing loss of balance. Determine if the treatment

has any effects and/or side effects that interfere with safe driving (e.g., drug, food, and/or alcohol

interactions, excessive drowsiness, or allergic reaction).

Categories include:

-*+3U"6.+% L%*3:* 8',3+3'*"$ J%9+3:'

Classifications of agents used to treat acute vertigo include:

• Antihistaminic antiemetics.

• Benzodiazepines

.

• Anticholinergics.

• Sympathomimetics.

-*+3U3*(%6+3@%F-* +3U 3* ($"44"+ '9 = - :%* +,

Infection and inflammation can be of the external auditory canal (EAC) and/or the middle ear.

Classifications of topical drops used to treat EAC include:

• Antibiotics.

• Stero

ids.

•

Antibiotic-ste

roid combinations.

Classification of oral drugs used to treat infections and inflammation of the middle ear (otitis media)

inc

lude:

• Antibiotics.

• Steroids.

F&$B !$("0(" 0%> 3'%>$&$'%(

1%*3%9%T, I3,%",%

The Conference on Neurological Disorders and Commercial Drivers report recommends disqualification

when there is a diagnosis of Meniere's disease.

J%9+3:'

Vertigo is generally caused by an inner ear abnormality. Uncontrolled vertigo is disqualifying.

The Conference on Neurological Disorders and Commercial Drivers re

port recommends that the driver

may be certified after completing at least 2 months symptom free with a diagnosis of:

• Benign positional vertigo.

•

Acute and chronic peripheral vestibulopathy.

Page 63 of 260

D"#=93*+/3*%&03,+.$"

The Conference on Neurological Disorders and Commercial Drivers report recommends disqualification

when there is a diagnosis of labyrinthine fistula.

;'*(.*6+3'*3*: D"# =93*+/

The Conference on Neurological Disorders and Commercial Drivers report recommends disqualification

when there is a diagnosis of nonfunctioning labyrinth.

To review the Conference of Neurological Disorders and Commercial Drivers report, visit:

http://www.fmcsa.dot.gov/facts-res

earch/research-technology/publications/medreports.htm.

W=A%9+%*,3'*

Americans With Hypertension

According to the Third Nati

onal Health and Nutrition Examination Survey, 29% of all U.S. adults 18 years

and older have BP greater than or equal to 140/90 or are taking medication for hypertension. The

prevalence of hypertension is nearly equal for men and women. Among adults with hypertension, 78%

are aware of their condition, 68% are treated with antihypertensive medication, and 64% achieve BP less

than 140/90 with treatment.

Risks Associated With Hypertension

Hypertension alone is unlikely to cause sudden collapse; however, hypert

ension is a potent risk factor for

the development of more serious cardiovascular disease (CVD), peripheral vascular disease, and chronic

renal insufficiency. BP greater than or equal to 140/90 is deemed high for most individuals without other

significant cardiovascular risk factors.

In individuals ranging from 40 to 89 years of age, for every 20 mm Hg systolic or 10 mm Hg diastolic

inc

rease in BP, there is a doubling of mortality from both ischemic heart disease and stroke. The

relationship between BP and risk of a CVD event is continuous, consistent, and independent of other risk

factors. Both elevated systolic and diastolic BP are risk factors for coronary heart disease (CHD).

Commercial Drivers at Greater Risk for Developing Hypertension

Once in the prof

ession, commercial motor vehicle (CMV) drivers have a greater propensity to develop

hypertension than their peers in other professions. The Cardiovascular Advisory Panel Guidelines for the

Medical Examination of Commercial Motor Vehicle Drivers includes data from Ragland, et al.,

demonstrating that the percentage of drivers with hypertension increased from 29% in drivers with fewer

than 10 years of driving experience, to 32% in drivers with 10-20 years of experience, and to 39% in

drivers with more than 20 years of driving experience. As the years of experience rise, part of the

increase in hypertension may relate to accompanying aging, increase in body mass, or decline in physical

activity.

Effective Treatment Reduces Risk

High BP can be a modifiable CVD r

isk factor. Lifestyle modification and pharmacotherapy are the

mainstays of antihypertensive treatment regimens. Effective hypertension management reduces

cardiovascular morbidity and mortality. The Chicago Heart Association Detection Project in Industry found

that antihypertensive therapy reduces the incidence of stroke, myocardial infarction, and heart failure.

Contemporary medical therapies are effective in lowering BP, reducing complications, and are generally

reg

arded as safe.

Page 64 of 260

L$''7&89%,,.9% ^L8_ <%:.$"+3'*,&O )0 QPRSOR^#_^c_ "* O )0 QPRSOQ^(_

12 34, 52S71SRQTRaT

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability

to operate a

commercial motor vehicle safely."

12 34, 52S715R#T W/''> X*"((.*" RWXT

"If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified

more frequently. An individual diagnosed with Stage 1 hypertension (BP is 140/90–159/99) may be

certified for one year. At recertification, an individual with a BP equal to or less than 140/90 may be

certified for one year; however, if his or her BP is greater than 140/90 but less than 160/100, a one-time

certificate for 3 months can be issued. An individual diagnosed with Stage 2 (BP is 160/100-179/109)

should be treated and a one-time certificate for 3-month certification can be issued. Once the driver has

reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter. An

individual diagnosed with Stage 3 hypertension (BP equal to or greater than 180/110) should not be

certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months."

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a CMV

safely. This examination is for public safety determination and is considered by the Federal Motor Carrier

Safety Administration (FMCSA) to be a “fitness for duty" examination.

As the medical examiner, your fundamental obligation is to establish whether a driver has high BP that is

lik

ely to interfere with the ability to operate a CMV safely, thus endangering public safety.

The examination is based on information provided by the driver

(history), objective data (measuring BP

and physical examination), and additional testing requested by the medical examiner. Your assessment

should reflect physical, psychological, and environmental factors.

Medical certification depends on a comprehensiv

e medical assessment of overall health and informed

medical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* L$-; WXYLMP"*&"%($'% ?">$B0/ NO0+$%0&$'%

During the physical examination, you should ask the same questions that you would for any individual

who is being assessed for high BP and/or with a current clinical diagnosis of hypertension.

A current diagnosis of hypertension exists when one or more antihypertensive agents are used to control

high

BP. When antihypertensive medication is used to treat an underlying condition other than high BP,

certification is based on the underlying condition and tolerance to the medication.

The FMCSA Medical Examination Report form includes questions about the health history o

f the driver

and requires measuring BP. Additional questions should be asked to supplement the information

requested on the Medical Examination Report form. You may ask about symptoms of hypertension and

use of antihypertensive medications. It is generally not the role of the medical examiner to determine

treatment for the disease.

Page 65 of 260

You should evaluate for other clinical cardiovascular diseases, including CHD, heart failure, and left

ventricular hypertrophy, as well as stroke or transient ischemic attack, peripheral artery disease,

retinopathy, nephropathy, and other target organ damage.

<%:.$"+3'*, C X'. 4.,+ 9%@3%V "*7 73,6.,, V3+/ +/% 793@%9 "*= Y=%,Y "*,V%9,

Does the driver:

• Have high BP?

• Take medication?

<%6'44%*7"+3'*, C Z.%,+3'*, +/"+ ='. 4"= ",K 3*6$.7%

Does the driver have:

• Contact information for the treating provider and a medical release form?

• Symptoms related to or caused by high BP?

• Limitations resulting from the disease or treatment?

• Lifestyle risk factors, particularly modifiable behaviors and conditions (e.g., smoking, obesity,

and/

or

lack of exercise)?

• Uncontrolled hypertension while using three or more antihypertensive medications at close to

maximum dosages? If the response is “yes,” an evaluation for secondary hypertension may be

appropriate.

<%:.$"+3'*, C X'. 4.,+ %@"$."+%

For every certification and recertification examination you must:

• Measure BP.

• Confirm BP greater than 139/89 with a second measurement taken later during the exam

ination.

• Check pulse rate, strength, and rhythm.

NOTE: Un

der the supervision of the medical examiner, trained assistive personnel may measure and

re

cord the BP; however, it is prudent for the medical examiner to confirm disqualifying BP personally.

?"0(.*" W/''> X*"((.*" 0%> 3;"BG X./("

1%",.9% L$''7 89%,,.9%

Because of the prevalence of hypertension in the commercial driving population, this routine test is an

essential tool as part of the physical examination to determine the medical fitness for duty of the driver.

Blood pressure (BP) should be measured in a standardized fashion using equipment that meets

certification criteria.

BP levels aid in evaluating the risk of an acute hypertensive event while driving and assist you as you

mak

e certification decisions that allow a driver who does not present an immediate safety risk to continue

working while obtaining primary care provider evaluation and implementing a primary care provider

treatment plan.

REMEMBER: You ar

e the medical examiner and not the treating provider. The purpose of the

examination is medical fitness for duty, not diagnosis and treatment of the underlying disease.

NOTE: Under the supervision of the medical examiner, trained assistive personnel may measure and

re

cord BP; however, it is prudent for the medical examiner to confirm disqualifying BP personally.

Page 66 of 260

)/%6K&8.$,%

Check the pulse and note rate, strength, and rhythm.

3'%#$*+ N/"A0&">)WX

Confirm BP higher than or equal to 140/90 with a second measurement taken later during the

examination. BP, especially systolic pressure, will fluctuate in a short time from normal to elevated and

back to normal as a response to many factors, including:

• Circadian cycle.

• Emotional and physical states.

• Transient hypertension (e.g., "white coat syndrome").

• Use of left versus right arm during BP measurement.

• Problems with technique, such as:

o Placing the BP cuff over clothing instead of on the skin.

o Usi

ng an inappropriately-size

d BP cuff.

o Positioning the arm incorrectly.

<%:.$"+3'*, C X'. 4.,+ 7'6.4%*+ 73,6.,,3'* V3+/ +/% 793@%9 "#'.+

• Any affirmative history, including if available:

o Onset date and diagnosis.

o Med

ication(s), dose, and frequency

.

o Any current limitation(s).

• Po

tential negative effects of medication used while driving, including over-the-cou

nter

medications.

• Any abnormal finding(s), noting:

o Ef

fect on driver ability to operate a CMV safely.

o Nec

essary steps to correct the con

dition as soon as possible, particularly if the untreated

condition could result in more serious illness that might affect driving.

• Any additional tests and evaluation.

REMEMBER: Me

di

cal fitness for duty includes the ability to perform strenuous labor. Overall

requirements for commercial drivers as well as the specific requirements in the job description of the

driver should be deciding factors in the certification process.

-7@3,'9= )93+%93"FG.37"*6%

N(("%&$0/ LMP"*&"%($'%

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure established three stages of hypertension that define the severity of hypertension

and guide therapy. To review the report, visit:

http://www.ncbi.nlm.nih.gov/books/NBK8632/.

49 CFR 391.43(f) Blood Pressure (BP) was amended to include the use of BP readings equivalent to the

st

ag

es of hypertension to determine driver certification status. The complete text of the amendment may

be accessed at http://www.fmcsa.dot.gov/rules-regu

lations/administration/rulemakings/03-

24736miscellaneous-amendment

s09-30-03.pdf.

Page 67 of 260

When you determine certification for the driver with high BP in the ranges of stage 1 or stage 2

hypertension (BP greater than 140/90 but less than 180/100), consider these additional factors:

• Type of examination (certification or recertification).

• Current certification interval (1-2

years or 3 months).

• Treatment (lifestyle changes, use of medication).

• Severity of hypertension prior to treatment (particularly if history of stage 3 hypertension).

The purpose of the one-ti

me, 3-month certificate is to allow the driver with high BP that is an absolute

indication for antihypertensive drug therapy to continue to drive while taking steps to lower the elevated

BP. It is not intended as a means to indefinitely extend driving privileges for a driver with a condition that

is associated with long-term risks.

For the driver with high BP or hypertension to maintain continuous certification, the driver must

dem

onstrate at examination BP at or less than 140/90.

NOTE: "O

ne-time" means you cannot issue consecutive 3-month certificates for BP greater than 140/90.

It does not mean once in a lifetime.

2+":%&R W=A%9+%*,3'*

Stage 1 hypertension is usually asymptomatic, and blood pressure (BP) in this range is considered a low

risk for hypertension-related acute incapacitation. However, all hypertensive drivers should be strongly

encouraged to pursue consultation with a primary care provider to ensure appropriate therapy and

healthcare education.

BP measurement greater than or

equal to 140/90 and less than 160/100.

E"3+3*: A%93'7

No recommended time frame

NOTE: Th

e driver who is disqualified for the presence of high BP/uncontrolled hypertension should not be

considered for recertification until the BP is stabilized at less than or equal to 140/90. Treatment should

be well tolerated before considering certifying a driver with a history of stage 3 hypertension.

I%63,3'*

Maximum certification period — 1 year OR one time for 3 months

Recommend to certify for 1 year if:

It is the first examination at which the driver has BP equivalent to stage 1 hypertension and the

driver:

• Has no history of hypertension.

• Does not use antihypertensive medication to control BP.

Recommend to certify one time for 3 months if:

The driver has:

• A 1-ye

ar certificate for untreated stage 1 hypertension.

• Not been prescribed antihypertensive medi

cation to control high BP.

Page 68

of 260

This applies to the recertification of the driver who has met the first examination 1-year certification

parameters. Advise the driver that failure to lower BP to less than or equal to 140/90 will render the driver

medically unqualified for continued certification.

The driver:

• Has a diagnosis of hypertension treated with medication.

• Tolerates treatment with no side effects that interfere with driving.

This applies to the driver with inadequately controlled BP. Advise the driver tha

t failure to lower BP to less

than or equal to 140/90 will render the driver medically unqualified for continued certification.

Recommend not to certify if:

The driver has:

• A one-time, 3-month certificate for elevated BP or hypertension and BP greater than 140/90.

• A history of stage 3 hypertension and BP greater than 140/90.

• BP greater than or equal to 180/110, regardless of any other considerations.

NOTE: "One-ti

me" means you cannot issue consecutive 3-month certificates for BP greater than 140/90.

It does not mean once in a lifetime.

1'*3+'93*:F!%,+3*:

The driver who is disqualified for stage 1 hypertension may be recertified for 1 year if BP is lowered to

less than 140/90.

The driver who is disqualified for stage 3 hypertension may be recertified for 6 months if BP is lowered to

les

s than 140/90 and medications are well tolerated.

0'$$'VU.A

The driver with elevated BP or hypertension should have at least an annual medical examination.

When certified for 3 months, the driver is to seek initiation or evaluation of drug therapy to lower BP to

les

s than or equal to 140/90 to be recertified at follow-up examination.

To review the Hyp

ertension Recommendation Table, see Appendix D of this handbook.

REMEMBER: Whe

n determining certification for the driver with high BP or hypertension, take into

consideration current driver certification status, use of antihypertensive medication, and severity of

hypertension prior to treatment.

2+":%&` W=A%9+%*,3'*

Stage 2 hypertension is considered an absolute indication for antihypertensive drug therapy, and the

driver should seek initiation or evaluation of therapy to lower blood pressure (BP). Effective BP

management includes routine primary provider follow-up and periodic screens for the presence of target

organ damage and clinical manifestations of cardiovascular disease.

BP measurement greater than or equal to 160/100 and less than 180/110.

Page 69 of 260

E"3+3*: A%93'7

No recommended time frame

NOTE: The driver who is disqualified for hig

h BP/uncontrolled hypertension should not be considered for

recertification until the BP is stabilized at less than or equal to 140/90. Treatment should be well tolerated

before considering certifying a driver with a history of stage 3 hypertension.

I%63,3'*

Maximum certification period — One time for 3 months

Recommend to certify if:

It is the first examination at which the driver has BP equivalent to stage 2 hypertension and the driver:

• Has no history of hypertension.

•

Do

es not use antihypertensive me

d

ication to control BP.

The driver:

•

Has a diagnosis of hypertension treated with medication.

•

To

lerates treatment with no side effects that interfere with driving.

NOTE: Advise the driver issued a one-ti

me, 3-month certificate that:

• To qualify at follow-up,

BP should be at or less than 140/90.

• If the driver at follow-up qual

ifies, a 1-year certificate will be issued from the date of the initial

examination, not the expiration date of the one-time, 3-month certificate.

• If the driver fails to lower BP by the expiration date of the one-time, 3-month certificate, the driver

will be disqualified until BP is at or less than 140/90 at examination.

Recommend not to certify if:

The driver has:

• A one-ti

me, 3-mo

nth certificate for stage 2 hypertension and BP greater hypertension and BP

greater than 140/90.

• A history of stage 3 hypertension and BP greater than 140/90.

• BP greater than or equal to 180/110, regardless of any other considerations.

1'*3+'93*:F!%,+3*:

Provided treatment is well tolerated and the driver demonstrates BP of 140/90 or less, the driver may be

certified for 1 year from the date of the initial examination.

0'$$'VU.A

The driver must follow-up on or before the one-time, 3-month certificate expiration date. If the driver has

BP less than or equal to 140/90, the driver may be certified for 1 year.

NOTE: The elapsed time of the one-ti

me, 3-month certificate is included in the annual certification

interval; it is not an extension to the certification period. This means that you use the date on the one-

Page 70 of 260

time, 3-month certificate to calculate the medical certificate expiration date. Do not use the date of the

follow-up examination at which the driver demonstrates adequate BP.

NOTE: "O

ne-time" means you cannot issue consecutive 3-month certificates for BP greater than 140/90.

It does not mean once in a lifetime.

REMEMBER: Wh

en determining certification for the driver with high BP or hypertension, take into

consideration current driver certification status, use of antihypertensive medication, and severity of

hypertension prior to treatment.

2+":%&Q W=A%9+%*,3'*

Stage 3 hypertension carries a high risk for the development of acute hypertension-related symptoms that

could impair judgment and driving ability. Acute manifestations of elevated blood pressure (BP) can

include sudden stroke, acute pulmonary edema, subarachnoid hemorrhage, aortic dissection, or aortic

aneurysm rupture.

Meningismus, acute neurological deficits, abrupt onset of shortness of breath, or severe, ripping back or

ch

est pain could signal an impending hypertensive catastrophe that requires immediate cessation of

driving and emergency medical care. Symptoms of hypertensive urgency such as headache and nausea

are likely to be more subtle, subacute in onset, and more amenable to treatment than a hypertensive

emergency.

BP measurement greater than or equal to 180/110.

E"3+3*: A%93'7

Not applicable.

I%63,3'*

Maximum certification period — 6 months with history of stage 3 hypertension

Recommend to certify if:

Not applicable.

Recommend not to certify

if:

The driver has BP equal to stage 3 hypertension, regardless of history or treatment.

NOTE: Th

e driver is at risk for an acute hypertensive event and should be advised to seek, or should be

provided immediate medical attention and must be medically disqualified.

1'*3+'93*:F!%,+3*:

Before the driver who is disqualified for stage 3 hypertension can be considered for recertification

(maximum 6 months), the driver must, at examination have:

• BP at or less than 140/90.

• Treatment that is well tolerated.

At future semi-annual

examinations, if BP is equivalent to stage 1 or stage 2 hypertension, on a case-by-

case basis, you should determine the appropriate use of the one-ti

me, 3-month certificate in accordance

with stage 1 or stage 2 hypertension guidelines.

Page 71

of 260

If you believe BP greater than 140/90 at rest indicates an unacceptable risk for development of stage 3

hypertension and the onset of acute hypertension-related symptoms, you may temporarily disqualify the

driver until BP is at or less than 140/90 and treatment is well tolerated. For example, when maximum

doses of multiple antihypertensive medications are used without achieving BP at or less than 140/90, it is

prudent that a more aggressive treatment plan should be monitored for effectiveness, interactions, and

tolerance prior to driver certification.

0'$$'VU.A

The driver should have a medical examination at least every 6 months.

REMEMBER: Whe

n determining certification for the driver with high BP or hypertension, take into

consideration current driver certification status, use of antihypertensive medication, and severity of

hypertension prior to treatment.

D"B'%>0*M)LMP"*&"%($'%

The prevalence of secondary hypertension in the general population is estimated at between 5% and

20%. You should obtain information that assesses the underlying cause, the effectiveness of treatment,

and any side effects that may interfere with driving.

Examples of primary conditions that may lead to secondary hypertension include pheochromocytoma,

pri

mary aldosteronism, renovascular disease, and unilateral renal parenchymal disease. Some of these

conditions may be amenable to surgical intervention.

E"3+3*: A%93'7

Minimum — 3 months post-surgical correction

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year post-surgical correction

NOTE: Determine nonsurgically repaired secondary hypertension using the essential hypertension

guidelines.

Recommend to certify if:

The driver has blood pressure that is less than or equal to 140/90.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical conditio

n of the driver

endangers the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

Page 72 of 260

)"973'@",6.$"9

The fundamental question when deciding if a commercial driver should be medically certified is whether

the driver has a CVD that increases the risk of sudden death or incapacitation and creates a danger to

the safety and health of the driver, as well as the public sharing the road.

A number of concerns beyond the typical cardiac risk factors predispose commercial drivers to an

inc

reased risk of CVD:

• According to the Commercial Driver’s License Information S

ystem, in 2009 the average age of a

driver is 39 years.

• Obesity and a sedentary lifestyle increase the risk of CVD. Both are more common in the

com

mercial driving population than in the general population.

• Driving stressors, such as traffic congestion, err

atic shift work, a sense of responsibility for others,

and emotional distress due to belligerent passengers, can lead to increased neurosympathetic

and adrenocortical catecholamine and cortisol release. This increases the likelihood of changes

in arterial tone, myocardial excitability and contractility, and thrombogenic propensity, particularly

given the aging workforce in the United States.

• Drivers are exposed to other environmental stressors that may be detrimental to the

car

diovascular system, such as excessive noise, temperature extremes, air pollution, and whole

body vibration.

The effect of CVD on the commercial driver is significant now and will increase in the future.

The major clinical manifestations of CVD are acute myocardial infarction, angina pec

toris, sudden death,

and congestive heart failure. Arrhythmia is the most likely cause of sudden driver incapacitation.

However, coronary heart disease (CHD) is the most common etiology. Estimated frequencies of initial

presentation of CHD are approximately 50% acute myocardial infarction, 30% angina, and 20% sudden

death. Sudden cardiac dysfunction is particularly relevant to safety-sensitive positions, such as pilots,

merchant marines, and commercial drivers. In these jobs, policies are expected to protect against gradual

or sudden incapacitation on the job and harm to the public.

The effect of heart disease on driving must be viewed in relation to the general health of the driver. Other

med

ical conditions may exacerbate a cardiovascular condition. Thus, medical certification to drive

depends on a comprehensive medical assessment of overall health and informed medical judgment

about the impact of single or multiple conditions on the whole person.

Disqualification requires that the CMV driver exhibit a higher

than acceptable likelihood of acute

incapacitation from a cardiac event, resulting in an increased risk to the safety and health of the driver

and the public.

)"973'@",6.$"9&<%:.$"+3'* O )0 QPRSOR^#_^O_

"A person is physically qualified to drive a commercial motor vehicle (CMV) if that person —

Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency,

thr

ombosis, or any other cardiovascular disease (CVD) of a variety known to be accompanied by

syncope, dyspnea, collapse, or congestive cardiac failure."

Page 73 of 260

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect driver ability to operate a CMV safely. This

examination is for public safety determination and is considered by the Federal Motor Carrier Safety

Administration (FMCSA) to be a “medical fitness for duty" examination.

As the medical examiner, your fundamental obligation during the cardiovascular assessment is to

est

ablish whether a driver has a cardiovascular disease or disorder that increases the risk for sudden

death or incapacitation, thus endangering driver and public safety and health.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* 30*>$'A0(B./0* NO0+$%0&$'%

During the physical examination, you should ask the same questions you would of any individual who is

being assessed for cardiovascular concerns. The FMCSA Medical Examination Report form includes

health history questions and physical examination checklists. Additional questions should be asked to

supplement information requested on the form. You should ask about and document cardiovascular

symptoms.

<%:.$"+3'*, C X'. 4.,+ 9%@3%V "*7 73,6.,, V3+/ +/% 793@%9 "*= YX%,Y "*,V%9,

Does the driver have:

• A current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, or

thr

ombosis?

• Syncope, dyspnea, or collapse?

• Heart failure?

• A history of heart disease or acute myocardial infarction?

• A history of other heart condition

s?

• A history of heart surgery (valve replacement/bypass, angioplasty, implantable cardiac

defi

brillator, pacemaker)?

• Use cardiovascular medications that effectively control a condition without side effects that

int

erfere with safe driving?

<%6'44%*7"+3'*, C Z.%,+3'*, +/"+ ='. 4"= ",K 3*6$.7%[

Does the driver have:

• Chest pain?

• Chest pressure or ache with exertion?

• Pain, pressure, or dyspnea at rest or with exertion?

• Recurrent and/or severe palpitations?

Page 74 of 260

• Pre-syncope (dizziness, light-headedness) or true syncope (loss of consciousness)?

• Medical therapy that requires monitoring?

,"B'*>

<%:.$"+3'*, C X'. 4.,+ %@"$."+%[

On examination, does the driver have:

• Murmurs, extra heart sounds, or arrhythmias?

• An enlarged heart?

• Abnormal pulse and amplitude, carotid or art

erial bruits, or varicose veins?

,"+"+Q"*

<%:.$"+3'*, C X'. 4.,+ 7'6.4%*+ 73,6.,,3'* V3+/ +/% 793@%9 "#'.+[

• Any affirmative history, including if available:

o Onset date, diagnosis.

o Med

ication(s), dose, and frequency.

o Any

current limitation(s).

• Po

tential negative effects of medication use, including over-the-co

unter medications, while

driving.

• Any abnormal finding(s), noting:

o Ef

fect on driver ability to operate a CMV safely.

o Nec

essary steps to correct the condition as soon as possible, particularly if the

untreated

condition could result in more serious illness that might affect driving.

• Any additional cardiovascular tests and evaluation.

REMEMBER: Me

di

cal fitness for duty includes the ability to perform strenuous labor. Overall

requirements for commercial drivers, as well as the specific requirements in the job description of the

driver, should be deciding factors in the certification process.

-7@3,'9= )93+%93"FG.37"*6%

C%&$B'0-./0%& <;"*0PM

The most current guidelines for the use of warfarin (Coumadin) for cardiovascular diseases are found in

the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle

Drivers.

To review the Veno

us Disease Recommendation Tables, see Appendix D of this handbook.

Anticoagulant therapy may be utilized in the treatment of cardiovascular or neurological conditions. The

guideli

nes emphasize that the certification decision should be based on the underlying medical disease or

disorder requiring medication, not the medication itself.

E"3+3*: A%93'7

Minimum — 1 month stabilized

Page 75 of 260

NOTE: If more than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is stabilized on medication for at least 1 month.

• Provides a copy of the international normalized ratio (INR) results at the examination.

• Has at least monthly INR monitoring.

Recommend not to certify if:

• INR is not being monitored.

• INR is not therapeutic.

• Underlying disease is disqualifying.

1'*3+'93*:F!%,+3*:

The driver should obtain INR monitoring at least monthly.

0'$$'VU.A

The driver should bring results of INR monitoring to the examination.

E"3+3*: A%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a cerebrovascular disorder.

NOTE: The rationale for disqualification is the high rate of complications associated with bleeding that can

incapacitate the driver while operating a vehicle.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

30*>$'A0(B./0* <0Q/"( C*B;$A"

Visit http://www.fmcsa.dot.gov/documents/cardio.pdf to review the Cardiovascular Tables Archive.

Page 76 of 260

C%".*M(+(H X"*$P;"*0/ V0(B./0* !$("0("H 0%> V"%'.( !$("0(" 0%> <*"0&+"%&(

The diagnosis of arterial disease should alert you to the need for an evaluation to determine the presence

of other cardiovascular diseases.

Rupture is the most serious complication of an abdominal aortic aneurysm

and is related to the size of the

aneurysm. Deep venous thrombosis can be the source of acute pulmonary emboli or lead to long-term

venous complications. Intermittent claudication is the primary symptom of peripheral vascular disease of

the lower extremities.

-#7'43*"$ -'9+36 -*%.9=,4

The majority of abdominal aortic aneurysms (AAAs) occur in the sixth and seventh decades of life and

occur more frequently in males than in females by a 3:1 ratio. The majority of AAAs are asymptomatic. An

AAA can be associated with other cardiovascular disease.

The overall detection rate of AAAs on examination is 31%. Detection during a physical examination

depends on aneur

ysm size and is affected by obesity. Clinical examination identifies approximately 90%

of aneurysms greater than 6 cm. Auscultation of an abdominal bruit may indicate the presence of an

aneurysm.

,$(G '# *.P&.*"

Rupture is the most serious complication of an AAA and can be life threatening. The risk of rupture

increases as the aneurysm increases in size.

An AAA:

• Less than 4 cm rarely ruptures.

• Smaller than 5 cm has a 1% to 3% per year rate of rupture.

• 5 cm to 6 cm has a 5% to 10% per year rate of rupture.

• Gre

ater than 7 cm has approximately a 20% per year rate of rupture.

Monitoring of an aneurysm is advised because the growth rate can vary and rapid expansion can occur.

E"3+3*: A%93'7

Minimum — 3 months for post-surgical repair of an aneurysm

NOTE: If mor

e than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The AAA is:

• Less than 4 cm and the driver is asymptomatic.

• Greater than 4 cm but less than 5 cm and the driver is asymptomatic and has clearance from a

ca

rd

iovascular specialist who understands the functions and demands of commercial driving.

• Surgically repaired and the driver meets post-surg

ical repair of aneurysm guidelines.

Recommend not to certify if:

Page 77 of 260

The driver has:

• Symptoms, regardless of AAA size.

• Recommendation for surgical repair, regardless of AAA size, from a cardiovascular specia

lis

t who

understands the functions and demands of commercial driving.

The AAA:

• Is greater than 4 cm but less than 5 cm and driver does not have medical clearance for

com

mercial driving from a cardiovascular specialist.

• Is greater than or equal to 5 cm.

• Has increased more than 0.5 cm during a 6 month period, regardless of size.

1'*3+'93*:F!%,+3*:

Ultrasound has almost 100% sensitivity and specificity for detecting an AAA and is recommended to

monitor change in size.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Ane

urysm Recommendation Table, see Appendix D of this handbook.

-6.+% I%%A J%3* !/9'4#',3,

The commercial driver is at an increased risk for developing acute deep vein thrombosis (DVT) due to

long hours of sitting as part of the profession. DVT can be the source of pulmonary emboli that can cause

gradual or sudden incapacitation or death. Adequate treatment with anticoagulants decreases the risk of

recurrent thrombosis by approximately 80%.

E"3+3*: A%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed, and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has no residual, acute DVT.

Recommend not to certify if:

The driver has DVT ineffectively treated.

1'*3+'93*:F!%,+3*:

When DVT treatment includes anticoagulant therapy, the driver should meet monitoring guidelines.

0'$$'VU.A

The driver should have an annual medical examination.

Page 78 of 260

To review the Venous Disease Recommendation Tables, see Appendix D of this handbook.

)/9'*36 !/9'4#'+36 J%*'., I3,%",%

Chronic thrombotic venous disease of the legs increases the risk of pulmonary emboli; however, there is

insufficient research to confirm the level of risk. As a medical examiner, you must evaluate on a case-by-

case basis to determine if the driver meets cardiovascular requirements.

E"3+3*: A%93'7

No recommended time frame

You should not certify the driver until etiology is confirme

d and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification period — 2 years

Recommend to certify if:

The driver has no symptoms.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endangers

the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have a biennial medical examination.

To review the Ven

ous Disease Recommendation Tables, see Appendix D of this handbook.

H*+%94 3++%* + ) $". 7 36"+ 3'*

Approximately 7% to 9% of persons with peripheral vascular disease develop intermittent claudication,

the primary symptom of obstructive vascular disease of the lower extremity. In cases of severe arterial

insufficiency, necrosis, neuropathy, and atrophy may occur.

E"3+3*: A%93'7

Minimum — 3 months for post-surgical repair

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Page 79 of 260

Recommend to certify if:

The driver, following surgery has:

• Relief of symptoms.

• No other disqualifying cardiovascular disease.

Re

commend not to certify if:

The driver has pain at rest.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Peripheral Vascular Disease Recommendation Table, see Appendix D of this handbook.

5+/%9 -*%.9=,4,

Aneurysms can develop in visceral and peripheral arteries and venous vessels. Rupture of any of these

aneurysms can lead to gradual or sudden incapacitation and death. Much of the information on aortic

aneurysms is applicable to aneurysms in other arteries.

E"3+3*: A%93'7

Minimum — 3 months post-surgical repair of an aneurysm

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver has:

• Surgical repair of the aneurysm and meets pos

t-su

rgical repair of aneurysm guidelines.

• Clearance from a cardiovascular specialist who understands the functions and demands of

co

mmercial driving.

Recommend not to certify if:

The driver has:

• Recommendation for surgical repair of an aneurysm, from a cardiovascular specialist who

unders

tands the functions and demands of commercial driving, but has not had surgical repair.

Page 80 of 260

1'*3+'93*:F+%,+3*:

You may, on a case-by-case basis, obtain additional tests and consultations to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aneurysm Recommendation Table, see Appendix D of this handbook.

8%93A/%9"$ J",6.$"9 I3,%",%

Aneurysms can develop in visceral and peripheral arteries and venous vessels. Rupture of any of these

aneurysms can lead to gradual or sudden incapacitation and death. Much of the information on aortic

aneurysms is applicable to aneurysms in other arteries.

E"3+3*: A%93'7

Minimum — 3 months post-surgical repair of an aneurysm

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver has:

• Surgical repair of the aneurysm and meets post-su

rgical repair of aneurysm guidelines.

• Clearance from a cardiovascular specialist who understands the functions and demands of

com

mercial driving.

Recommend not to certify if:

The driver has:

• Recommendation for surgical repair of an aneurysm, from a cardiovascular specialist who

unders

tands the functions and demands of commercial driving, but has not had surgical repair.

Monitoring/Testing

You may, on a case-by-case basis, obtain additional tests and consultations to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aneurysm Recommendation Table, see Appendix D of this handbook.

Page 81

of 260

8',+U2.9:36"$ <%A"39 '( -*%.9=,4

With improved surgical outcomes, and without contraindication for surgery, aneurysms can be electively

repaired to prevent rupture. The decision by the treating provider not to surgically repair an aneurysm

does not mean that the driver can be certified to drive safely. However, a recommendation to surgically

repair an aneurysm disqualifies the driver until the aneurysm has been repaired and a satisfactory

recovery period has passed.

E"3+3*: A%93'7

Minimum — 3 months post-surgical repair

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic.

• Has clearance from a cardiovascular specialist who understands the functions and demands of

com

mercial driving.

Recommend not to certify if:

The driver has:

• Recommendation for surgical repair of an aneurysm from a c

ardiovascular specialist who

understands the functions and demands of commercial driving, but has not had surgical repair.

1'*3+'93*:F!%,+3*:

When post-surgical treatment includes anticoagulant therapy, the driver should meet monitoring

guidelines.

To review the Ven

ous Disease Recommendation Tables, see Appendix D of this handbook.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aneurysm Recommendation Table, see Appendix D of this handbook.

8.$4'*"9= >4#'$3

Deep vein thrombosis can be one of the sources of pulmonary emboli (PE). PE can cause gradual or

sudden incapacitation and significant morbidity and mortality.

E"3+3*: A%93'7

Minimum — 3 months with no pulmonary embolism

Page 82 of 260

NOTE: If more than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Appropriate long-ter

m treatment.

• No other disqualifying cardiovascular disease.

Recommend not to certify if:

The driver has symptoms.

1'*3+'93*:F!%,+3*:

When PE treatment includes anticoagulant therapy, the driver should meet monitoring guidelines.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Venous Disease Recommendation Tables, see Appendix D of this handbook.

2.A%9(363"$ 8/$%#3+3,

Although superficial phlebitis is a benign and self-limited disease, deep vein thrombosis (DVT) is often a

coexisting condition and needs to be excluded during the course of examination.

E"3+3*: A%93'7

No recommended time frame

You should not certify the driver until etiology is confi

rmed and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification period— 2 years

Recommend to certify if:

The driver is otherwise medically qualified.

Recommend not to certify if:

The driver has coexisting DVT a

nd does not meet the DVT guidelines.

Page 83 of 260

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess

driver medical fitness for duty.

0'$$'VU.A

The driver should have a biennial medical examination.

To review the Venous Disease Recommendation Tables, see Appendix D of this handbook.

!/'9"636 -*%.9=,4

While relatively rare, thoracic aneurysms are increasing in frequency. Size of the aorta is considered the

major factor in determining risk for dissection or rupture of a thoracic aneurysm.

E"3+3*: A%93'7

Minimum — 3 months post-surgical repair

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Has a thoracic aneurysm less than 3.5 cm.

• Has a surgically repaired thoracic aneurysm and the driver meets post-su

rgical repair of

aneurysm guidelines, including:

o Has completed surgical repair waiting period.

o

Has medical clearance from a cardiovascular specialist who understands the functions

and

demands of commercial driving.

Recommend not to certify if:

The driver has a thoracic aneurysm greater than 3.5 cm.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aneurysm Recommendation Table, see Appendix D of this handbook.

Page 84

of 260

J"936',% J%3*,

Varicose veins with the associated symptoms and complications affect more than 20 million people in the

United States. Complications include chronic venous insufficiency, leg ulcerations, and recurrent deep

vein thrombosis.

The presence of varicose veins does not medically disqualify the commercial driver.

E"3+3*: A%93'7

No recommended time frame

You should not certify the driver until eti

ology is confirmed and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification period — 2 years

Recommend to certify if:

The driver has no complications.

Recommend not to certify if:

As the medical examiner, you

believe that the nature and severity of the medical condition of the driver

endangers the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have a biennial medical examination.

To review the Venou

s Disease Recommendation Tables, see Appendix D of this handbook.

30*>$0B C**;M&;+$0( 0%>)<*"0&+"%&

The majority of sudden cardiac deaths are thought to be secondary to ventricular tachycardia or

ventricular fibrillation and occur most often when there is no prior diagnosis of heart disease.

Risk determination is difficult because of the number of variables that must be considered. The prognosis

is gen

erally determined by the underlying heart disease. While defibrillation may restore a normal rhythm,

there remains a high risk of recurrence.

When the driver has a history of arrhythmia or uses an anti-arrhy

thmia device, you, as a medical

examiner, should consider the following:

• Is the underlying heart disease disqualifying?

• What is the risk for sudden death?

• What is the risk for cerebral hypoperfusi

on and loss of consciousness?

Page 85 of 260

H4A$"* +"# $% ) " 97 3'@ % 9+% 9U I%(3#93$$"+'9,

Implantable cardioverter-defibrillators (ICD) are electronic devices that treat cardiac arrest, ventricular

fibrillation, and ventricular tachycardia through the delivery of rapid pacing stimuli or shock therapy.

ICDs treat but do not prevent arrhythmias. Therefore, the driver remains at risk for syncope. The

man

agement of the underlying disease is not effective enough for the driver to meet cardiovascular

qualification requirements. Combination ICD/pacemaker devices are also ineffective in preventing

incapacitating cardiac arrhythmia events.

E"3+3*: A%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has an:

• ICD.

• ICD/pacemaker combination device.

Monitoring/Testing

Not applicable.

0'$$'VU.A

Not applicable.

To review the Implantable Defibrillator Recommendation Table, see Appendix D of this handbook.

8"6%4"K%9,

A pacemaker is an implantable device designed to treat bradycardia. When assessing the risk for sudden,

unexpected incapacitation in a driver with a pacemaker, the underlying disease responsible for the

pacemaker indication must be considered.

• Both sinus node dysfunction and atrioventricular (AV) block have variable long-ter

m prognoses,

depending on the underlying disease.

• Cerebral hypoperfusion is usually corrected by support of heart rate via the implantation of a

pacem

aker.

Currently, pacemakers and the lead systems a

re reliable and durable over the long term.

E"3+3*: A%93'7

Minimum — 1 month post-pacemaker implantation if underlying disease is:

• Sinus node dysfunction.

• AV block.

Page 86 of 260

Minimum — 3 months post-pacemaker implantation if underlying disease is:

• Neurocardiogenic sy

ncope.

• Hypersensitive carotid sinus with syncope.

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Documentation indicating the presence of a functioning pacemaker.

• Documentation

i

ndicating completion of routine pacemaker checks.

• No disqualifying underlying disease.

Recommend not to certify if:

The driver has:

• An implantable cardiac defibrillator/pacemaker combination device.

• A disqualifying underlying disease.

1'*3+'93*:F!%,+3*:

The driver should:

• Comply with pacemaker center scheduled function checks.

• Provide documentation of pacemaker function checks at examination.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Pacemaker Recommendation Table, see Appendix D of this handbook.

2.A9"@%*+936.$"9 -99/=+/43",

Supraventricular arrhythmias fall into two main categories: supraventricular tachycardia (SVT) and atrial

fibrillation.

• Supraventricular tachycardia

SVT

is a common arrhythmia that is usually not considered a risk for sudden death. On occasion,

SVT c

an cause loss of consciousness or compromise cerebral function. Treatment by catheter

ablation is usually curative and allows drug therapy to be withdrawn.

• Atrial fibrillation

Page 87 of 260

The major risk associated with atrial fibrillation is the presence of an embolus which can cause a

stroke. Anticoagulant therapy decreases the risk of peripheral embolization in individuals with risk

factors for stroke.

See the Supraventricular Tachycardias Recommendation Table for diagnosis-sp

ecific recommendations.

The following are general recommendations.

E"3+3*: A%93'7

Minimum — 1 month anticoagulated adequately and diagnosis is atrial fibrillation

• As cause of stroke or risk for stroke.

• Following thoracic surgery.

Minimum — 1

month post-isthmus ablation and diagnosis is atrial flutter

Minimum — 1 month asymptomatic/treated asymptomatic and diagnosis is:

• Atrioventricular nodal reentrant tachycardia.

• Atrioventricular reentrant tachycardia and Wolff-Pa

rkinson-White syndrome.

• Atrial tachycardia.

• Junctional tachycardia.

NOTE: If m

ore than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Heart rate that is controlled.

• Treatment for prevention of emboli that is effective and tolerated.

• No underlying disease that is disqualifying.

• Clearance from a cardiovascular specialist who understands the functions and demands of

co

mmercial driving.

Recommend not to certify if:

The condition causes:

• Loss of consciousness.

• Compromised cerebral function.

• Sudden death resuscitation.

Page 88

of 260

1'*3+'93*:F!%,+3*:

The driver should:

• Comply with anticoagulant therapy guidelines, when appropriate.

• Have annual ev

aluation by a cardiovascular specialist who understands the functions and

demands of commercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

REMEMBER: The

re are times when the medical assessment and the guidelines may yield different

conclusions about the severity of the condition. A driver could have a benign underlying medical problem

with an excellent prognosis but still not be medically qualified as a commercial driver. For example, if a

benign supraventricular arrhythmia causes syncope, the driver cannot be medically certified until the

problem has been corrected.

J%*+936.$"9 -99/=+/43",

Ventricular arrhythmias are categorized as ventricular fibrillation and ventricular tachycardia and are

responsible for the majority of instances of cardiac sudden death. Most cases are caused by coronary

heart disease, but can also occur in people with hearts that are structurally normal.

Certification parameters include:

• Left ventricular ejection fraction (LVEF).

• Nonsustained ven

tricular tachycardia (NSVT).

• Ventricular tachycardia (VT).

See the Ventricular Arrhythmias Recommendation Table in Appendix D of this handbook for

diagnosis-

specific recommendations.

E"3+3*: A%93'7

Minimum — 1 month after drug or other therapy and diagnosis is:

• Coronary heart disease.

• Right ventricular outflow VT.

• Idiopathic left ventricular VT.

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic.

Page 89

of 260

• Has an identified non-disqualifying cardiac cause.

• Has clearance from

a cardiovascular specialist who understands the functions and demands of

commercial driving.

Recommend not to certify if:

The driver:

• Is symptomatic.

• Has sustained VT.

• Has NSVT, LVEF less than 0.40.

• Has a diagnosis of:

o Hy

pertrophic cardiomyopathy.

o Long Q

T interval syndrome.

o Bru

gada syndrome.

1'*3+'93*:F!%,+3*:

Have annual evaluation by a cardiovascular specialist who understands the functions and demands of

commercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

See the Ventricular Arrhythmias Recommendation Table for diagnosis-speci

fic recommendations.

30*>$'A0(B./0* <"(&(

Detection of an undiagnosed heart or vascular finding during a physical examination may indicate the

need for further testing and examination to adequately assess medical fitness for duty. Diagnostic-specific

testing may be required to detect the presence and/or severity of cardiovascular diseases. The additional

testing may be ordered by the medical examiner, primary care physician, cardiologist, or cardiovascular

surgeon.

When requesting additional evaluation from a specialist, the specialist must understand the role and

func

tion of a driver; therefore, it is helpful if you include a description of the role of the driver and a copy of

the applicable medical standard(s) and guidelines with the request.

Record additional tests in the Medical Examination Report form, Section 6. LABORATORY AND OTHER

TEST

FINDINGS, and/or attach additional test reports.

Figure 23 - Medical Examination Report Form: Laboratory and Other Test Findings

>6/'6"973':9"A/=

Left ventricular ejection fraction (LVEF) may be assessed by echocardiography. Imaging studies have

superior sensitivity and specificity compared to the standard exercise tolerance test (ETT) and are

indicated in the presence of an abnormal resting electrocardiogram or non-diagnostic standard ETT.

Page 90 of 260

Driver should have:

• An LVEF greater than or equal to 40%.

• No pulmonary hypertension.

NOTE: Pu

lmonary hypertension is pulmonary artery pressure greater than 50% of systemic systolic blood

as det

ermined by echocardiography or cardiac catheterization.

REMEMBER: If ech

ocardiography test results are inconclusive, some form of radionuclide imaging may

be used to obtain the ejection fraction measurement.

>?%963,% !'$%9"*6% !%,+

The exercise tolerance test is the most common test used to evaluate workload capacity and detect

cardiac abnormalities.

Driver should be able to:

• Exercise to a workload capacity greater than 6 Metabolic Equivalents (METs) (through Bruce

pr

otoc

ol stage II or equivalent).

• Attain a heart rate greater than or equal to 85% of predicted maximum (unless on beta blockers).

• Have a rise in systolic blood pressure greater than or equal to 20 mm Hg without angina.

• Have no significant ST segment depression.

NOTE: METs — Ext

ensive literature exists on the energy requirements for many physical tasks.

• Sedentary activity requires fewer than 2 METs. These activities include sitting, slow walking, and

liftin

g light objects of no more than 10 pounds.

• Light work requires 2 to 4 METs and includes carrying lightweight objects of no more than 20

pounds.

• Me

dium work requires 4 to 6 METs and includes carrying moderate weight objects of up to 50

pounds.

• Heavy and very heavy work requires greater than 6 METs and includes carrying heavy ob

jects

and climbing stairs rapidly.

REMEMBER: Medi

cal fitness for duty includes the ability to perform strenuous work. Overall

requirements for commercial drivers along with the specific requirements in the job description should be

deciding factors in the certification process.

30*>$'A0(B./0* ,"B'++"%>0&$'% <0Q/"(

See Appendix D of this handbook.

3'*'%0*M)L"0*& !$("0("( 0%> <*"0&+"%&(

As a medical examiner, it is your decision whether the nature and severity of the condition of the driver

will result in gradual or sudden incapacitation. The major clinical manifestations of coronary heart disease

(CHD) are acute myocardial infarction, angina pectoris (either stable or unstable), congestive heart

failure, and sudden death.

Page 91 of 260

Sudden death occurs when an individual goes from a usual state of health to death within 1 hour. In some

cases, those who suffer sudden death are asymptomatic with the first symptom of CHD being sudden

death.

The incidence of crashes ca

used by sudden death is relatively low, primarily because of the length of time

between the onset of the cardiovascular event and the incapacitation of the driver. Therefore, it is

important that you educate the driver about warning signs of an impending CHD event. Emphasize that

the driver may have only a short time following the onset of symptoms to safely stop the vehicle and call

for medical assistance.

89':*',+36 3*736"+'9, ('9 )WI

The major predictor of CHD is left ventricular function. Other indicators to be considered include:

• General heath.

• Age.

• Arrhythmias.

• Angina pectoris.

• Associated vascular disease.

• Severity of CHD.

G%*%9"$ )WI&9%6'44%*7"+3'* ,.44"9=

The qualified driver with CHD should:

• Secure clearance from a cardiovascular specialist who understands the functions and demands

of

commercial driving.

• Tolerate cardiovascular medication and be:

o Kn

owledgeable about medications used while driving.

o Fr

ee from side effects that compromise driving ability.

o Co

mpliant with the ongoing treatment plan.

-6.+% 1='6"973"$ H*("96+3'*

The first few months following an acute myocardial infarction (MI) pose the greatest risk of mortality, with

the majority of deaths classified as sudden death. Current opinion among clinicians states that post-MI

drivers may safely return to any occupational task provided there is no exercise-induced myocardial

ischemia or left ventricular dysfunction.

E"3+3*: 8%93'7

Minimum — 2 months

NOTE: If m

ore than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

Page 92 of 260

• Is asymptomatic.

• Tolerates medications.

• Has a satisfactory exer

cise tolerance test (ETT).

• Has a resting left ventricular ejection fraction (LVEF) greater than or equal to 40%.

• Has no electrocardiogram ischemic changes.

NOTE: Fo

r an initial certification following an MI, an in-hos

pital post-MI echocardiogram showing an

LVEF greater than or equal to 40% is sufficient.

Recommend not to certify if:

The driver has:

• Rest angina or change in angina pattern within 3 months of examination.

• Ischemic changes on rest electrocardiogram (ECG).

• Intolerance to cardiovascular therapy

.

1'*3+'93*:F!%,+3*:

The driver should obtain:

• Clearance from a cardiovascular specialist who understands the functions and demands of

com

mercial driving.

• Biennial ETT.

NOTE: Drivers in a rehabilitation program can receive comprehensive secondary preventi

on therapy.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Com

mercial Drivers With Known CHD Recommendation Tables, see Appendix D of this

handbook.

-*:3*" 8%6+'93,

Angina pectoris is at the lower end of the spectrum for risk of adverse clinical outcomes among

individuals with coronary heart disease (CHD). The presence of this condition usually implies that at least

one coronary artery has hemodynamically significant narrowing.

When evaluating the driver with angina, you should distinguish between stable and unstable angina. The

pres

ence of unstable angina may be a precursor to a cardiovascular episode known to be accompanied

by syncope, dyspnea, collapse, or congestive cardiac failure.

Stable angina

May be precipitated by a predictable pattern, including:

• Exertion.

• Emotion.

Page 93 of 260

• Extremes in weather.

• Sexual activity.

Unstable angina

Has an unpredictable course characterized by:

• Pain occurring at rest.

• Changes in pattern (i.e., increased frequency and longer duration).

• Decreased response to medication.

E"3+3*: 8%93'7

Minimum — 3 months with no rest angina or change in angina pattern

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Has stable angina.

• Is asymptomatic.

• Tolerates medications.

• Has a satisfactory exercise tolerance test (ETT).

Re

commend not to certify if:

The driver has had unstable angina within 3 months of examination.

1'*3+'93*:F!%,+3*:

The driver should obtain:

• Evaluation from a cardiovascular specialist who understands the function

s and demands of

commercial driving.

• Biennial ETT.

NOTE: If an ETT is inconclusive, an imaging stress test may be indicated.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Com

mercial Drivers With Known CHD Recommendation Tables, see Appendix D of this

handbook.

Page 94 of 260

)WI <3,KU>\.3@"$%*+ C 1.$+3A$% )WI <3,K 0"6+'9,

The presence of one or more of these medical conditions may be insufficient to not certify a driver.

However, the presence of these conditions can cause the driver to be at as great a risk of sudden death

or incapacitation as the driver with known coronary heart disease (CHD).

CHD risk-equivalent conditions include:

• Presence of diabetes mellitus.

• Presence of peripheral vascular disease.

• A Framingham risk score predicting a 20% CHD event risk over the next 10 years. To view the

Fra

mingham Heart Study, visit: http://www.nhlbi.nih.gov/guidelines/cholesterol/risk_tbl.htm.

• Being over 45 years of age with multiple risk factors for CHD.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does not

endanger the health and safety of the driver and the public.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endangers

the health and safety of the driver and the public.

NOTE: The decision not to medically certify a co

mmercial driver should not depend solely on the

detection of multiple risk factors.

1'*3+'93*:F!%,+3*:

The driver should obtain:

• Ongoing treating provider follow-up.

• Aggressive comprehensive risk factor management.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Com

mercial Drivers Without Known CHD Recommendation Tables, see Appendix D of

this handbook.

Page 95 of 260

)'9'*"9= -9+%9= L =A",, G9"(+3*:

Coronary artery bypass grafting (CABG) surgery is frequently the preferred choice of therapy for

individuals with multi-vessel coronary heart disease, narrowing of the proximal left main coronary artery,

and extensive atherosclerosis in the presence of left ventricular dysfunction or debilitating angina.

Following CABG surgery, individuals are at less risk of sudden death than those who are treated

me

dically. Most drivers who undergo CABG surgery are able to return to work. A longer waiting period is

recommended to allow sternal incision healing. The sternum should be completely healed before

certifying a driver.

A significant risk associated with CABG surgery is the high long-te

rm reocclusion rate of the bypass graft.

E"3+3*: 8%93'7

Minimum — 3 months regardless of type of CABG surgery performed

NOTE: If m

ore than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic.

• Tolerates cardiovascular medications with no orthostatic symptoms.

• Has a left ventricular ejection fraction (LVEF) greater than or equal to 40%.

• Is examined and appr

oved by a cardiologist for medical fitness to drive.

• Has a healed sternum.

Recommend not to certify if:

The driver:

• Is symptomatic.

• Has orthostatic symptom side effects from cardiovascular medication.

• Has an LVEF less than 40%.

• Is examined and is not approved by a cardiologist for medical fitness to drive.

• Has a sternum that has not healed.

1'*3+'93*:F!%,+3*:

Because of the risk of reocclusion over time, 5 years post-CABG surgery, the driver should obtain:

•

Annual exercise tolerance test.

• Imaging stress test, if indicated.

Page 96 of 260

0'$$'VU.A

The driver should have an annual medical examination.

To review the Com

mercial Drivers With Known CHD Recommendation Tables, see Appendix D of this

handbook.

W%"9+ 0"3$.9%

Coronary artery bypass grafting (CABG) surgery is frequently the preferred choice of therapy for

individuals with multi-vessel coronary heart disease, narrowing of the proximal left main coronary artery,

and extensive atherosclerosis in the presence of left ventricular dysfunction or debilitating angina.

Following CABG surgery, individuals are at less risk of sudden death than those who are treated

med

ically. Most drivers who undergo CABG surgery are able to return to work. A longer waiting period is

recommended to allow sternal incision healing. The sternum should be completely healed before

certifying a driver.

A significant risk associated with CABG surgery is the high long-te

rm reocclusion rate of the bypass graft.

E"3+3*: 8%93'7

Minimum — 3 months regardless of type of CABG surgery performed

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic.

• Tolerates cardiovascular medications with no orthostatic sy

m

ptoms.

• Has a left ventricular ejection fraction (LVEF) greater than or equal to 40%.

• Is examined and approved by a cardiologist for medical fitness to drive.

• Has a healed sternum.

Recommend not to certify if:

The driver:

• Is symptomatic.

• Has orthostatic sy

m

ptom side effects from cardiovascular medication.

• Has an LVEF less than 40%.

• Is examined and is not approved by a cardiologist for medical fitness to drive.

• Has a sternum that has not healed.

Page 97

of 260

1'*3+'93*:F!%,+3*:

Because of the risk of reocclusion over time, 5 years post-CABG surgery, the driver should obtain:

• Annual exercise tolerance test.

• Imaging stress test, if indicated.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Com

mercial Drivers With Known CHD Recommendation Tables, see Appendix D of this

handbook.

8%96.+"*%'., )'9'*"9= H*+%9@%*+3'*

The Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle

Drivers recommendations for percutaneous coronary intervention (PCI) encompass angioplasty and other

catheter-based techniques aimed at relieving coronary obstructions.

In the setting of an uncomplicated, elective procedure to treat stable angina, the post-proc

edure waiting

period is 1 week. The waiting period allows for a small threat caused by acute complications at the

vascular access site. Drivers undergoing PCI in the setting of an acute myocardial infarction or unstable

angina should be restricted from driving duties for the longer waiting period recommended for these

conditions.

E"3+3*: 8%93'7

Minimum — 1 week

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic at examination.

• Tolerates medications.

• Has no injury to the vascular

access site.

NOTE: Initially certify for up to 6 months. Recertify for up to 1 year if ex

ercise tolerance test (ETT) results

are satisfactory.

Page 98 of 260

Recommend not to certify if:

The driver has:

• Incomplete healing or complication at vascular access site.

• Rest angina.

• Ischemic electrocardiogram (ECG) changes.

1'*3+'93*:F!%,+3*:

NOTE: Following initial certification, the driver should have an ETT 3 to 6 months post-percutaneous

coronary intervention and bring results to a 6-month follow-up examination.

The driver should obtain:

• Clearance from a cardiovascular specialist who understands the functions and demands of

commercial driving.

• Biennial ETT.

NOTE: If an ETT is inconclusive, an imaging stress test may be indicated.

0'$$'VU.A

The driver should have an annual medical examination.

NOTE: Delayed restenosis is the major PCI limitation and requires intensive secondary prevention.

Typ

ical angina symptoms should prompt evaluation with a stress imaging study or repeat angiography.

To review the Comm

ercial Drivers With Known CHD Recommendation Tables, see Appendix D of this

handbook.

3'%-"%$&0/ L"0*& !$("0("

Heart failure and sudden death are the major causes of death among individuals with congenital heart

disease. Due to the complexity of these problems, the Cardiovascular Advisory Panel Guidelines for the

Medical Examination of Commercial Motor Drivers recommend that the driver has regular, ongoing follow-

up by a cardiologist knowledgeable in adult congenital heart disease.

The driver with congenital heart disease must meet the qualification standards. As a medical examiner,

your

decision to certify should be based on:

• Anatomic diagnosis.

• Severity of the congenital defect.

• Results of treatment.

• Present fitness status.

• Risk of sudden death or incapacitation.

Congenital Heart Disease Recommendation Table (PDF)

Page 99 of 260

NOTE: The Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor

Vehicle Drivers discusses multiple congenital heart diseases, many of which are self-limiting. Advances in

surgical and medical management are expected to result in an increased number of individuals with

congenital heart disease seeking driver certification. Ebstein anomaly is included in the handbook

because it is a condition you are likely to encounter in the clinical setting.

>#,+%3*&-*'4"$=

Ebstein anomaly is a congenital downward displacement of the tricuspid valve. The natural history of the

patient with Ebstein anomaly depends on its severity. Adults with a mild form of Ebstein anomaly can

remain asymptomatic throughout their lives.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

Th

e driver:

• Is asymptomatic.

• Has a mild tricuspid anomaly.

• Has mild cardiac enlargement.

• Has mild right ventricular dysfunction.

Recommend not to certify if:

The driver has a(n):

• Moderate or severe anomaly.

• Intracardiac lesion.

• Shunt.

• Symptomatic ar

r

hythmia.

• Accessory conduction pathway.

1'*3+'93*:F!%,+3*:

Annual cardiovascular re-evaluation should include echocardiography and evaluation by a cardiologist

knowledgeable in adult congenital heart disease and who understands the functions and demands of

commercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Con

genital Heart Disease Recommendation Table, see Appendix D of this handbook.

Page 100 of 260

L"0*& <*0%(P/0%&0&$'%

Although the number of heart transplant recipients is relatively small, some recipients may wish to be

commercial motor vehicle drivers. The major medical concerns for certification of a commercial driver

heart recipient are transplant rejection and post-transplant atherosclerosis.

E"3+3*: 8%93'7

Minimum — 1 year post transplant

NOTE: If mor

e than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 6 months

Recommend to certify if:

The driver:

• Is asymptomatic.

• Tolerates medications.

• Has clearance from

a c

ardiovascular specialist who understands the functions and demands of

commercial driving.

• Has no signs of transplant rejection.

• Meets all other qualification requirements.

Recommend not to certify if:

As the medical examiner, you believe that the natur

e and

severity of the medical condition endangers the

health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

Monitoring the driver with a heart transplant should include re-evaluation and recertification every 6

months by a cardiovascular specialist who:

• Is an expert in the fields of cardiology and transplant medicine.

• Understands the functions and demands of commercial driving.

• Evaluates the possibility of atherosclerosis, the status of the transplant, and the general health of

the d

river.

0'$$'VU.A

The driver should have a medical examination every 6 months.

To review the Heart Transplantation Recommendation Table, see Appendix D of this handbook.

LMP"*&"%($'%

See the Hypertension section of this handbook.

Page 101 of 260

?M'B0*>$0/ !$("0("

Myocardial diseases are often progressive and require long-term follow-up. Even so, improved diagnostic

testing and treatment can increase the number of drivers with myocardial disease who seek commercial

motor vehicle driver certification.

W=A%9+9'A/36 )"973'4='A"+/=

Hypertrophic cardiomyopathy is a complex disease characterized by marked morphologic, genetic, and

prognostic heterogeneity. Some individuals experience a benign and stable clinical course, while in others

the disease is characterized by progressive symptoms. For some individuals, sudden death is the first

definitive manifestation of the disease.

E"3+3*: 8%93'7

If you note an enlarged heart in a driver, you should not certify the driver until evaluation by a

cardiovascular specialist who understands the functions and demands of commercial driving to confirm or

rule out a diagnosis of hypertrophic cardiomyopathy.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of hypertrophic cardiomyopat

hy.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

To review the Card

iomyopathies and Congestive Heart Failure Recommendation Table, see Appendix

D of this handbook.

<%,+936+3@% )"973'4='A"+/=

The Mayo Clinic performed a study on idiopathic restrictive cardiomyopathy between 1979 and 1996. The

Clinical Profile and Outcome of Idiopathic Restrictive Cardiomyopathy report indicated a 5-year survival

rate of only 64%, compared with an expected survival rate of 85%.

E"3+3*: 8%93'7

If you suspect restrictive cardiomyopathy in a driver, you should not certify the driver until evaluation by a

cardiovascular specialist who understands the functions and demands of commercial driving to confirm or

rule out a diagnosis of restrictive cardiomyopathy.

I%63,3'*

Recommend to certify if:

Not applicable.

Page 102

of 260

Recommend not to certify if:

The driver has a diagnosis of restrictive cardiomyopathy.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

To review the Card

iomyopathies and Congestive Heart Failure Recommendation Table, see Appendix

D of this handbook.

DM%B'P"

Syncope is a symptom, not a medical condition, that can present an immediate threat to public safety

when causing the driver of a commercial motor vehicle to lose control of the vehicle.

As an example, syncope as a consequence of an arrhythmia while driving, places the driver and others

around t

he driver at the time in serious jeopardy. Medications are available that are effective in managing

ventricular arrhythmias and, although they are designed to prevent occurrences, they are not "fail-safe"

and if an arrhythmia recurs, syncope may follow.

Recurrent, unexplained syncope and syncope from cardiac causes may herald a markedly increased

futur

e risk for sudden death.

As a medical

examiner, you should ensure that:

• Diagnosis distinguishes between pre-synco

pe (i.e., dizziness, lightheadedness) and true syncope

(i.e., loss of consciousness).

• The medications used by the driver do not predispose the driver to precipitous declines in blood

pressure, syncope, fatigue, or electrolyte shifts and imbalances.

• Cardiac-based s

yncope is differentiated from other causes of syncope.

o Conduction system diseases that cause syncope must be treated before the driver is

con

sidered for certification.

• Other forms of syncope, such as neurological-based c

onditions (e.g., migraine headache,

seizures) are adequately evaluated.

You may refer to the Cardiovascular Advisory Panel Guidelines for the Medical Examination of

Comm

ercial Motor Vehicle Drivers for diagnosis-specific recommendations for:

• Hypersensitive carotid sinus with syncope.

• Neurocardiogenic syncope.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/ef

fective, safe, and stable.

Page 103 of 260

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Has been treated for symptomatic disease.

• Is asymptomatic.

• Tolerates medications.

• Is at low risk for syncope/near syncope.

• Has clearance from an

appropr

iate specialist (e.g., cardiologist, neurologist) who understands the

functions and demands of commercial driving.

Recommend not to certify if:

The driver:

• Experiences syncope as a consequence of the disease process, regardless of the underlying

co

nd

ition.

• Is at high risk for syncope/near syncope, regardless of the underlying heart disease and/or

treatment.

NOTE: Distinguish between treatments that reduce the risk for syncope and treatments where the driver

rem

ains at risk for syncope. Certification also depends on the risk for syncope and gradual or sudden

incapacitation from the underlying heart disease that may remain even after successful treatment of the

conduction system disease.

1'*3+'93*:F!%,+3*:

The driver should:

• Comply with medication and/or t

reatment guidelines, when appropriate.

• Have annual evaluation by a cardiovascular specialist who understands the functions and

demands of

commercial driving (refer to diagnosis-specific recommendations).

0'$$'VU.A

The driver should have an annual medical examination.

See the Supraventricular Tachycardias Recommendation Table and Pacemakers Recommendation

Tabl

e in Appendix D of this handbook for d

iagnosis-specific recommendations.

V0/A./0* L"0*& !$("0("( 0%>)<*"0&+"%&(

Murmurs are a common sign of valvular heart conditions; however the presence of a murmur may be

associated with other cardiovascular conditions. As a medical examiner, you must distinguish between

functional murmurs and pathological murmurs that are medically disqualifying.

Page 104 of 260

Classification of Murmur Severity

The intensity of murmurs is classified on a scale of I to VI, from the least pronounced murmur to the

lo

udest. Classification is rated as follows:

• Grade I – Mu

st strain to hear a murmur.

• Grade II – Ca

n hear a faint murmur without straining.

• Grade III – Ca

n easily hear a moderately loud murmur.

• Grade IV – Ca

n easily hear a moderately loud murmur that has a thrill.

• Grade V – Ca

n hear the murmur when only part of the stethoscope is in contact with the skin.

• Grade VI – Ca

n hear the murmur with the stethoscope close to the skin; it does not have to be in

contact with the skin to detect the murmur.

Murmurs that are:

• Systolic and grade I or II are usually benign if the driver has no signs or sy

mptoms of heart

disease.

• Mid-sy

stolic are usually benign if the driver has no signs or symptoms of heart disease.

Additional evaluation is recommended when murmurs are:

• Systolic, grade I or II, and the driver has signs or symptoms of heart disease.

• Systolic

and grade III or higher.

• Holosystolic or late systolic.

• Diastolic or continuous.

Exceptions are common with the higher grade murmurs. When in doubt about the severity of a heart

mu

rmur, you should obtain additional evaluation.

-'9+36 <%:.9:3+"+3'*

Aortic regurgitation is usually a chronic condition characterized by a prolonged asymptomatic phase and

gradual left ventricular (LV) dilatation. Other conditions such as infective endocarditis and aortic

dissection can result in acute severe aortic regurgitation. The recommendations are for chronic aortic

regurgitation.

Recommendation parameters for aortic regurgitation include the severity of the diagnosis, LV size, and

th

e presence of signs or symptoms.

Mild or moderate aortic regurgitation oc

curs in the presence of normal LV systolic function and little or no

LV enlargement.

Severe aortic regurgitation oc

curs with a normal LV systolic function but significant LV dilatation.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequat

e/effective, safe, and stable.

Page 105

of 260

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Mild aortic regurgitation that is asymptomatic.

• Moderate aortic regurgitation with normal LV function, no or mild LV enlargement, and

t

he driver

is asymptomatic.

Recommend not to certify if:

The driver has:

• Symptoms.

• Moderate aortic regurgitation with abnormal LV function or more than mild LV enlargement.

1'*3+'93*:F!%,+3*:

Echocardiography repeated every 2 to 3 years when certified with mild or moderate aortic regurgitation.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aortic Regurgitation Recommendation Table, see Appendix D of this handbook.

E"3+3*: 8%93'7

Minimum — 3 months if post-aortic valve repair

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 6 months if not surgically repaired

Maximum certification period — 1 year if post-aortic valve repair

NOTE: The certification interval should not exceed the interval required for adequate monitoring.

Re

commend to certify if:

The driver has:

• No symptoms.

• Normal LV function.

Page 106

of 260

• LV dilatation:

o LV end-di

astolic dimension (LVEDD) less than or equal to 60 mm.

o LV end-sy

stolic dimension (LVESD) less than or equal to 50 mm.

The driver who has had surgical repair for severe aortic regurgitation and meets guidelines for post-aor

tic

valve repair may be recertified for 1 year.

Recommend not to certify if:

The driver:

• Is symptomatic.

• Is unable to achieve workload greater than 6 METS on Bruce protocol.

• Has reduced left ventricular ejection fraction less than 50%.

• Has LV dilatation:

o LVEDD greater than 70 mm.

o LVESD greater than 55 mm.

1'*3+'93*:F!%,+3*:

Echocardiography repeated every:

• 6 to 12 months if LVEDD less than 60mm or LVESD less than 50 mm.

• 4 to 6 months if LVEDD equal to 60mm or LVESD equal to 50 mm.

NOTE: Th

e certification interval for severe aortic regurgitation that has not been surgically repaired

sh

ould not exceed 6 months even if the monitoring interval is greater than 6 months.

0'$$'VU.A

The driver with severe aortic regurgitation should have a semi-annual medical examination. If surgically

repaired, the driver may have an annual medical examination.

To review the Aor

tic Regurgitation Recommendation Table, see Appendix D of this handbook.

-'9+36 2+%*',3,

The most common cause of aortic stenosis in adults is a degenerative process associated with many of

the risk factors underlying atherosclerosis. Aortic stenosis may cause a heart murmur.

Recommendation parameters for aortic stenosis include the severity of the diagnosis and the presence of

sig

ns or symptoms.

E"3+3*: 8%93'7

Minimum — 3 months if post surgery

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 107 of 260

Recommend to certify if:

The driver has:

• Mild aortic stenosis that is asymptomatic.

• Moderate aortic stenosis that is asymptomatic and the driver has no disqualifying findings and/or

cond

itions.

• Severe aortic stenosis that has been surgically repaired and meets all aortic valve repair surgical

guidelines.

Recommend not to certify if:

The driver has moderate aortic stenosis with one or more of the following:

• Angina.

• Heart failure.

• Atrial fibrillation.

• Left ventricular dysfunction with ejection fraction less than

50%.

•

Thr

omboembolism.

The driver has severe aortic stenosis regardless of symptoms or left ventricular function.

1'*3+'93*:F!%,+3*:

Echocardiography repeated every:

• 5 years if mild aortic stenosis.

• 1 to 2 years if moderate aortic stenosis.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aortic Stenosis Recommendation Table, see Appendix D of this handbook.

-'9+36 J"$@% <%A"39

Aortic valve repair is a technique for repairing the existing aortic valve and usually does not require

anticoagulant therapy. Early post-operative evaluation is required to assess adequacy of repair and

extent of residual aortic regurgitation.

E"3+3*: 8%93'7

Minimum waiting period — 3 months

NOTE: If mor

e than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 108 of 260

Recommend to certify if:

The driver:

•

Meets asymptomatic aortic stenosis or aortic regurgitation qualification requirements.

• Has clearance from a cardiovascular specialist who understands the functions and demands of

commercial driving.

Recommend not to certify if:

The driver has thromboembolic complications.

1'*3+'93*:F!%,+3*:

Two-dimensional echocardiography with Doppler should be performed prior to discharge. Additional

monitoring and testing should be based on aortic regurgitation severity.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Aor

tic Regurgitation Recommendation Table or the Aortic Stenosis Recommendation

Table, see Appendix D of this handbook.

13+9"$ <%:.9:3+"+3'*

Recommendation parameters for mitral regurgitation include the severity of the diagnosis and the

presence of signs or symptoms. The development of symptoms, especially dyspnea, fatigue, orthopnea,

and/or paroxysmal nocturnal dyspnea, is a marker of a poor prognosis, including an inability to perform

driver tasks and increased risk for sudden cardiac death.

E"3+3*: 8%93'7

Minimum — 3 months if post-surgical commissurotomy

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Mild or moderate mitral regurgitation if asymptomatic

, normal left ventricular (LV) size and

function, normal pulmonary artery pressure.

• Severe mitral regurgitation that is asymptomatic.

• Surgical mitral valve repair for mitral regurgitation, is asymptomatic, and has clearance from a

car

diovascular specialist who understands the functions and demands of commercial driving.

Page 109 of 260

Recommend not to certify if:

The driver has mild, moderate, or severe mitral regurgitation and has:

• Symptoms.

• Less than 6 METs on Bruce protocol.

• Ruptured chordae or flail leaflet.

• Atrial fibrillation.

• LV dysfunction.

• Thromboembolism.

• Pulmonary hypertension.

1'*3+'93*:F!%,+3*:

The driver with:

•

Moderate mitral regurgitation should have an annual echocardiography.

• Severe mitral regurgitation should have an exercise tolerance test and echocardiography every 6 to 12

months.

Follow-up

The driver should have an annual medical examination.

To review the Mitral Regurgitation Recommendation Table, see Appendix D of this handbook.

13+9"$ 2+%*',3,

Recommendations for mitral stenosis are based on valve area size and the presence of signs or

symptoms. Inquire about episodes of angina or syncope, fatigue, and the ability to perform tasks that

require exertion.

E"3+3*: 8%93'7

Minimum — 4 weeks if post-percutaneous balloon mitral valvotomy

Minimum — 3 months if post-surgical commissurotomy

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Mild mitral stenosis that is asymptomatic.

Page 110 of 260

• Moderate mitral stenosis that is asymptomatic.

• Severe mitral stenosis and a clearance from a cardiovascular specialist who understands the

fun

ctions and demands of commercial driving following:

Recommend not to certify if:

The driver has severe mitral stenosis, until successfully treated.

1'*3+'93*:F!%,+3*:

The frequency of cardiovascular specialist evaluation depends on the development and severity of

symptoms; however, it should be performed at least annually, including:

• Chest X-ray.

•

Electrocardiogram.

• Two-dimensional echocardiography with Doppler or

other mitral stenosis severity assessment.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Mitral Stenosis Recommendation Table, see Appendix D of this handbook.

13+9"$ 2+%*',3, !9%"+4 %*+

Management of mitral stenosis is based primarily on the development of symptoms and pulmonary

hypertension rather than the severity of the stenosis itself. Treatment options for mitral stenosis include

enlarging the mitral valve or cutting the band of mitral fibers.

Procedures include:

• Percutaneous balloon mitral valvotomy.

• Surgical commissurotomy.

Symptomatic improvement occurs almost immediately, but after 9 years, recurrent symptoms are present

in approximately 60% of individuals.

E"3+3*: 8%93'7

Minimum — 4 weeks

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 111 of 260

Recommend to certify if:

The driver:

• Is asymptomatic.

• Has clearance from a cardiovascular specialist who understands the functions and demands of

com

mercial driving.

• Has experienced no thromboembolic complications.

• Has experienced

no pulmonary hypertension.

• Meets the certification recommendations for the underlying condition.

Recommend not to certify if:

The driver has:

• Thromboembolic complications.

• Pulmonary hypertension (pulmonary pressure greater than 50% of systemic blood

pressure).

1'*3+'93*:F!%,+3*:

The driver should have an annual cardiology evaluation which should include:

• History.

• Physical examination.

• Electrocardiogram.

• Chest X-ra

y.

•

Two-dimensional echocardiography with Doppler performed after the procedure and prior to

di

scharge. The frequency of repeat echo-Doppler examinations is variable and depends upon the

initial periprocedural outcome and the occurrence of symptoms.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Mitral Stenosis Recommendation Table, see Appendix D of this handbook.

E"3+3*: 8%93'7

Minimum — 3 months

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 112 of 260

Recommend to certify if:

The driver:

• Is asymptomatic.

• Has clearance from a cardiovascular specialist who understands the

functions and demands of

commercial driving.

• Has experienced no thromboembolic complications.

• Has experienced no pulmonary hypertension.

• Meets the certification recommendations for the underlying condition.

Recommend not to certify if:

The driver has:

• Thromboembolic complications.

• Pulmonary hypertension (pulmonary pressure greater than 50% of systemic blood pressure).

1'*3+'93*:F!%,+3*:

The driver should have an annual cardiology evaluation which should include:

• History.

• Physical examination.

• Electrocar

diogram.

•

Chest X-ray.

•

Two-dimensional echocardiography with Doppler performed after the procedure and prior to

di

scharge. The frequency of repeat echo-Doppler examinations is variable and depends upon the

initial periprocedural outcome and the occurrence of symptoms.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Mit

ral Stenosis Recommendation Table, see Appendix D of this handbook.

13+9"$ J"$@% 89'$"A,%

The natural history of mitral valve prolapse is extremely variable and depends on the extent of

myxomatous degeneration, the degree of mitral regurgitation, and association with other conditions.

Mitral valve prolapse is usually a benign condition. In some cases, mitral regurgitati

on may be

progressive, resulting in left ventricular (LV) and left atrial enlargement, atrial fibrillation, and congestive

heart failure.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and tre

atment has been shown to be

adequate/effective, safe, and stable.

Page 113 of 260

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Symptoms or reduced effort tolerance due to mitral valve prolapse or mitral regurgitation.

• Ruptured chordae or flail leaflet.

• Systemic emboli.

• Atrial

fibrillation.

• Syncope or documented ventricular tachycardia.

• Severe mitral regurgitation or LV dysfunction.

1'*3+'93*:F!%,+3*:

Exercise tolerance testing may be helpful to assess symptoms.

Drivers who have definite mitral regurgitation (even if mild) or markedly thickened leaflets, should have:

• Echocardiography at least annually.

• Clearance from a cardiovascular specialist who understands the functions and demands of

co

mmercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

13+9"$ J"$@% <%A"39 ('9 13+9"$ <%:.9:3+"+3'*

The majority of inadequate valvular repair procedures can be detected in the early perioperative period.

Careful evaluation at this time includes a two-dimensional echocardiography with Doppler and, if

necessary, transesophageal echocardiography.

E"3+3*: 8%93'7

Minimum — 3 months

NOTE: If m

ore than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 114

of 260

Recommend to certify if:

The driver is asymptomatic and meets the underlying mild, moderate, or severe mit

ral regurgitation

recommendations. The driver should also have clearance from a cardiovascular specialist who

understands the functions and demands of commercial driving.

Recommend not to certify if:

The driver has:

• Thromboembolic complications.

• Atrial fibrillation.

• Pulmonary hypertension.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Mitral Regurgitation Recommendation Table, see Appendix D of this handbook.

89',+/%+36 J"$@%,

Prosthetic valves can be mechanical or biological. There are a wide range of reported complications

depending upon the variable methods of reporting, the make and model of the prosthesis, the site of

implantation, comorbidities, and underlying left ventricular (LV) function, among other causes.

The clinical course is heavily influenced by factors other than valve-rel

ated complications, for example,

LV dysfunction, congestive heart failure, progression of disease in other valves, coronary disease, or

pulmonary hypertension.

E"3+3*: 8%93'7

Minimum — 3 months

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver:

• Is asymptomatic.

• Has clearance from a cardiovascular specialist who understands the functions and demands of

com

mercial driving.

Page 115 of 260

Recommend not to certify if:

The driver has:

•

Persistent symptoms.

• LV dysfunction (ejection fraction less than 40%).

• Thromboembolic complications post procedure.

• Atrial fibrillation.

• Pulmonary hypertension.

• Inadequate anticoagulation based on International Normalized Ratio (INR) checks at least

mon

thly.

1'*3+'93*:F!%,+3*:

If treatment includes anticoagulant therapy, the driver should meet INR monitoring guidelines.

Echocardiography is in

dicated in the event of concerns about prosthetic valve dysfunction, perivalvular

leaks, new murmurs, or LV function.

Exercise tolerance testing may be required to assess work capacity.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Val

ve Replacement Recommendation Table, see Appendix D of this handbook.

8.$4'*"9= J"$@% 2+%*',3,

Pulmonary valve stenosis is usually a well-tolerated cardiac lesion normally exhibiting a gradual

progression. Gradual or sudden incapacitation may, however, occur in certain circumstances.

E"3+3*: 8%93'7

Minimum — 1 month if post-balloon valvuloplasty

Minimum — 3 months if post-surgical valvotomy

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Recommend to certify if:

The driver has:

• Mild or moderate pulmonary valve stenosis.

• Pulmonary valve stenosis cor

rected by surgical valvotomy or balloon valvuloplasty.

Page 116 of 260

Recommend not to certify if:

The driver has:

• Symptoms of dyspnea, palpitations, or syncope.

• Pulmonary valve peak gradient greater than 50 mm Hg in the presence of a normal cardiac

output.

•

Right ventricular pressure greater than 50% systemic pressure.

• More than mild right ventricular hypertrophy noted by echocardiography.

• More than mild right ventricular dysfunction noted by echocardiography.

• More than moderate pulmonary valve regurgitation noted by echocar

diography.

• Main pulmonary artery diameter more than 5 cm noted by echocardiography or other imaging

moda

lity.

1'*3+'93*:F!%,+3*:

The driver should have annual cardiology evaluations by a cardiovascular specialist who is

knowledgeable in adult congenital heart disease and who understands the functions and demands of

commercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

To review the Cong

enital Heart Disease Recommendation Table, see Appendix D of this handbook.

<%,A39"+'9= ^#_^d_

The commercial driver spends more time driving than the average individual. Driving is a repetitive and

monotonous activity that demands the driver be alert at all times. Symptoms of respiratory dysfunction or

disease can be debilitating and can interfere with the ability to remain attentive to driving conditions and

to perform heavy exertion. Even the slightest impairment in respiratory function under emergency

conditions (when greater oxygen supply may be necessary for performance) can be detrimental to safe

driving.

There are many primary and secondary respiratory conditions that interfere with oxygen exchange and

may r

esult in gradual or sudden incapacitation, for example:

• Asthma.

• Carcinoma.

• Chronic bronchitis.

• Em

physema.

• Obstructive sleep apnea.

• Tuberculosis.

In addition, medications used to treat respiratory conditions, both prescription and those available without

a pres

cription, may cause cognitive difficulties, compound the risk for excessive daytime sleepiness

(EDS), or cause other forms of incapacitation.

Page 117 of 260

<%,A39"+'9 <%:.$"+3'*&O )0 QPRSOR^#_^d_

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with

his

/her ability to control and drive a commercial motor vehicle safely."

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely. This examination is for public safety determination and is

considered by the Federal Motor Carrier Safety Administration (FMCSA) to be a “medical fitness for duty"

examination.

As the medical examiner, your fundamental obligation during the respiratory assessment is to establish

whe

ther a driver has a respiratory disease or disorder that increases the risk for sudden death or

incapacitation, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* ,"(P$*0&'*M)NO0+$%0&$'%

During the physical examination, you should ask the same questions as you would for any individual who

is being assessed for respiratory diseases or disorders. The FMCSA Medical Examination Report form

includes health history questions and physical examination checklists. Additional questions about

symptoms of respiratory disease should be asked to supplement information requested on the form.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver have:

• Shortness of breath?

• Lung disease?

• Emphysema?

• Asthma?

• Chronic bronchitis?

• Sleep disorder?

• Pauses in breathing while asleep?

• Daytime sleepiness?

• Loud snoring?

Page 118 of 260

Recommendations — Questions that you may ask include

Does the driver:

• Smoke? If yes, how much and for how long?

• Feel short of breath while driving?

• Cough frequently? If yes, is the cough productive of sputum?

• Experience tightness of the chest while resting or exercising?

• Wheeze during the day or night?

• Use respiratory agents?

• Use oxygen therapy?

• Self-re

port sleepiness that may indicate increased risk for EDS?

Regulations — Yo

u must evaluate

On examination, does the driver have:

• Impaired respiratory function?

• Cyanosis?

• Abnormal:

o Ch

est wall expansion?

o Re

spiratory rate?

o Br

eath sounds, including wheezes or alveolar rales?

o Fi

ndings that may require further testing such as pulmonary tests and/or X-ray of chest?

Recommendations — Yo

u may request

A detailed pulmonary function evaluation or consultation with a pulmonologist when the physical

ex

amination reveals:

• Clubbing of the fi

ngers.

• Cyanosis.

• Prolonged expiration.

• Tachypnea at rest.

• Pulmonary wheezes and rhonchi, pulmonary rales.

• Absent or decreased breath sounds.

• Pleural friction rub.

• Unequal inflation-def

lation contours of the right and left thorax.

• Significant kyphosis or sco

liosis of the thoracic spine.

• Use of accessory muscles of ventilation at rest.

NOTE: Wh

en requesting additional evaluation from a specialist, the specialist must understand the role

and function of a driver; therefore, it is helpful if you include a copy of the description of the driver role

Page 119

of 260

found in the Medical Examination Report form and a copy of the applicable medical standard and

guidelines with the request.

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative respiratory history, including if available:

o On

set date, diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of medication use, including over-the-co

unter medications, while

driving.

• Any abnormal finding(s), noting:

o Ef

fect on driver ability to operate a CMV safely.

o

Necessary steps to correct the condition as soon as possible, particularly if the untreated

co

ndition could result in more serious illness that might affect driving.

• Any additional r

espiratory tests and evaluation.

REMEMBER: Med

ical fitness for duty includes the ability to perform strenuous labor. Overall

requirements for commercial drivers as well as the specific requirements in the job description of the

driver should be deciding factors in the certification process.

-7@3,'9= )93+%93"FG.37"*6%

C%&$;$(&0+$%" <;"*0PM

Both prescription and over-the-counter antihistamines are used to treat respiratory tract congestion.

First generation antihistamines have sedating side effects that may o

ccur without the driver being aware.

Many first generation antihistamines are available without prescription.

Second generation antihistamines have less incidence of sedating side effects and most do not interfere

wit

h driving. Some are available without prescription.

NOTE: You should discuss common prescriptions and over-th

e-counter medications relative to the side

effects and the risks associated with using medications while driving. Educate the driver to read warning

labels on all medications.

E"3+3*: 8%93'7

Minimum — The driver should abstain from medication for 12 hours prior to operating a vehicle

NOTE: The individuals responsible for commercial driver work schedules should relieve affected drivers

fr

om duty until proper treatment for the illness has been completed.

Page 120 of 260

I%63,3'*

Recommend to certify if:

As the medical examiner, you believe that the treatment does not endanger the health and safety of the

dri

ver and the public.

Recommend not to certify if:

Treatment interferes with driving ability.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

C//"*-$"()0%> C(&;+09*"/0&">)!$("0("(

-$$%9:36 </3*3+3,

Allergic rhinitis, which involves inflammation of the nasal portion of the upper respiratory tract, should

rarely render the driver medically unqualified for commercial driving. The symptoms should be treated

with nonsedating antihistamines or with local steroid sprays that do not interfere with driving ability.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*&

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does not

endanger the health and safety of the driver and the public.

Recommend not to certify

if:

The driver has complications and/or treatment that impairs function, including:

• Severe conjunctivitis affecting vision.

• Inability to keep eyes open.

• Photophobia.

• Uncontrollable sneezing fits.

• Sinusitis with severe headaches.

• Medications that cause se

d

ation or other side effects that interfere with safe driving.

Page 121 of 260

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

-$$%9:=U9%$"+%7 D3(%U+/9%" +%*3* : )' *7 3+3'* ,

These conditions encompass systemic anaphylaxis and acute upper airway obstruction induced by

allergens, genetic deficiencies, or unknown mechanisms, including:

• Stinging insect allergy that may result in acute anaphylaxis following a sting. Preventive

me

asures include carrying an epinephrine injection device in the truck cab and evaluating the

driver for immunotherapy.

• Hereditary or acquired angioedema due to deficiency of a serum protein controlling complement

fu

nction that may result in an acute, life-threatening airway obstruction or severe abdominal pain

requiring urgent medical attention. Prevention and control can and should be accomplished with

appropriate prophylactic medication.

• Acute recurrent episodes of idiopathic anaphylaxis or angioedema that may occur unpredictably

in

some individuals and lead to sudden onset of severe dyspnea, visual disturbance, loss of

consciousness, or collapse. Similar episodes occur due to known allergens, including

medications, which ordinarily can be avoided.

E"3+3*: 8%93'7

Individuals with a history of an allergy-related life-threatening condition must have undertaken successful

preventive measures and/or treatment without adverse effects before the driver can be considered

medically qualified.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the nature and sever

ity of the medical condition and the

prevention and treatment regimen do not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver with a history of an allergy-re

lated life-threatening condition does not have:

• Effective treatment regimen.

• Successful preventive measures.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

Page 122

of 260

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

-,+/4"

Asthma is a common disease. Individuals with asthma generally exhibit reversible airway obstruction that

can be treated effectively with pharmaceutical agents such as bronchodilators and corticosteroids;

however, asthma ranges in severity from essentially asymptomatic to potentially fatal.

In some drivers, complications of asthma and/or side effects of therapy may interfere with safe driving.

You

are responsible on a case-by-case basis for ensuring that the driver is medically fit for duty.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the etiology is confirmed and treatment has been shown to be

adequat

e/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition is stable and

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver exhibits either:

• Continual, uncontrolled, symptomatic asthma.

• Significant impairment of pulmonary function (forced expiratory volume in the first second of

ex

piration (FEV

1

) less than 65%) and significant hypoxemia (partial pressure of arterial oxygen

(PaO

2

) less than 65 millimeters of mercury (mm Hg)).

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

W=A%9,%*,3+3@3+= 8*%.4'*3+3,

Hypersensitivity pneumonitis is an immune-mediated granulomatous interstitial pneumonitis that may

present as an acute recurrent, subacute, or chronic illness variously manifested by dyspnea, cough, and

fever. The condition may not prevent an individual from qualifying for commercial driving; however, the

driver with this condition requires medical care to alleviate symptoms of dyspnea, cough, and fever.

Page 123

of 260

Also, the driver should avoid exposure to the causative agent (e.g., transporting the agent) because

severe respiratory impairment could occur with repeated exposure.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you beli

eve that the nature and severity of the medical condition of the driver

does not endanger the health and safety of the driver and the public.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical con

dition of the driver

endangers the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

Chest X-ray usually reveals interstitial disease. Serum contains precipitating antibodies to the causative

antigen.

0'$$'VU.A

The driver should have at least biennial medical examinations.

3;*'%$B FQ(&*.B&$A" X./+'%0*M)!$("0("

Chronic obstructive pulmonary disease (COPD) is not a single disease, but a group of medical conditions

characterized by chronic reduction of maximal expiratory flow most often caused by:

• Chronic bronchitis.

• Emphysema.

Most drivers with COPD have a combination of chronic bronchitis and emphysema. COPD has an

ins

idious onset. The driver may have substantial reduction in lung function prior to developing dyspnea on

exertion. The cardinal symptoms are:

• Chronic cough.

• Sputum production.

• Dyspnea on exertion.

As the disease progresses, these symptoms can become incapacitating. In the majority of cases,

cig

arette smoking is a primary etiologic factor.

E"3+3*: 8%93'7

No recommended time frame

Page 124 of 260

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the natur

e and severity of the medical condition of the driver is

stable and does not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Hypoxemia at rest.

• Chronic respiratory failure.

• History of continuing co

u

gh with cough syncope.

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

NOTE: Smokers have a high incidence of COPD, yet individuals may have a significant reduction in lung

fu

nction without symptoms. Spirometry should be performed in all smokers over the age of 35 years.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

I%#"B&$'.( ,"(P$*0&'*M)!$("0("(

-6.+% H*(%6+3'., I3,%",%,

For illnesses such as the common cold, influenza, and acute bronchitis, the driver should:

• Be relieved from duty until proper treatment for the illness has been completed.

• Abstain from driving a vehicle for a

t least 12 hours after taking sedating medications.

• Avoid operating a vehicle during the time that the disease is contagious.

Many of these conditions are of short duration and proper treatment for the illness must be completed for

ret

urn-to-work.

E"3+3*: 8%93'7

No recommended time frame

I%63,3'*

Maximum certification — 2 years

Page 125 of 260

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endanger

s the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

Medications used to treat respiratory tract congestion, such as prescriptions and/or over-the-counter

antihistamines or narcotic antitussives, can cause drowsiness and loss of attention. You should educate

the driver to refrain from operating a vehicle for at least 12 hours after taking a medication with sedating

side effects.

0'$$'VU]A

The driver should have at least biennial medical examinations.

-+=A36"$ !.#%96.$',3,

Atypical tuberculosis (TB) covers the same broad spectrum of symptoms and disability as TB. Many

individuals are colonized, but not infected with atypical organisms, usually Mycobacterium avium and

Mycobacterium intracellulare. The broad group of atypical Mycobacteria are considered noninfectious and

do not pose the problem of contagion. The major issue to be determined is the amount of disease the

patient has and the extent of the symptoms. Many cases of Mycobacteria cause very few symptoms. The

X-ray findings are often migratory and are associated with cough, mild hemoptysis, and sputum

production.

Atypica

l TB is not generally treated with medication; however, if the driver is using medication, you should

assess for side effects that interfere with driving ability.

The certification issues include the amount of disease the driver has experienced and the se

verity of the

symptoms. The potential risk is that if the disease is progressive, respiratory insufficiency may develop.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to

be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The disease remains relatively stable and the driver has normal lung function and tolerates the medical

regimen.

Page 126

of 260

Recommend not to certify if:

The driver has:

• Extensive pulmonary dysfunction.

• Weakness.

• Fatigue.

• Adverse reaction to medical treatment.

1'*3+'93*:F!%,+3*:

You should perform pulmonary function tests if you suspect the disease has become progressive and

may cause extensive pulmonary symptoms.

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

8.$4'*"9= !.#%96.$',3,

Although modem therapy has been extremely successful in controlling this disease, pulmonary

tuberculosis (TB) persists in some individuals while on therapy or in individuals who are noncompliant

with therapy. Advanced TB may cause respiratory insufficiency; however, risk of recurrence after

adequate therapy is low.

E"3+3*: 8%93'7

No recommended time frame

You should not certify until:

• Driver is determined not to be contagious.

• Etiology is confirmed and treatment has been shown to be adequat

e/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The driver:

• Is not contagious.

• Has completed streptomycin therapy without affecting hearing and/or balance.

• Is compliant with antitubercular therapy.

• Has no side effects that interfere with safe driving.

Page 127

of 260

Recommend not to certify if:

The driver has:

• Advanced TB with respiratory insufficiency not meeting pulmonary function test criteria.

• Chronic TB.

• Exhibited noncompliance with antitubercular therapy.

• Not co

mpleted streptomycin therapy.

•

Residual eighth cranial nerve damage that affects balance and/or hearing to an extent that

int

erferes with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

A positive intermediate tuberculin skin test (5 tuberculin units (TU)) indicates a previous TB infection. A

posi

tive purified protein derivative (PPD) skin test associated with a normal chest X-ray requires no

further action. If X-ray changes are present suggesting pulmonary TB findings, there is a need for further

evaluation.

If the conversion occurred within the last year, active disease may develop and prophylactic therapy

sho

uld take place. This circumstance would not require limiting the activities of the driver unless

medication side effects and/or adverse reactions occur.

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

c'%9$%#"B&$'.( ,"(P$*0&'*M)!$("0("(

This category includes a number of diseases that cause significant long-term structural changes in the

lungs and/or thorax and, therefore, interfere with the functioning of the lungs. Obvious difficulty breathing

in a resting position is an indicator for additional pulmonary testing. Certification is determined by clinical

evaluation.

)/%,+ E"$$ I%('943+3%,

Acute or chronic chest wall deformities may affect the mechanics of breathing with an abnormal vital

capacity as the predominant abnormality. Examples of these disorders include kyphosis, kyphoscoliosis,

pectus excavatum, ankylosing spondylitis, massive obesity, and recent thoracic/upper abdominal surgery

or injury.

The driver certified with a chest wal

l deformity should have airway function near normal.

No specific medication exists for treatment of this category. However, individuals may be particularly

sen

sitive to the side effects of alcohol, antidepressants, and sleeping medications, even in small doses.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and any associated treatment has been shown

to b

e adequate/effective, safe, and stable.

Page 128 of 260

I%63,3'*

Maximum certification — 2 years

Recommend to cer

tify if:

As the medical examiner, you believe that the nature and severity of the medical condition does not

endanger

the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Hypoxemia at rest.

• Chronic respiratory

failure.

• History of continuing cough with cough syncope.

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

)/9'*36 5#,+9.6+3@% 8.$4'*"9= I3,%",%

Chronic obstructive pulmonary disease (COPD) is not a single disease, but a group of medical conditions

characterized by chronic reduction of maximal expiratory flow most often caused by:

• Chronic bronchitis.

• Emphysema.

Most drivers with COPD have a combination of chronic bronchitis and emphysema. COPD has an

in

sidious onset. The driver may have substantial reduction in lung function prior to developing dyspnea on

exertion. The cardinal symptoms are:

• Chronic cough.

• Sputum production.

• Dyspnea on exertion.

As the disease progresses, these symptoms can become incapacitating. In the majority of cases,

ci

garette smoking is a primary etiologic factor.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequat

e/effective, safe, and stable.

Page 129

of 260

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medic

al examiner, you believe that the nature and severity of the medical condition of the driver is

stable and does not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Hypoxemia at rest.

• Chronic respir

atory failure.

• History of continuing cough with cough syncope.

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

NOTE: Sm

okers have a high incidence of COPD, yet individuals may have a significant reduction in lung

function without symptoms. Spirometry should be performed in all smokers over the age of 35 years.

0'$$'VU]A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

)=,+36 03#9',3,

Until recently, few individuals with cystic fibrosis (CF) lived into adulthood, but with modern therapy the

number of survivors continues to increase. Treatment for CF may require almost continuous antibiotic

therapy and daily respiratory therapy to mobilize abnormal secretions. Chronic debilitating illness may

result in limited physical strength. Some individuals have a mild form of the disease that may not be

diagnosed until early adulthood.

Individuals must be evaluated as to the extent of their disease and

symptoms and ability to obtain therapy

while working.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until it has been documented that treatment has been shown to be

adequat

e/effective, safe, and stable and the driver complies with continuing medical surveillance by the

appropriate specialist.

I%63,3'*

Maximum certification — 2 years

Page 130

of 260

NOTE: When the driver has a condition or treatment that you believe requires frequent monitoring, the

Agency believes that in the absence of other defined parameters, the general recommendation from the

1988 neurological conference report stating, "Any driver with a deficit that requires special evaluation and

screening should have annual recertification," is a reasonable guideline for maximum certification not to

exceed 1 year.

Recommend to certify if:

As the medical examiner, you believe that the nature and seve

rity of the medical condition of the driver

does not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Hypoxemia at rest.

• Chronic respiratory failure.

• History of continuing cough with cough syncope.

• Not met spirometry parameters.

• Unstable condition and/or treatment regimen.

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating specialist, but at least annually.

H*+%9,+3+3"$&D. * : I 3,% ", %

The interstitial lung diseases (ILDs) are a heterogeneous group of diseases classified together because

of common clinical X-ray, physiologic, and pathologic features. Occupational and environmental

exposures are common causes of ILDs.

A history of breathlessness while driving, walking short distances, climbing stairs, handling cargo or

equi

pment, and entering or exiting the cab or cargo space should initiate a careful evaluation of

pulmonary function for any disqualifying secondary conditions.

Although the course of ILDs is variable, progression of the disease is common and often insidious.

Tr

eatment side effects pose a significant potential problem because of the use of conicosteroids and

cytotoxic agents and should be taken into account when assessing commercial drivers.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed

and treatment has been shown to be

adequate/effective, safe, and stable.

Page 131

of 260

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Hypoxemia at rest.

• Chronic respiratory failure.

• History of continuing cough with cough syncope.

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

8*%.4'+/'9"?

Pneumothorax (air in the pleural space) may follow trauma to the chest or may occur spontaneously.

Traumatic Pneumothorax - A medical history and physical examination will provide the details of the

event but may not help to ascertain recovery. Complete recovery should be confirmed by chest X-rays.

Spontaneous Pneumothorax - If spontaneous pneumothorax complicates an existing lung disease

(e.g., emphysema), then the underlying lung disease will determine the chance of a recurrent

pneumothorax and the certification outcome. Chest X-rays (especially views in deep inspiration and full

expiration) will confirm the resolution of air from the pleural space but may show some residual pleural

scarring or apical blebs or bullae.

E"3+3*: 8%93'7

No recommended time frame

Ensure complete recovery using chest X-ra

ys. If there is air in the pleural space and/or air in the

mediastinum (pneumomediastinum) additional time away from work is indicated.

I%63,3'*

Maximum certification — 2 years

Page 132

of 260

Recommend to certify if:

The driver:

• Is asymptomatic without chest pain or shortness of breath.

• Has no disqualifying underlying lung disease.

• Has confirmed resolution of the single spontaneous pneumothorax.

• Has successful pleurodesis and meets acceptable pulmonary parameters.

Recommend not to c

ertify if:

The driver has:

• Not met certification parameters.

• A history of two or more spontaneous pneumothoraces on one side if no successful surgical

proc

edure has been done to prevent recurrence.

• Hypoxemia at rest.

• Chronic respiratory failure.

• A histor

y of continuing cough with cough syncope.

1'*3+'93*:F!%,+3*:

Chest X-rays with the frequency determined by both clinical assessment and by recurrence rates.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

X./+'%0*M)4.%B&$'% <"(&(

Physiological impairment is potentially present in many lung disorders. Indicators for obtaining pulmonary

function testing (PFT) include:

• History of any specific lung disease.

• Symptoms of shortness of breath, cough, chest tightness, or wheezing.

• Cigarette smoking in drivers 35 years of age or older.

2A39'4%+9=

You should obtain forced expiratory volume in the first second of expiration (FEV1), forced vital capacity

(FVC), and FEV1/FVC ratio when any of the following indicators are present:

• History of any specific lung disease.

• Symptoms of shortness of breath, cough, chest tightness, or wheezing.

• Cigarette smoking in drivers 35 years of age or older.

No further testing is necessary

i

f the lung function is normal and no other abnormality is suspected.

Abnormal lung function should be further evaluated.

Page 133 of 260

Screening pulse oximetry and/or arterial blood gas (ABG) analysis are indicated when:

• Condition causes airway obstruction and pulmonary

function test results are:

o FEV

1

less than 65% of the predicted value.

o FEV

1

/FVC ratio less than 65%.

• Restrictive impairment is present and FVC is less than 60%.

269%%*3*:&8.$,%&5?34%+9=

If oximetry is less than 92% (oximetry equals 70), the driver must have an ABG analysis.

-9+%93"$ L$''7 G", -*"$=,3,

Recommend not to certify the driver when ABG measurements reveal:

• Partial pressure of arterial oxygen (PaO

2

) less than:

o 65 millimeters of mercury (mm Hg) at altitudes below 5,000 feet.

o

60 mm Hg at altitudes above 5,000 feet.

•

Partial pressure of arterial carbon dioxide (PaCO

2

) greater than 45 mm Hg at any altitude.

D"B'%>0*M),"(P$*0&'*M)3'%>$&$'%( 0%> =%>"*/M$%- !$('*>"*(

)'9 8.$4'*"$%

Cor pulmonale refers to enlargement of the right ventricle secondary to disorders affecting lung structure

or function. In North America, the most common pulmonary cause of cor pulmonale is hypoxic pulmonary

vasoconstriction in individuals with chronic obstructive pulmonary disease. The most common cause of

right ventricular dilation or enlargement is pulmonary hypertension secondary to left heart disease.

The major risks are:

• Dizziness.

• Hypotension.

• Syncope.

• Common side effects of vasodilators that may interfere with driving.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until diagnosis is confirmed and/or treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

NOTE: When the driver has a condition or treatment that you believe requires frequent monitoring, the

Ag

ency believes that in the absence of other defined parameters, the general recommendation from the

1988 neurological conference report stating, "Any driver with a deficit that requires special evaluation and

screening should have annual recertification," is a reasonable guideline for maximum certification not to

exceed 1 year.

Page 134 of 260

Recommend to certify if:

As the medical examiner, you believe that the nature and seve

rity of the medical condition does not

endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Dyspnea at rest.

• Dizziness.

• Hypotension.

• Partial pressure of arterial oxygen (PaO

2

) in arterial blood greater than 65 millimeters of mercury

(mm Hg).

1'*3+'93*:F!%,+3*:

Obvious difficulty breathing in a resting position is an indicator for additional pulmonary function tests. If

the forced expiratory volume in the first second of expiration (FEV1) is less than 65% of that predicted,

arterial blood gas measurements should be evaluated.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

8.$4'*"9= W=A%9+%*,3'*

Pulmonary hypertension can occur with or without cor pulmonale. Significant pulmonary hypertension is

pulmonary artery pressure greater than 50% systemic systolic blood pressure from any cause.

An increased risk for incapacitation and sudden death is associated with:

• Primary pulmonary hypertension.

• Secondary pulmonary hypertension (e.g., Eisenmenger’s syndrome).

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until diagnosis is confirmed and/or treatment has been shown to be

adequat

e/effective, safe, and stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of th

e medical condition does not

endanger the health and safety of the driver and the public.

Page 135

of 260

Recommend not to certify if:

The driver has:

• Dyspnea at rest.

• Dizziness.

• Hypotension.

• Partial pressure of arterial oxygen (PaO

2

) less than 65 millimeters of mercury (mm Hg).

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have follow-up dependent upon the clinical course of the condition and

recommendation of the treating healthcare provider.

;%.9'$':36"$ ^#_^e_^f_^P_

Commercial motor vehicle (CMV) drivers must be able to sustain vigilance and attention for extended

periods in all types of traffic, road, and weather conditions. Neurological demands of driving include:

• Cognitive demands:

o Sustained vigilance and attention.

o Qui

ck reactions.

o Com

munication skills.

o App

ropriate behavior.

• Ph

ysical demands:

o Coordination.

,$(G #*'+ L"0>0B;"(

Most individuals have experienced the symptoms of headaches, vertigo, and dizziness. While generally

inconsequential, these symptoms may constitute a problem for the driver of a CMV.

Headache and chronic "nagging" pain may be present to such a degree that certification for driving a

CMV i

s inadvisable and the medication used to treat headaches may further interfere with safe driving.

Complaints should be thoroughly examined when determining the overall fitness of the driver. Disorders

with incapacitating symptoms, even if periodic or in the early stages of disease, warrant the decision to

not certify the driver.

,$(G #*'+ V"*&$-')0%> !$ee$%"((

Multiple conditions may affect equilibrium or balance resulting in acute incapacitation or varying degrees

of chronic spatial disorientation. Types of vertigo and dizziness with incapacitating symptoms, even if

periodic or in the early stages of disease warrant the decision to not certify the driver when symptoms

interfere with one or more of the following:

• Cognitive abilities.

• Judgment.

Page 136 of 260

• Attention.

• Concentration.

• Sensory or mot

or function.

,$(G #*'+ D"$e.*"( 0%> NP$/"P(M

Safety is the major reason the driver with epilepsy or seizures is restricted from commercial driving. Loss

of consciousness endangers the driver and the public.

The physical and mental demands of commercial d

riving expose seizure prone individuals to conditions

that may increase the risk for seizures and may interfere with management of seizures, including:

• Inconsistent access to medical evaluation and care for acute problems.

• Delays in replacement of ant

i

convulsant medication if lost or forgotten.

The length of time an individual is seizure free and off anticonvulsant medication is considered the best

predi

ctor of future risk for seizures. Other considerations include:

• The underlying cause of the seizure.

•

The area of the brain affected by disease or injury.

Many driver tasks, from shifting to securing loads, require coordinated voluntary movements. You should

con

sider the following safety implications when evaluating a driver:

• What is the nature and sever

ity of the dysfunction?

• What is the degree of limitation?

• Is the limitation likely to get worse?

• How predictable is the degeneration?

• What is the probability of the dysfunction happening without warning versus progressing over the

sp

a

n of months or years?

• What is the potential for gradual or sudden incapacitation?

;%.9'$':36"$ <%:.$"+3'*, O )0< QPRSOR^#_^e_^f_^P_

49 CFR 391.41(b)(7)

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no established medical history o

r clinical diagnosis of rheumatic, arthritic, orthopedic, muscular,

neuromuscular, or vascular disease which interferes with his/her ability to control and operate a

commercial motor vehicle safely."

49 CFR 391.41(b)(8)

"Has no established medical history o

r clinical diagnosis of epilepsy or any other condition which is likely

to cause loss of consciousness or any loss of ability to control a commercial motor vehicle."

Page 137 of 260

49 CFR 391.41(b)(9)

"Has no mental, nervous, organic, or functional disease or psychiat

ric disorder likely to interfere with

his/her ability to drive a commercial motor vehicle safely."

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a CMV

safely. This examination is for public safety determination and is considered by the Federal Motor Carrier

Safety Administration (FMCSA) to be a “medical fitness for duty" examination.

As the medical examiner, your fundamental obligation during the neurological assessment is to establish

whe

ther a driver has a neurological disease or disorder that increases the risk for sudden death or

incapacitation, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* c".*'/'-$B0/ NO0+$%0&$'%

During the physical examination, you should ask the same questions as you would any individual who is

being assessed for neurological concerns. The FMCSA Medical Examination Report form includes health

history questions and physical examination checklists. Additional questions about neurological symptoms

should be asked and documented to supplement information requested on the form.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver have:

• Seizures, epilepsy, and/or use anticonvulsant medication?

• History of head/brain injuries, disorders, or illnesses?

• Episodes of loss of or altered consciousness?

• Episodes of fainting or dizziness?

• History of stroke with residual paral

ysis?

• Spinal injury or disease with residual effects?

Recommendations — Que

stions that you may ask include

Does the driver:

• Have current limitations resulting from any neuromuscular, nervous, organic, or functional

dis

order?

• Have symptoms related to or c

aused by neurological diseases?

Page 138 of 260

• Use medication to treat neurological disorders, including:

o Anticonvulsants (anticonvulsant therapy recommendations).

o

Anticoagulants (ant

icoagulant therapy recommendations).

o Antiplatelet drugs.

o

Central nervous system stimulants and depressants.

Do

es history of seizures include:

• Childhood febrile seizures?

• Provoked seizures (e.g., induced by anesthesia, hypoglycemia, medi

c

ations, or fever)?

• Unprovoked seizures:

o Single episode?

o

Two or more unprovoked seizures (epilepsy)?

Do

es the driver have signs of undiagnosed neurological disease? Consider:

• Is the information correct and complete?

• Are instructions followed and the res

ponses appropriate and relevant?

• Is the appearance:

o Reasonable for the situation?

o

Reflective of good personal hygiene?

•

Do questions and responses demonstrate alertness, comprehension, appropriateness, and

rel

evance?

• Is behavior appropriate to the neurolog

ical functioning required to drive safely?

Regulations — You

must evaluate

On examination, does the driver have:

• Compromised equilibrium, coordination, and/or speech pattern?

• Asymmetrical deep tendon reflexes?

• Abnormal patellar and Babinski reflexes?

• Sensory abnormalities?

•

Positional abnormalities?

• Ataxia?

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative history, including if available:

o Onset date and diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitat

ion(s).

• Potential negative effects of medication use, including over-the-co

unter medications, while

driving.

Page 139 of 260

• Any abnormal finding(s), noting:

o Effect on driver ability to operate a CMV safely.

o

Necessary steps to correct the condition as soon as possible, par

ticularly if the untreated

condition could result in more serious illness that might affect driving.

• Any additional neurological tests and evaluation.

REMEMBER: Me

d

ical fitness for duty includes the ability to perform strenuous labor. Medical fitness for

duty also requires the driver to be free of any neurological residual limitations sufficiently severe to

interfere with:

• Cognitive abilities.

• Judgment.

• Attention.

• Concentration.

• Vision.

• Physical strength.

• Agility.

• Reaction time.

Overall requirements for co

m

mercial drivers, as well as the specific requirements in the job description of

the driver, should be deciding factors in the certification process.

-7@3,'9= )93+%93"FG.37"*6%

C%&$B'0-./0%& <;"*0PM

The most current guidelines for the use of warfarin (Coumadin) for cardiovascular diseases are found in

the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle

Drivers.

Anticoagulant therapy may be utilized in the treatment of cardiovascular or neurological condition

s. The

guidelines emphasize that the certification decision should be based on the underlying medical disease or

disorder requiring medication, not the medication itself.

E"3+3*: 8%93'7

Minimum — 1 month stabilized

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification period — 1 year

Page 140 of 260

Recommend to certify if:

The driver:

• Is st

abilized on medication for at least 1 month.

• Pr

ovides a copy of the international normalized ratio (INR) results at the examination.

• Has at least monthly INR monitoring.

Recommend not to certify if:

• INR is not being monitored.

• INR is not therapeutic.

• Underlying disease is disqualifying.

1'*3+'93*:F!%,+3*:

The driver should obtain INR monitoring at least monthly.

0'$$'VU.A

The driver should bring results of INR monitoring to the examination.

To review the Venous Disease Recommendation Tables, see Appendix D of this handbook.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a cerebrovascular disorder.

NOTE: The rationale for disqualification is the high rate of complications associated with bleeding that

can incapacitate the driver while operating a vehicle.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

C%&$B'%A./(0%& <;"*0PM

Anticonvulsant therapy is used to control or prevent seizures. Even with effective therapy there is still a

risk for a seizure should the medication be missed inadvertently.

Page 141 of 260

Anticonvulsants are also prescribed for other conditions that do not cause seizures, including some

psychiatric disorders (for antimanic and mood-stabilizing effects) and to lessen chronic pain.

Side effects may include:

• Depressed mood.

• Cognitive deficits.

• Decreased reflex responses.

• Unsteadiness.

• Sedation.

Small doses used for chronic pain are less likel

y to be associated with side effects that can interfere with

safe driving than the doses used to treat other disorders.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the medication has been shown to be adequate/

effective, safe, and

stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe:

• Nature and severity of the underlying condition does not interfere with safe driving.

• Effects of medication used whi

le operating a commercial motor vehicle does not endanger the

safety of the driver and the public.

Recommend not to certify if:

The driver uses anticonvulsant medications to control or prevent seizures.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have annual medical examinations.

NP$('>$B c".*'/'-$B0/ 3'%>$&$'%(

Episodic neurological conditions guidance can be grouped based on the type of risk associated with the

condition.

The first group considers the types of headache, vertigo, and dizziness that can affect cognitive abilities,

jud

gment, attention, and concentration, as well as impact sensory or motor function sufficiently to interfere

with the ability to drive a commercial motor vehicle safely.

Page 142 of 260

The second group addresses the conditions that are known to cause or increase the risk for seizures,

including epilepsy.

-6.+% 2%3g.9%, C 2+9.6+.9"$ H*,.$+ +' +/%&L9"3*

Individuals may have a seizure at the time of a brain insult. In many situations, the occurrence of seizures

is a reflection of the site of injury but may also be a surrogate for severity. Nonetheless, most neurological

conditions in which acme or early seizures may occur are also risk factors for later unprovoked seizures.

In fact, the occurrence of early seizures adds a significant increment of risk for later epilepsy to that

associated with the primary condition. In general, the risk for subsequent unprovoked seizures is greatest

in the first 2 years following the acute insult.

Approximately 12% of individuals suffering an occlusive cerebrovascular insult resulting in a fixed

neur

ological deficit will experience a seizure at the time of the insult. Unprovoked seizures will occur

within the next 5 years in 16% of all individuals with an occlusive vascular insult. This rate seems not to

be modified significantly by the occurrence of early seizures. The risk is increased primarily in individuals

with lesions associated with cerebral cortical or subcortical deficits. The same risk of seizure and

recommendations are applicable for intracerebral or subarachnoid hemorrhage.

The length of time an individual is seizure free and off anticonvulsant medication is considered th

e best

predictor of future risk for seizures. Therefore, according to medical guidelines, for the entire waiting

period before being considered for certification, the driver should be both:

• Seizure free.

• Off anticonvulsant medication prescribed for control

of seizures.

For those individuals who survive severe head injury, the risk for developing unprovoked seizures does

not

decrease significantly over time. Based upon the risk for unprovoked seizures alone, the driver should

not be considered for certification.

NOTE: Su

rgical procedures involving dural penetration have a risk for subsequent epilepsy similar to that

of severe head trauma. Individuals who have undergone such procedures, including those who have had

surgery for epilepsy, should not be considered eligible for certification.

E"3+3*: 8%93'7

Minimum — 1 year seizure free and off anticonvulsant medication following:

• Mild insult without early seizures.

• Stroke without risk for seizures.

• Intracerebral or subarachnoid hemorrhage without risk for seizures.

Minimum — 2

years seizure free and off anticonvulsant medication following:

• Moderate insult without early seizures.

• Mild insult with early seizures.

Minimum — 5

years seizure free and off anticonvulsant medication following:

• Moderate insult with ear

ly seizures.

• Stroke with risk for seizures.

• Intracerebral or subarachnoid hemorrhage with risk for seizures.

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

Page 143

of 260

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver with a history of mild or moderate insult has:

• Completed the minimum waiting period seizure free and off anticonvulsant medica

tion.

• Normal physical examination, neurological examination including neuro-opht

halmological

evaluation, and neuropsychological test.

• Clearance from a neurologist who understands the functions and demands of commercial driving.

Recommend not to certify if

:

The driver has a history of a severe brain insult with or without early seizures.

Th

e driver with a mild or moderate insult:

• Has not completed the minimum waiting period seizure free and off anticonvulsant medication.

• Does not have a normal physical ex

amination, neurological examination including neuro-

ophthalmological evaluation, or neuropsychological test.

• Does not have clearance from a neurologist who understands the functions and demands of

commercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

-6.+% 2%3g.9%, C 2=,+%436 1%+"#'$36 H$$*%,,

Seizures are the normal reaction of a properly functioning nervous system to adverse events. In the

presence of systemic metabolic illness, seizures are generally related to the consequences of a general

systemic alteration of biochemical homeostasis and are not known to be associated with any inherent

tendency to have further seizures. The risk for recurrence of seizures is related to the likelihood of

recurrence of the inciting condition.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is co

nfirmed and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Page 144

of 260

Recommend to certify if:

• The underlying systemic metabolic dysfunction has been corrected.

• The driver has no disqualifying risk of re

currence of the primary condition.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endanger

s the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations.

)/3$7/''7&0%#93$% 2%3g.9%,

Febrile seizures occur in from 2% to 5% of the children in the United States before 5 years of age and

seldom occur after 5 years of age. From a practical standpoint, most individuals who have experienced a

febrile seizure in infancy are unaware of the event and the condition would not be readily identified

through routine screening. Most of the increased risk for unprovoked seizure is appreciated in the first 10

years of life.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and tr

eatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The history of seizures is limited to childhood febrile seizures.

Recommend not to certify if:

As the medical examiner, yo

u believe that the nature and severity of the medical condition of the driver

endangers the health and safety of the driver and the public.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations.

Page 145

of 260

>A3$%A,=

The advisory criteria for 49 CFR 391.41(b)(8) says, "Epilepsy is a chronic functional disease

characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control

which may lead to loss of consciousness and/or seizures. Therefore, the following drivers cannot be

qualified: (1) a driver who has a medical history of epilepsy; (2) a driver who has a current clinical

diagnosis of epilepsy; or (3) a driver who is taking antiseizure medication."

Following an initial unprovoked seizure, the commercial motor vehicle (CMV) driver should be seizure

fr

ee and off anticonvulsant medication for at least 5 years to distinguish between a medical history of a

single instance of seizure and epilepsy. A second unprovoked seizure, regardless of the elapsed time

between seizures, would constitute a medical history of epilepsy and the driver would no longer meet the

physical requirements for 49 CFR 391.41(b)(8).

NOTE: Ep

ilepsy medical guidelines are currently under review by the Federal Motor Carrier Safety

Administration. While there have been no changes through the rulemaking process to the wording of 49

CFR 391.41(b)(8), current advisory criteria allow that some "drivers with a history of epilepsy/seizures off

antiseizure medication and seizure-free for 10 years may be qualified to drive a CMV in interstate

commerce."

E"3+3*: 8%93'7

Minimum —10 years off anticonvulsant medication and seizure free

I%63,3'*

Recommend to certify if:

The driver has completed a waiting period of 10 years off anticonvulsant medication and seizure free and

yo

u, as the medical examiner, believe that the nature and severity of the medical condition of the driver

does not endanger the health and safety of the driver and the public.

According to regulation, you must not certify if:

The driver has:

• An established medical history of epilepsy.

• A clinical diagnosis of epilepsy.

• Any other condition likely to ca

use loss of consciousness or any loss of ability to control a CMV.

NOTE: If y

ou choose to certify a driver with an established medical history of epilepsy, be sure to include

in your documentation reference to the advisory criteria and all medical evaluation supporting your

decision.

Recommend not to certify if:

The driver is taking anticonvulsant medication because of a medical history of one or more seizures or is

at

risk for seizures.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty. Clearance from a specialist in neurological diseases who understands the

Page 146

of 260

functions and demands of commercial driving is a prudent course of action if choosing to certify the driver

with an established history of epilepsy.

0'$$'VU.A

The driver should have an annual medical examination.

W%"7"6/%,

Chronic or chronic-recurring headache syndromes can potentially interact with other neurological

diagnostic categories in two ways:

• Through complications (e.g., stroke in relation to migraine).

• As a result of associated features of a particular syndrome (e.g., the visual distortion or

di

sequilibrium associated with a migraine attack).

The fo

llowing types of headaches may interfere with the ability to drive a commercial motor vehicle safely:

• Migraines.

• Tension-ty

pe headaches.

• Cluster headaches.

• Post-tr

aumatic head injury syndrome.

• Headaches associated with substances or withdrawal.

• Cranial neur

algias.

• Atypical facial pain.

Consider headache frequency and severity when evaluating a driver whose history includes headaches.

In

addition to pain, inquire about other symptoms caused by headaches, such as visual disturbances, that

may interfere with safe driving.

Consider the treatment used to relieve headaches. Do the effects or side effects of treatment interfere

wi

th safe driving?

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has

been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endanger

s the health and safety of the driver and the public.

Page 147

of 260

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations.

23*:$%&]*A9'@'K%7 2%3g.9%

An unprovoked seizure occurs in the absence of an identifiable acute alteration of systemic metabolic

function or acute insult to the structural integrity of the brain. There may be a known or distant cause of

the seizure.

While individuals who experience a single unprovoked sei

zure do not have a diagnosis of epilepsy, they

are clearly at a higher risk for having further seizures. The overall rate occurrence is estimated to be 36%

within the first 5 years following the seizure. After 5 years, the risk for recurrence is down to 2% to 3% per

year for the total group.

Following an initial unprovoked seizure, the driver should be seizure free and off ant

iconvulsant

medication for at least 5 years to distinguish between a medical history of a single unprovoked seizure

and epilepsy (two or more unprovoked seizures). A second unprovoked seizure, regardless of the

elapsed time between seizures, would constitute a medical history of epilepsy, and the driver would no

longer meet the physical requirements for 49 CFR 391.41(b)(8).

The length of time an individual is seizure free and off anticonvulsant medication is considered the best

pr

edictor of future risk for seizures. Therefore, for the entire waiting period before being considered for

certification, the driver should be both:

• Seizure free.

• Off anticonvulsant medication prescribed for control of seizures.

E"3+3*: 8%93'7

Minimum — 5 years seizure free and off anticonvulsant medication

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver has:

• Completed the minimum waiting period seizure free and off anticonvulsant medication.

• Clearance from a neurologist who specializes in epilepsy and understands the functions and

dem

ands of commercial driving.

Page 148

of 260

Recommend not to certify if:

The dr

iver:

• Has not completed the minimum waiting period seizure free and off anticonvulsant medication.

• Does not have clearance from a neurologist who specializes in epilepsy and understands the

fu

nctions and demands of commercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations.

J%9+3:' "*7 I3gg3*%,,

The normal ability to maintain balance and orientation while operating a commercial motor vehicle (CMV)

depends upon peripheral nervous system (PNS) sensory input from three major systems and the

appropriate motor integration in the central nervous system (CNS). The three PNS sensory systems are

vestibular, visual, and proprioception. Inappropriate interactions of these systems or interactions within

the CNS may produce an unsafe degree of vertigo or dizziness that endangers the health and safety of

the driver and the public.

The most common medications used to treat vertigo are antihistamines, benzodiazepines, and

phenot

hiazines. Use of either benzodiazepines or phenothiazines for the treatment of vertigo would

render the driver medically unqualified. Special consideration should be given to the possible sedative

side effects of antihistamines. The medical examiner should determine if these drugs produce sedation in

the individual driver.

E"3+3*: 8%93'7

Minimum — 2 months asymptomatic with diagnosis of:

• Benign positional vertigo.

• Acute

and chronic peripheral vestibulopathy.

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 2 years

NOTE: An

y driver with a deficit that requires special evaluation and screening should be recertified

annually.

Recommend to certify if:

The driver has a diagnosis of:

• Benign positional vertigo and has completed the appropriate sympto

m-free waiting period.

Page 149

of 260

• Acute and chronic peripheral vestibulopathy and has completed the appropriate symptom-free

waiting period.

• A medical condition of a nature and severity that does not endanger the health and safety of the

dri

ver and the public.

Recommend not to certify if:

Th

e driver has a diagnosis of:

• Benign positional vertigo and has been symptomatic within the past 2 months.

• Acute and chronic peripheral vestibulopathy and has been symptomatic within the past 2 months.

• Meniere's disease.

• Labyrinthine fistula.

• Nonfunctioning labyrinths.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations.

I%#"B&$'%( '# &;" 3"%&*0/ c"*A'.( DM(&"+

The guidelines for central nervous system (CNS) infection consider diagnosis and whether or not the

driver has a history of early seizures with the condition. Aseptic meningitis is not associated with any

increase in risk for subsequent unprovoked seizures; therefore, no restrictions should be considered for

such individuals, and they should be considered qualified to obtain a license to operate a commercial

vehicle.

A driver with a current clinical CNS diagnosi

s or signs and symptoms of a CNS infection should not be

considered for certification until the etiology is confirmed and treatment has been shown to be

adequate/effective, safe, and stable.

Page 150 of 260

E"3+3*: 8%93'7

Minimum — 1 year seizure free and off anticonvulsant medication following:

• Bacterial meningitis without early seizures.

• Viral encephalitis without early seizures.

Min

imum — 5 years seizure free and off anticonvulsant medication following:

• Bacterial meningitis

with early seizures.

Minimum — 10 years seizure free and off anticonvulsant medication following:

• Viral encephalitis with early seizures.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The driver has a history of:

• Aseptic meningitis

.

• Bacterial meningitis and has completed the appropriate recommended waiting period.

• Viral encephalitis and has completed the appropriate recommended waiting period.

Recommend not to certify if:

The driver has a current CNS infection.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

You may on a case-by-case basis determine that annual medical examination is appropriate.

c".*'+.(B./0* !$("0("(

As a group, neuromuscular diseases are usually insidious in onset and slowly progressive. The rate of

progression will vary and is generally measured in months to years. Rare neuromuscular diseases may

be episodic producing weakness over minutes to hours.

You must consider the effects of neuromuscular conditions on the physical abilities of the driver to initiate

and m

aintain safe driving including steering, braking, clutching, getting in and out of vehicles, and

reaction time.

Examination by a neurologist or physiatrist who understands the functions and demands of commercial

dri

ving may be required to assess the status of the disease. As the medical examiner, you determine

certification status.

Page 151 of 260

-.+'*'436 ;%.9'A"+/=

Autonomic neuropathy affects the nerves that regulate vital functions, including the heart muscle and

smooth muscles.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been shown to be

adequat

e/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As a medical examiner, you believe that the nature and severity of the medical condition of the driver

does

not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Cardiovascular autonomic neuropathy that causes:

o Re

sting tachycardia.

o Or

thostatic blood pressure.

• Other organ autonomic neuropathy that interferes with driving ability.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have a biennial physical examination or more frequently if needed to adequately

monitor medical fitness for duty.

)'*73+3'*, -,,'63"+%7&V3+/&-#*'94"$ 1.,6$% -6+3@3+=

This group of disorders is characterized by abnormal muscle excitability caused by abnormalities either in

the nerve or in the muscle membrane.

E"3+3*: 8%93'7

No recommended time frame

You should not ce

rtify the driver until etiology is confirmed and treatment has been shown to be

adequate/effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Page 152

of 260

Recommend to certify if:

As a medical examiner, you believe that the nature and severity of the

medical condition of the driver

does not endanger the health and safety of the driver and the public.

Recommend not to certify if:

The driver has a diagnosis of:

• Myotonia.

• Isaac's syndrome.

• Stiff-ma

n syndrome.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have a biennial physical examination or more frequently if needed to adequately

monitor medical fitness for duty.

)'*:%*3+"$ 1='A"+/3%,

Congenital myopathies are a group of disorders that may be distinguished from others because of

specific, well-defined structural alterations of the muscle fiber and may be progressive or nonprogressive.

These disorders include:

•

Central core disease.

• Centronuclear myopathy.

• Congenital muscular dystrophy.

• Rod (nemaline) myopathy.

Inflammatory myopathies are acquired muscle diseases that may be treated. These disorders include:

•

Dermatomyositis.

• Inclusion body myositis.

• Polymyositis.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of a congenital myopathy disorder.

Page 153

of 260

NOTE: Neuromuscular disorders represent a complex group of conditions. The severity can vary with the

individual and in certain instances may be treatable or nonprogressive. Guidelines for reconsideration of

the decision not to certify include:

• Evaluation by a neurologist or physiatrist who understands the functions and demands of

commercial driving. Specialist may recommend a simulated driving skills test or equivalent

functional test.

• Annual recertification that repeats specialist evaluation and driving test when indicated.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

1%+"#'$36 1.,6$% I3,%",%,

Metabolic muscle diseases are a group of disorders comprised of conditions affecting the energy

metabolism of muscle or an imbalance in the chemical composition either within or surrounding the

muscle. Conditions may affect glycogen and glycolytic metabolism, lipid metabolism, mitochondrial

metabolism, or potassium balance of the muscle. Unlike most other neuromuscular disorders, these

conditions may either be insidiously progressive or episodic.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of a metabolic muscle disease.

NOTE: Ne

uromuscular disorders represent a complex group of conditions. The severity can vary with the

individual and in certain instances may be treatable or nonprogressive. Guidelines for reconsideration of

the decision not to certify include:

• Evaluation by a neurologist or physiatrist who understands the functions and demands of

commercial driving. Specialist may recommend a simulated driving skills test or equivalent

functional test.

• Annual recertification that repeats specialist evaluation and driving test when indicated.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

Page 154

of 260

1'+'9 ;%.9'* I3,%",%,

This group of disorders includes:

• Hereditary spinal muscular atrophy in both juvenile and adult forms.

• Acquired amyotrophic lateral sclerosis conditions producing degeneration of the motor nerve cells

in

the spinal cord.

As a group these are debilitating, insidiously progr

essive conditions that interfere with the ability to drive

commercial vehicles.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of a motor neuron disease.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

1.,6.$"9 I=,+9'A/3%,

Muscular dystrophies are hereditary, progressive, degenerative diseases of the muscle that interfere with

safe driving.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of a muscular dystrophy disease.

Page 155

of 260

NOTE: Neuromuscular disorders represent a complex group of conditions. The severity can vary with the

individual and in certain instances may be treatable or nonprogressive. Guidelines for reconsideration of

the decision not to certify include:

• Evaluation by a neurologist or physiatrist who understands the functions and demands of

commercial driving. Specialist may recommend a simulated driving skills test or equivalent

functional test.

• Annual recertification that repeats specialist evaluation and driving test when indicated.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

;%.9'4.,6.$"9 M.*6+3'* I3,'97%9,

This group of disorders includes:

• Myasthenia gravis.

• Myasthenic syndrome.

In addition to limb muscle weakness, vision is often affected and easy fatigability is a common

ma

nifestation.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not

to certify if:

The driver has a diagnosis of a neuromuscular junction disorder.

NOTE: Ne

uromuscular disorders represent a complex group of conditions. The severity can vary with the

individual and in certain instances may be treatable or nonprogressive. Guidelines for reconsideration of

the decision not to certify include:

• Evaluation by a neurologist or physiatrist who understands the functions and demands of

commercial driving. Specialist may recommend a simulated driving skills test or equivalent

functional test.

• Annual recertification that repeats specialist evaluation and driving test when indicated.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

Page 156

of 260

8%93A/%9"$ ; %.9'A"+/3%,

This group of disorders consists of hereditary and acquired conditions where the nerves, including the

axon and myelin or the myelin selectively outside the spinal cord, are affected. These conditions may

affect the sensory or motor nerves individually, or both may be affected.

Peripheral neuropathy may be a complica

tion of diabetes mellitus. You should evaluate the sensory

modalities of pain, light touch, position, and vibratory sensation in the toes, feet, fingers, and hands for

signs of peripheral neuropathy.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of a peripheral neuropathy.

NOTE: Neuromuscular disorders represent a complex group of conditions. The severity can vary with the

individual and in certain instances may be treatable or nonprogressive. Guidelines for reconsideration of

the decision not to certify include:

• Evaluation by a neurologist or physiatrist who understands the functions and demands of

commercial driving. Specialist may recommend a simulated driving skills test or equivalent

functional test.

• Annual recertification that repeats specialist evaluation and driving test when indicated.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

X*'-*"(($A" c".*'/'-$B0/ 3'%>$&$'%(

Guidelines recommend that any driver having neurological signs or symptoms be referred to a neurologist

for more detailed and qualified evaluation of neurological status in relation to certification for driving a

commercial motor vehicle.

When requesting additional evaluation fro

m a specialist, the specialist must understand the role and

function of a driver; therefore, it is helpful if you include a copy of the Medical Examination Report form

description of the driver role and a copy of the applicable medical standards (page 4) and guidelines with

the request.

)%*+9"$ ;%9@'., 2=,+%4 !.4'9,

The central nervous system (CNS) is the seat of our intelligence and emotions, and an affliction of the

CNS impacts everyday functioning in a direct and visible manner. Brain tumors may alter cognitive

abilities and judgment, and these symptoms may occur early in the course of the condition. Sensory and

Page 157 of 260

motor abnormalities may be produced both by brain tumors and by spinal cord tumors, depending on the

location. For some benign tumors, certification may be possible after successful surgical treatment.

The lengt

h of time an individual is seizure free and off of anticonvulsant medication is considered the best

predictor of future risk for seizures. Therefore, for the entire waiting period before being considered for

certification, the driver must be both:

• Seizur

e free.

• Off anticonvulsant medication prescribed for control of seizures.

E"3+3*: 8%93'7

Minimum — 1 year post-surgical removal of:

• Infratentorial meningiomas.

• Acoustic neuromas.

• Pituitary adenomas.

• Spinal benign tumors.

• Benign extra-ax

ial tumors.

Minimum — 2 years post-surgical removal of:

• Benign supratentorial tumors.

• Spinal tumors.

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver has:

• Completed the appropriate minimum waiting period.

• Stable nonprogressive deficit or no neurological deficit.

• Imaging that shows no tumors.

NOTE: If th

e driver has a history of seizures, use the appropriate seizure guidelines.

Recommend not to certify if:

The driver has:

• Not completed appropriate waiting period.

• Primary or metastatic malignant tumors of the nervous system.

• Benign nervous system tumor

s.

Page 158

of 260

1'*3+'93*:F!%,+3*:

Since meningiomas may be multiple, residual examinations must show no evidence of recurrent or new

tumors. Evaluation should be performed by a neurologist or physiatrist who understands the functions

and demands of commercial driving.

0'$$'VU.A

The driver should have an annual medical examination.

I%4%*+3"

Dementia is a progressive decline in mental functioning that can interfere with memory, language, spatial

functions, higher order perceptual functions, problem solving, judgment, behavior, and emotional

functions. Alzheimer's and Pick's diseases both cause dementia and have symptoms that are

incompatible with the safe driving. Neither disease has a specific diagnostic test, with mild symptoms

typically present for years before the diagnosis is made. Alzheimer's is the most common degenerative

disease.

The rationale for making a decision not to certify when a diagnosis of dementia is present includes:

•

There are no current data providing evidence that a driver with diagnosed dementia can drive a

commercial motor vehicle safely.

• The disease rate of progression is variable.

E"3+3*: 8%93'7

Not applicable.

I%63,3'*

Recommend to certify if:

Not applicable.

Recommend not to certify if:

The driver has a diagnosis of dementia.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

Not applicable.

D&0&$B c".*'/'-$B0/ 3'%>$&$'%(

Static neurological conditions include common cerebrovascular disease, as well as head and spinal cord

injuries.

Cerebrovascular events may cause cognitive, judgment, attention, concentration, and/or motor and

sen

sory impairments that can interfere with normal operation of a commercial motor vehicle (CMV).

Drivers with several types of cerebrovascular disease are also at risk for recurring events that can happen

without warning. Drivers with ischemic cerebrovascular disease are also at high risk for acute cardiac

events, including myocardial infarction or sudden cardiac death. Recurrent cerebrovascular symptoms or

cardiac events can occur with sufficient frequency to cause concern about the safe operation of a CMV.

Page 159 of 260

The common types of cerebrovascular disease are:

• Transient ischemic attack/minor stroke with minimal or no residual impairment.

• Embolic or thrombotic cerebral infarction with moderate to major residual impai

rment.

• Intracerebral or subarachnoid hemorrhage.

Head injury recommendations include complete physical examination, neurological examination, and

neur

opsychological testing with normal results and the use of the seizure guidelines to determine

certification status. Spinal cord injury resulting in paraplegia is disqualifying. Any weakness should be

evaluated to determine whether the deficit interferes with the job requirements of a commercial driver.

Any driver with a neurological deficit that requires speci

al evaluation and screening should have annual

medical examinations.

>4#'$36 "*7 !/9'4#'+36 2+9'K%,

More than 3 million individuals have survived a stroke, and it is a major cause of long-term disability.

Embolic and thrombotic cerebral infarctions are the most common forms of cardiovascular disease. Risk

for complicating seizures is associated with the location of the lesions.

• Cerebellum and brainstem vascular lesions are not associated with an increased risk for seizures.

• Cortical and subcortical deficits

are associated with an increased risk for seizures.

• Evaluation by a neurologist is necessary to confirm the area of involvement.

Drivers with embolic or thrombotic cerebral infarctions will have residual intellectual or physical

im

pairments. Fatigue, prolonged work, and stress may exaggerate the neurological residuals from a

stroke. Most recovery from a stroke will occur within 1 year of the event.

The neurological examination should include assessment of:

• Cognitive abilities.

• Judgment.

• Attention.

• Concentration.

• Vision.

• Physical strength and agility.

• Reaction time.

E"3+3*: 8%93'7

Minimum — 1 year if not at risk for seizures (cerebellum or brainstem vascular lesions)

Minimum — 5

years if at risk for seizures (cortical or subcortical deficits)

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Page 160

of 260

Recommend to certify if:

The

driver with a history of stroke has:

• Completed the appropriate waiting period.

• Normal physical examination, neurological examination including neuro-opht

halmological

evaluation, and neuropsychological testing.

• No neurological residuals or, if present, residuals of a severity that does not interfere with ability

to operate a commercial motor vehicle.

• Clearance from a neurologist who understands the functions and demands of commercial driving.

Recommend not to certify if:

The driver:

• Has not completed the appr

opriate waiting period.

• Uses oral anticoagulant therapy because of the risks associated with excessive bleeding.

• Uses any other drug or combination of drugs that have potentially high rates of complications

(e

.g., depressing effects on the nervous system).

• Has residual intellectual or physical impairments that interfere with commercial driving.

• Does not have clearance from a neurologist who understands the functions and demands of

co

mmercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

H*+9"6%9% # 9" $&"* 7 2. # "9 "6 /* ' 37 W % 4 ' 99 / ": %,

Intracerebral hemorrhage results from bleeding into the substance of the brain and subarachnoid

hemorrhage reflects bleeding primarily into the spaces around the brain. Bleeding occurs as a result of a

number of conditions including hypertension, hemorrhagic disorders, trauma, cerebral aneurysms,

neoplasms, arteriovenous malformations, and degenerative or inflammatory vasculopathies.

Subarachnoid and intracerebral hemorrhages can cause serious residual neurological deficits in:

• Cognitive abilities.

• Judgment.

• Attention.

• Physical skills.

The risk for seizures fo

llowing intracerebral and subarachnoid hemorrhages is associated with the

location of the hemorrhage:

• Cerebellum and brainstem vascular hemorrhages are not associated with an increased risk for

se

izures.

Page 161

of 260

• Cortical and subcortical hemorrhages are associated with an increased risk for seizures.

• Appropriate evaluation by a neurologist is required to confirm the area of involvement.

The recommendations for intracranial and subarachnoid hemorrhages parallel recommendations for

st

rokes.

E"3+3*: 8%93'7

Minimum — 1 year if not at risk for seizures (cerebellum or brainstem vascular lesions)

Minimum — 5 years if at risk for seizures (cortical or subcortical deficits)

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver with a history of intracranial or subarachnoid hemorrhage has:

• Completed the appropriate waiting period.

• Normal physical examination, neurological examination including neuro-opht

halmological

evaluation, and neuropsychological testing.

• No neurolo

gical residuals or, if present, residuals of a severity that do not interfere with the ability

to operate a commercial motor vehicle.

• Clearance from a neurologist who understands the functions and demands of commercial driving.

Recommend not to certify if:

The driver:

• Has not completed the appropriate waiting period

• Uses oral anticoagulant therapy because of the risks associated with excessive bleeding.

• Uses any other drug or drug combination with a potentially high rate of complications (e.g.,

depr

essing effects on the nervous system).

• Has residual intellectual or physical impairments that interfere with commercial driving.

• Does not have clearance from a neurologist who understands the functions and demands of

co

mmercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

Page 162

of 260

!9"*,3%*+ H,6/%436 -++"6K

Intracerebral hemorrhage results from bleeding into the substance of the brain and subarachnoid

hemorrhage reflects bleeding primarily into the spaces around the brain. Bleeding occurs as a result of a

number of conditions including hypertension, hemorrhagic disorders, trauma, cerebral aneurysms,

neoplasms, arteriovenous malformations, and degenerative or inflammatory vasculopathies.

Subarachnoid and intracerebral hemorrhages can cause serious residual neurological deficits in:

• Cognitive abilities.

• Judgment.

• Attention.

• Physical skills.

The risk fo

r seizures following intracerebral and subarachnoid hemorrhages is associated with the

location of the hemorrhage:

• Cerebellum and brainstem vascular hemorrhages are not associated with an increased risk for

se

izures.

• Cortical and subcortical hemorrhages ar

e associated with an increased risk for seizures.

• Appropriate evaluation by a neurologist is required to confirm the area of involvement.

The recommendations for intracranial and subarachnoid hemorrhages parallel recommendations for

st

rokes.

E"3+3*: 8%93'7

Minimum — 1 year if not at risk for seizures (cerebellum or brainstem vascular lesions)

Minimum — 5

years if at risk for seizures (cortical or subcortical deficits)

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver with a history of intracranial or subarachnoid hemorrhage has:

• Completed

the appropriate waiting period.

• Normal physical examination, neurological examination including neuro-opht

halmological

evaluation, and neuropsychological testing.

• No neurological residuals or, if present, residuals of a severity that do not interfere with the ability

to

operate a commercial motor vehicle.

• Clearance from a neurologist who understands the functions and demands of commercial driving.

Page 163

of 260

Recommend not to certify if:

The driver:

• Has not completed the appropriate waiting period

• Uses oral ant

icoagulant therapy because of the risks associated with excessive bleeding.

• Uses any other drug or drug combination with a potentially high rate of complications (e.g.,

depr

essing effects on the nervous system).

• Has residual intellectual or physical impairments that interfere with commercial driving.

• Does not have clearance from a neurologist who understands the functions and demands of

co

mmercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

!9".4"+36 L9"3* H*b.9=

Traumatic brain injury (TBI) is an insult to the brain caused by an external physical force, which may

produce a diminished or altered state of consciousness, including coma, resulting in long-term impairment

of cognitive or physical function.

Disturbances of behavioral or emotional functioning may result in total or partial disability and/or

ps

ychological maladjustment. Many people with TBI suffer loss of memory and reasoning ability,

experience speech and/or language problems, and exhibit emotional and behavioral changes that are

medically disqualifying for commercial driving.

TBI is classified by depth of dural penetrat

ion and duration of loss of consciousness. The three classes

are:

• Severe head injury penetrates the dura and causes a loss of consciousness lasting longer than

24

hours. There is a high risk for unprovoked seizures, and the risk does not diminish over time.

• Moderate head injury does not penetrate the dura but causes a loss of consciousness lasting

lo

nger than 30 minutes, but less than 24 hours.

• Mild head injury has no dural penetration or loss of consciousness and lasts for fewer than 30

minutes. Be sure to distinguish between mild TBI with or without early seizures.

The length of time an individual is seizure free and off anticonvulsant medication is considered the best

pr

edictor of future risk for seizures. Therefore, for the entire waiting period before being considered for

certification, the driver must be both:

• Seizure free.

• Off anticonvulsant medication prescribed for control of seizure.

NOTE: Su

rgical procedures involving dural penetration have a risk for subsequent epilepsy similar to that

of severe head trauma. Individuals who have undergone such procedures, including those who have had

surgery for epilepsy, should not be considered eligible for certification.

Page 164

of 260

E"3+3*: 8%93'7

Minimum — 2 years seizure free and off anticonvulsant medication following:

• Moderate TBI without early seizures.

• Mild TBI with early seizures.

Mi

nimum — 5 years seizure free and off anticonvulsant medication following:

• Moderate TBI with early seizures.

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Maximum certification — 2 years for mild TBI without early seizures

Recommend to certify if:

The driver with a mild or moderate TBI who has:

• Completed the minimum waiting period seizure free and off anticonvulsant medication.

• Normal physical examination, neurological examination including neuro-opht

halmological

evaluation, and neuropsychological test.

• Clearance from a neurologist who understands the functions and demands of commercial driving.

Recommend not to certify if:

The driver has sustained a severe TBI with or without early seizures.

Th

e driver with a mild or moderate TBI:

• Has not completed the minimum waiting period seizure free and off anticonvulsant medication.

• Does not have a normal physical examination, neurological examination including neuro-

ophthalmological evaluation, or neuropsychological test.

• Does not have clearance from a neurologist who understands the functions and demands of

co

mmercial driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver should have an annual medical examination.

Page 165

of 260

D.++0*M)'# c".*'/'-$B0/ :0$&$%- X"*$'>(

2%3g.9%&E"3+3*:&8%93'7,

The driver must complete the minimum waiting period seizure free and off anticonvulsant medication.

Waiting Period

Diagnosis

10 years

History of epilepsy.

Viral encephalitis with early seizures.

5 years

Single unprovoked seizure, no identified

acute change, may be distant cause (possible

earlier return to driving if normal neurological

examination by a specialist in epilepsy who

understands the functions and demands of

commercial driving, and the driver has a

normal electroencephalogram).

Bacterial meningitis and early seizures.

2 years

Acute seizure with acute structural central

nervous system insult.

Based on risk of recurrence of primary

condition.

Acute seizure with acute systemic/metabolic

illness.

Table 5 - Seizure Waiting Periods

5+/%9 ;%.9'$':36"$ >@%*+ E"3+3*: 8%93'7,

The driver must complete the minimum waiting period seizure free and off anticonvulsant medication.

Waiting Period

Diagnosis

5 years

Moderate traumatic brain injury (TBI) with early

seizures.

Stroke with risk for seizures.

Intracerebral or subarachnoid hemorrhage with

risk for seizures.

2 years

Moderate TBI without early seizures.

Surgically removed supratentorial or spinal

tumors.

1 year

Transient ischemic attack, stroke, or

intracerebral or subarachnoid hemorrhages with

no risk for seizures.

Surgically-repaired arteriovenous

malformations/aneurysm with no risk for

seizures.

Page 166 of 260

Surgically removed infratentorial meningiomas,

acoustic neuromas, pituitary adenomas, and

benign spinal tumors or other benign extraaxial

tumors with no risk for seizures.

Infections of the central nervous system (e.g.,

bacterial meningitis, viral encephalitis without

early seizures).

Table 6 - Other Neurological Event Waiting Periods

1.,6.$',K%$%+"$ ^#_^R_^`_^e_

Disorders of the musculoskeletal system affect driving ability and functionality necessary to perform

heavy labor tasks associated with the job of commercial driving. Medical certification means the driver is

physically able to safely drive and perform nondriving tasks as described in the driver role section of the

Federal Motor Carrier Safety Administration (FMCSA) Medical Examination Report form.

Drivers have a multitude of job demands. The least physically demanding part may be the actual driving.

For

example, the duties of a commercial driver may include loading and unloading, making multiple stops,

driving cross-country and in heavy city traffic, working with load securement devices, and changing tires.

Other common driving tasks include:

• Manipulating th

e

wheel.

• Shifting gears.

• Maintaining pressure on the pedals.

• Braking.

• Monitoring traffic.

Ot

h

er job tasks include:

• Performing pre- and pos

t-trip safety checks.

• Ensuring the vehicle is loaded properly.

• Securing the load.

• Evaluating and managing vehicle break

dow

ns.

• Responding to emergency situations.

1.,6.$',K%$%+"$ <%:.$"+3'*, O )0 QPRSOR^#_^R_^`_^e_

49 CFR 391.41(b)(1)

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no loss of a foot, a leg, a hand, or an arm, or has

been granted a skill performance evaluation

certificate pursuant to §391.49."

49 CFR 391.41(b)(2)

"Has no impairment of:

Page 167 of 260

(i) A hand or finger which interferes with prehension or power grasping; or

(ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating

a c

ommercial motor vehicle; or any other significant limb defect or limitation which interferes with the

ability to perform normal tasks associated with operating a commercial motor vehicle; or has been

granted a skill performance evaluation certificate pursuant to §391.49."

49 CFR 391.41(b)(7)

"Has no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular,

neurom

uscular, or vascular disease which interferes with his/her ability to control and operate a

commercial motor vehicle safely."

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely. This examination is for public safety determination and is

considered by FMCSA to be a “medical fitness for duty" examination.

As a medical examiner, your fundamental obligation during the musculoskeletal assessment is to

est

ablish whether a driver has the musculoskeletal strength, flexibility, dexterity, and balance to maintain

control of the vehicle and safely perform nondriving tasks.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* ?.(B./'(G"/"&0/ NO0+$%0&$'%

During the physical examination, you should ask the same questions as you would for any individual who

is being assessed for musculoskeletal concerns. Adapt the observation, inspection, palpation, and

screening tests of the general musculoskeletal examination to ensure that the physical demands of

commercial driving are assessed (e.g., rotation of the outstretched arms against resistance as if turning a

large steering wheel, movement of the legs in braking and clutching, etc.).

The FMCSA Medical Examination Report form includes health history questions. Additional questions

sh

ould be asked to supplement information requested on the form. You may ask about musculoskeletal

symptoms. Any musculoskeletal or neuromuscular condition should be evaluated for the nature and

severity of the condition, the degree of limitation present, the likelihood of progressive limitation, and the

potential for gradual or sudden incapacitation.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver have:

• A muscular disease?

• A missing hand, arm, foot, leg, finger, or toe?

• A nonfunctioning or dysfunctional hand, arm, foot, leg, finger, or toe?

Page 168

of 260

• An injury or disease of the spine?

• Chronic low back pain?

Recommendations — Que

stions that you may ask include

Does the driver:

• Have physical limitations caused by weakness, pain, or decreased mobility and range of motion

(n

a

ture and degree)?

• Use musculoskeletal agents (effects and/or side effects)?

• Have mild, moderate, or severe chronic musculoskeletal pain (frequency and intensity)?

Regulations — Yo

u

must evaluate

Does the driver have:

• A missing or impaired leg, foot, toe, arm, hand, or finger?

• Sufficient power grasp and prehension of hands and fingers to maintain steering wheel gr

i

p?

• Sufficient strength and mobility in lower limbs to operate pedals properly?

• A perceptible limp?

• Signs of previous spine or other musculoskeletal surgery?

• Deformities of the spine and/or torso?

• Sufficient mobility and strength of spine and/or torso to dr

i

ve safely and perform other job tasks?

• Limitations of motion of the spine and/or torso?

• Spine, torso, and/or other musculoskeletal tenderness?

NOTE: As a medical examiner, you determine if the severity of a reversible or progressive

mu

sculoskeletal disease interferes with driving ability. If findings so dictate, radiology and other

examinations should be used to diagnose congenital or acquired defects or spondylolisthesis and

scoliosis.

Examination by a neurologist or physiatrist who understands the funct

ions and demands of commercial

driving may be required to assess the status of the disease. However, as a medical examiner, it is your

responsibility to determine certification status.

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative musculoskeletal history, including if available:

o Onset date and diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of medication used while driving, including over-the-co

unter medication.

• Any abnormal finding(s), noting:

Page 169

of 260

• Effect on driver ability to operate a CMV safely.

o Necessary steps to correct the condition as soon as possible, particularly if the untreated

con

dition could result in more serious illness that might affect driving.

• Any additional tests and evaluation.

REM

EMBER: Medi

cal fitness for duty includes the ability to perform strenuous labor. Overall

requirements for commercial drivers as well as the specific requirements in the job description of the

driver should be deciding factors in the certification process.

-7@3,'9= )93+%93"FG.37"*6%

4$O"> !"#$B$& '# 0% NO&*"+$&M

When the loss of (hand, foot, leg, or arm) or a fixed impairment to an extremity may interfere with the

ability of the driver to operate a commercial motor vehicle (CMV) safely, you are responsible for

determining if the driver is otherwise medically fit to drive. A driver may be allowed to drive if the

qualification requirements for a Skill Performance Evaluation (SPE) certificate under 49 CFR 391.49 are

met.

DG$// X"*#'*+0%B" NA0/.0&$'% K 1 34, 52S712

See the Skill Performance Evaluation section of this handbook.

NOTE: As a medical examiner, you determine if the severity of a fixed deficit that is less than the whole

hand i

s medically disqualifying unless the driver has an SPE certificate pursuant to 49 CFR 391.49. The

SPE is applicable only for fixed deficits of the extremities.

In order to legally operate a CMV, the driver must carry an SPE certificate and a valid medical examiner's

cert

ificate. The driver is responsible for ensuring that both certificates are renewed prior to expiration.

E"3+3*: 8%93'7

No recommended time frame

The driver must be otherwise medically fit for duty before certification or recertification in accordance with

49 CF

R 391.49.

I%63,3'*

Maximum certification period — 2 years

Recommend to certify (accompanied by an SPE) if:

The driver has:

• A fixed deficit of an extremity and is otherwise medically qualified at physical examination

(re

qu

ired for both certification and recertification).

• A valid SPE certificate and documentation of compliance with medical requirements (required for

rece

rtification with a current SPE certificate).

NOTE: The SPE applies only to fixed deficits of the extremities, not those caused by a progressive

dis

ease. To be certified, the driver with a deficit of an extremity caused by a progressive disease must

Page 170 of 260

meet 49 CFR 391.41 requirements, including adequate range of motion, strength, grip, and prehension to

safely operate a CMV.

Recommend not to certify if:

The driver has:

•

An impairment that affects the torso.

• Not provided proof of compliance with SPE certification requirements.

• A disqualifying limb impairment caused by a progressive disease (e.g., multiple sclerosis).

NOTE: The SPE applies only to fixed deficits of the extremities, not those caused by a progressive

di

sease. The driver with a deficit of an extremity caused by a progressive disease must not be certified if

the driver cannot meet 49 CFR 391.41 requirements.

Recommend not to certify if:

1'*3+'93*:F!%,+3*:

SPE initial and renewal applications also require a medical evaluation summary completed by either a

board qualified or board certified physiatrist or orthopedic surgeon. You should review the report at

recertification for any medical changes before determining driver certification status.

0'$$'VU.A

The driver should have at least biennial physical examinations or more frequently when indicated. The

driver is responsible for maintaining current medical and SPE certification.

?.(B./'(G"/"&0/ <"(&(

Detection of an undiagnosed musculoskeletal finding during the physical examination may indicate the

need for further testing and examination to adequately assess medical fitness for duty. Diagnostic-specific

testing may be required to detect the presence and/or severity of the musculoskeletal condition. The

additional testing may be ordered by the medical examiner, primary care physician, or musculoskeletal

specialist (e.g., orthopedic surgeon, physiatrist).

When request

ing additional evaluation, the specialist must understand the role and function of a driver;

therefore, it is helpful if you include a description of the role of the driver and a copy of the applicable

medical standard(s) and guidelines with the request.

,"B'*>

Record additional tests in the Medical Examination Report form, "6. LABORATORY AND OTHER TEST

FINDINGS" section and/or attach additional test reports.

Table 7 - Medical Examination Report Form: Laboratory and Other Test Findings

Page 171 of 260

G93A 2+9%*:+/ !%,+,

The Federal Motor Carrier Safety Administration does not require any specific test for assessing grip

power. Examples of grip strength tests include:

•

Dynamometer designed to measure grip strength.

• Sphygmomanometer used as a screening test for grip by having the applicant repeatedly squeeze

the inflated cuff while noting the maximum deflection on the gauge.

REMEMBER: The driver must have sufficient grasp and prehension to control an oversize steering

wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.

c".*'+.(B./0* !$("0("(

See Neuromuscular Diseases section of this handbook.

I3"#%+%, 1%$$3+.,

The Center for Disease Control and Prevention (CDC) 2007 National Diabetes Fact Sheet reports the

prevalence of diagnosed and undiagnosed diabetes mellitus in the United States, for all ages, as:

• Total: 23.6 million people, or 7.8% o

f the population, have diabetes.

• Diagnosed: 17.9 m

illion people.

• Undiagnosed: 5.7 m

illion people.

The most common form of diabetes mellitus is Type 2 (adult onset or non-insu

lin-dependent diabetes

mellitus). Individuals with Type 2 diabetes mellitus:

• Can produce insulin and have intact blood glucose control counter-reg

ulatory mechanisms.

• May preserve blood glucose control counter-regu

latory mechanisms for many years with lifestyle

changes and oral hypoglycemic medications.

• May, over time, have insulin producti

on fail and require insulin replacement therapy.

While the detection and management of both hyperglycemia and hypoglycemia are important aspects of

the o

verall medical management of a person with diabetes mellitus, the detection and management of

hypoglycemia is more relevant to safety considerations, in the certification of the commercial motor

vehicle (CMV) driver, with diabetes mellitus.

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Some of the factors related to commercial driving that affect blood glucose control include:

• Fatigue.

• Lack of sleep.

• Poor diet.

• Missed meals.

• Emotional conditions.

• Stress.

• Concomitant illness.

Page 172 of 260

These same factors may hasten the need for the driver with diabetes mellitus who does not use insulin to

start insulin therapy. Poorly controlled diabetes mellitus can result in serious, life-threatening health

consequences. However, with good management of the disease process, a driver with diabetes mellitus

can safely operate a CMV.

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Poor blood glucose control can lead to fatigue, lethargy, and sluggishness. Complications related to acute

hyperglycemia may affect the ability of a driver to operate a motor vehicle. Although ketoacidosis and

hyperosmolar states significantly impair cognitive function. Onset is gradual and frequency is generally

low.

The complications of diabetes mellitus can lead to medical conditions severe enough to be disqualifying,

such

as neuropathy, retinopathy, and nephropathy. Accelerated atherosclerosis is a major complication of

diabetes mellitus involving the coronary, cerebral, and peripheral vessels. Individuals with diabetes

mellitus are at increased risk for coronary heart disease and have a higher incidence of painless

myocardial infarction than individuals who do not have diabetes mellitus.

Preventing hypo

glycemia is the most critical and challenging safety issue for any driver with diabetes

mellitus. Hypoglycemia can occur in individuals with diabetes mellitus who both use and do not use

insulin. Mild hypoglycemia causes rapid heart rate, sweating, weakness, and hunger. Severe

hypoglycemia can cause symptoms that interfere with safe driving. The Federal Motor Carrier Safety

Administration (FMCSA) defines a severe hypoglycemic reaction as one that results in:

• Seizure.

• Loss of consciousness.

• Need of assistance

from another person.

• Period of impaired cognitive function that occurred without warning.

The occurrence of a severe hypoglycemic reaction while driving endangers the safety and health of the

dri

ver and the public.

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"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for

con

trol."

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The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the driver ability to operate a CMV safely.

This examination is for public safety determination and is considered by FMCSA to be a “medical fitness

for duty" examination.

As a medical examiner, your fundamental obligation during the assessment of a driver with diabetes

mel

litus is to establish whether the driver is at an unacceptable risk for sudden death or incapacitation,

thus endangering public safety. The risk may be associated with the disease process and/or the

treatment for the disease.

Page 173 of 260

The examination is based on information provided by the driver (history), objective data (physical

examination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

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Medical qualification of the driver with diabetes mellitus should be determined through a case-by-case

evaluation of the ability of the driver to manage the disease and meet qualification standards. The

FMCSA Medical Examination Report form includes health history questions and physical examination

checklists. Additional questions about diabetes mellitus symptoms, treatment, and driver adjustment to

living with a chronic condition should be asked to supplement information requested on the form.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver have diabetes mellitus or elevated blood glucose controlled by:

• Diet?

• Pills?

• Insulin?

• Other injectable medications?

Recommendations — Que

stions that you may ask include

Does the driver:

• Routinely monitor blood glucose level?

• Use over-th

e-counter medications and/or supplements?

• Use an incretin mimetic?

• Have a history of fainting, dizziness, or loss of consciousness?

• Have a history of hypoglycemic reactions that resulted in:

o Seizure?

o

Loss of consciousness?

o

Need of assistance from another person?

o

Period of impaired cognitive function that occurred without warning?

NO

TE: When the driver has a positive history for severe hypoglycemic reactions, ask about occurrences,

in

cluding has the driver had:

• One or more occurrences within last 12 mon

ths?

• Two or more occurrences within last 5 years?

Page 174 of 260

Regulations — You must evaluate

On examination, does the driver have:

• Glycosuria (dip stick urinalysis)?

• Signs of target organ damage associated with dysfunction of the senses, including:

o

Retinopathy?

o Macular degeneration?

o Peripheral neuropathy?

• Signs of target organ damage that can cause gradual or sudden incapacitation, including:

o

Coronary heart disease?

o Cerebrovascular disease, including:

 Transient ischemic attack?

 Embolic or thrombotic stroke?

 Peripheral vascular disease?

o Autonomic neuropathy?

o Nephropathy?

,"B'*>

Regulations — You must document discussion with the driver about

•

Any affirmative history, including if available:

o Onset date, diagnosis.

o Medication(s), dose, and frequency.

o Any current limitation(s).

• Potential negative effects of medication use, including over-the-counter medications, while driving.

• Any abnormal finding(s), noting:

o Effect on driver ability to operate a CMV safely.

o Necessary steps to correct the condition as soon as possible, particularly if the condition, if

neglected, could result in more serious illness that might affect driving.

• Any additional medical tests and evaluation.

REMEMBER: The diabetes qualification standard parameter is use of insulin, not the diagnosis of

diabetes mellitus.

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!$0Q"&"( ?"//$&.(

The driver with diabetes mellitus who does not use insulin is eligible for certification, unless the driver also

has a disqualifying complication, comorbidity, or fails to meet one or more of the other standards for

qualification.

You may choose to consult with the primary care provider and/or specialist to adequately assess driver

med

ical fitness for duty. When requesting additional evaluation, including a copy of the Medical

Examination Report form description of the driver role and medical standards is helpful.

Remember that the provider treating the driver is primarily concerned with minimizing target organ

damage

associated with elevated levels of blood glucose. As a medical examiner, your assessing any

driver with diabetes mellitus for the risk of a severe hypoglycemic episode is the most critical and

challenging safety issue.

Page 175 of 260

NOTE: If the driver with diabetes mellitus uses insulin, use the Federal Diabetes Exemption Program and

insulin therapy guidelines to determine certification status. See the Federal Diabetes Exemption Program

section of this document.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the treatment has been shown to be adequate/effective, safe, and

st

able.

I%63,3'*

Maximum certification — 2 years

NOTE: Be

cause of the progressive nature of diabetes mellitus, the Federal Motor Carrier Safety

Administration (FMCSA) believes that 1 year maximum certification time is reasonable when the driver

has a diagnosis of diabetes mellitus.

Recommend to certify if:

The driver with diabetes mellitu

s:

• Meets all the physical qualification standards.

• Has a treatment plan that manages the disease and does not:

o In

clude the use of insulin.

o In

terfere with safe driving.

Recommend not to certify if:

The driver with diabetes mellitus has:

• In the last 12 mont

hs, experienced a hypoglycemic reaction resulting in:

o Se

izure.

o Los

s of consciousness.

o Ne

ed of assistance from another person.

o Pe

riod of impaired cognitive function that occurred without warning.

• In the last 5 years, had recurring (two or more) disqualifying hypoglycemic reactions (as

des

cribed above).

• Loss of position sensation.

• Loss of pedal sensation.

• Resting tachycardia.

• Orthostatic hypotension.

• Diagnosis of:

o Pe

ripheral neuropathy.

o Pr

oliferative retinopathy (e.g., unstable proliferative or non-proliferative).

Page 176

of 260

1'*3+'93*:F!%,+3*:

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Glycosuria may indicate poor blood glucose control. When urinalysis shows glycosuria, you may elect to

perf

orm a finger stick test to obtain a random blood glucose.

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Hemoglobin A1c (HbA1c) greater than 10% is an indicator of poor blood glucose control. It is

rec

ommended that you obtain further evaluation or monitor the driver more frequently to determine if the

disease process interferes with medical fitness for duty and safe driving.

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The driver must have biennial physical examinations. You may require the driver to have more frequent

examinations, if indicated, to adequately monitor the progression of the condition.

NOTE: Encourage the dr

iver with diabetes mellitus to participate in annual diabetes mellitus education.

I%B*"&$%)?$+"&$B

An incretin mimetic, such as exenatide (Byetta), is used to improve glycemic control in people with Type 2

diabetes by reducing fasting and postprandial glucose concentrations. An incretin mimetic is indicated as

adjunctive therapy to individuals who are taking metformin or a combination of other oral agents. Use of

an incretin mimetic in conjunction with a sulfonylurea has an increased risk of hypoglycemia.

Incretin mimetics are not insulin and can be used without an exemption.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the treatment has been shown to be adequate/effective, safe, and

sta

ble.

I%63,3'*

Maximum certification — 1 year

NOTE: The Federal Motor Carrier Safety Administration (FMCSA) recommends frequent monitoring

det

ermined on a case-by-case basis.

Recommend to certify if:

The driver with diabetes mellitus who uses an incretin mimetic:

• Meets all the phy

s

ical qualification standards.

• Has a treatment plan that manages the disease and does not:

o In

clude the use of insulin.

o

Have side effects that interfere with safe driving.

Re

commend not to certify if:

As a medical examiner, you believe that the nature and s

everity of the medical condition and/or the

treatment of the driver endangers the safety and health of the driver and the public.

Page 177 of 260

1'*3+'93*:F!%,+3*:

FMCSA recommends that a driver taking an incretin mimetic provide a written statement from the treating

health care professional. The written statement should:

• Describe driver tolerance to the medication.

• Indicate how frequently the driver is monitored for adequate blood glucose control.

• Include efficacy of treatment.

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FMCSA recommends frequent monitoring of the driver who is taking an incretin mimetic.

I%(./$% <;"*0PM

Individuals who require insulin for control of diabetes mellitus blood glucose levels also have treatment

conditions that can be adversely affected by the use of too much or too little insulin, or food intake that is

not consistent with the insulin dosage.

The administration of insulin is a complicated process requiring insulin, syringe, needle, alcohol sponge,

and a

sterile technique. Factors related to long-haul commercial motor vehicle (CMV) operations, such as

fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the

dangers. The Federal Motor Carrier Safety Administration (FMCSA) has consistently held that a driver

with diabetes mellitus who uses insulin does not meet the minimum physical requirements of 49 CFR

391.41.

Some drivers with diabetes mellitus who use insulin may be medically certified if the driver:

• Has or is eligible to apply for a Federal diabetes

exemption.

• Has an FMCSA-iss

ued letter that states the driver may be qualified by operation of 49 CFR

391.64(a) (grandfathered status).

NOTE: Proof of grandfathered status is the original letter from 1996 granting the right to continue to drive

as

long as the driver can meet physical qualification requirements. If a letter is not provided, you may

verify driver participation in the study program—and the driver can obtain a new copy of the letter—by

calling the FMCSA Exemption Program Office at 703-448-3094.

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Preventing hypoglycemia is the most critical and challenging safety issue for any driver with diabetes

mellitus. Individuals who use insulin are at an increased risk for hypoglycemic reactions.

NOTE: FMCSA defines a severe hypoglycemic

reaction as one that results in:

• Seizure.

• Loss of consciousness.

• Need of assistance from another person.

• Period of impaired cognitive function that occurs without warning.

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In some cases, hypoglycemia can be self-treated by the ingestion of at least 20 grams of glucose tablets

or carbohydrates. Consuming "rescue" glucose or carbohydrates may avert a hypoglycemic reaction for

Page 178 of 260

less than a 2-hour period. The driver with a diabetes exemption must carry a source of rapidly absorbable

glucose while driving.

E"3+3*: 8%93'7

Minimum — 1 month, if the driver with diabetes mellitus was previously diagnosed and on treatment that

did not include the use of insulin

Minimum — 2

months, if the driver with diabetes mellitus is newly diagnosed and was not on prior

treatment

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver with diabetes mellitus:

• Meets all other physical qualification requirements of 49 CFR 391.41(b) except for use of insulin

and:

o Ha

s a Federal diabetes exemption or is eligible to apply for the exemption.

o Wa

s a participant in good standing on March 31, 1996, in the Federal diabetes waiver

study program and continues to meet all qualification requirements of 49 CFR 391.64(a).

Recommend not to certify if:

The driver with

diabetes mellitus has:

• Other than the use of insulin to treat diabetes mellitus, any other medical problem or condition

th

at prevents certification in accordance with the qualification requirements of 49 CFR 391.41(b).

• In the last 12 months, had a severe hypoglycemic reaction resulting in:

o Se

izure.

o Los

s of consciousness.

o Ne

ed of assistance from another person.

o Pe

riod of impaired cognitive function that occurred without warning.

• In the last 5 years, has had recurring (two

or more) disqualifying severe hypoglycemic reactions

(as described above).

• Loss of position sensation.

• Loss of pedal sensation.

• Resting tachycardia.

• Orthostatic hypotension.

• Diagnosis of:

o Pe

ripheral neuropathy that interferes with safe driving.

o Pr

oliferative retinopathy (e.g., unstable proliferative or non-proliferative).

Page 179

of 260

1'*3+'93*:F!%,+3*:

-**."$ <%6%9+3(36"+3'* 8/=,36"$ >?"43*"+3'*,

The driver with a Federal diabetes exemption should provide you with a copy of the completed Ann

ual

Diabetes Assessment Package that includes the:

• Endocrinologist Annual Evaluation Checklist.

o Exemption requires evaluation by a boar

d-certified or board-eligible endocrinologist.

• Vision Annual Evaluation Checklist.

o Ex

emption requires evaluation by an ophthalmologist or optometrist.

o

The driver diagnosed with diabetic retinopathy is required to have an eye examination by

an

ophthalmologist.

The grandfathered driver should provide a copy of the endocrinologist report addressing the requirements

list

ed in 49 CFR 391.64(a).

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Glycosuria may indicate poor blood glucose control. When urinalysis shows glycosuria, you may elect to

per

f

orm a finger stick test to obtain a random blood glucose.

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Poor blood glucose control may indicate a need for further evaluation or more frequent monitoring to

deter

mine if the disease process interferes with safe driving.

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3+'93*: G.37%$3*%,

The Federal Diabetes Exemption Program guidelines for blood glucose monitoring include using a device

tha

t records the results for later review and measuring blood glucose level:

• Before driving.

• Every 2 to 4 hours while driving.

Blood

glucose levels that remain within the 100 milligrams per deciliter (mg/dL) to 400 mg/dL range are

gener

ally considered safe for commercial driving.

NOTE: You should review and consider the findings of the most recent specialist evaluation reports and

bl

ood glucose monitoring documentation before determining if the driver is medically fit for duty.

0'$$'VU.A

The driver must have an annual physical examination.

NOTE: The driver is responsible for maintaining both a current Medical Examiner’s Certificate and

Fe

deral diabetes exemption.

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Hypoglycemic drugs taken orally are frequently prescribed for persons with diabetes mellitus to help

stimulate natural body production of insulin. If diabetes mellitus can be controlled by the use of oral

medication and diet, an individual may be considered for driver certification using the physical

qualification requirements of 49 CFR 391.41.

NOTE: If the

driver with diabetes mellitus uses insulin, use the Federal Diabetes Exemption Program and

insulin therapy guidelines to determine certification status.

Page 180 of 260

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the treatment has been shown to be adequate/effective, safe, and

sta

ble.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver with diabetes mellitus who uses an oral hypoglycemic medication:

• Meets all the physical qualification standards.

• Has a treatment plan that manages the disease and does not:

o Include the use of insulin.

o

Have side effects that interfere with safe driving.

Re

commend not to certify if:

As a medical examiner, you believe that the nature and severity of the medical condition and/or the

tre

atment of the driver endangers the safety and health of the driver and the public.

1'*3+'93*:F!%,+3*:

Not applicable.

0'$$'VU.A

The driver should have biennial physical examinations. You may require the driver to have more frequent

physical examinations, if indicated, to adequately monitor driver medical fitness for duty.

5+/%9 I3,%",%,

The fundamental question when deciding if a commercial driver should be certified is whether the driver

has a condition that so increases the risk of sudden death or incapacitation that the condition creates a

danger to the safety and health of the driver, as well as to the public sharing the road.

The qualification standards cover 13 areas that directly relate to the driving function; however, on a case-

by-case basis, use your clinical skills and knowledge of the Fe

deral Motor Carrier Safety Administration

(FMCSA) physical qualification standards to evaluate the overall medical fitness for duty of the driver.

The medical advisory criteria for 49 CFR 391.41(b)(9) includes examples of how medical conditions might

inter

fere with operation of a commercial motor vehicle (CMV). You are expected to assess the nature and

severity of the medical condition and determine certification outcomes on a case-by-case basis and with

knowledge of the demands of commercial driving.

• "Emotional or adjustment problems contribute directly to an individual’s level of memory,

re

asoning, attention, and judgment. These problems often underlie physical disorders."

• "A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness, or

paralysis that may lead to incoordination, inattention, loss of functional control, and susceptibility

to crashes while driving."

Page 181 of 260

• "Physical fatigue, headache, impaired coordination, recurring physical ailments, and chronic

’nagging’ pain may be present to such a degree that certification for commercial driving is

inadvisable."

Disorders of the genitourinary and gastrointestinal systems have not been widely associated with

sig

nificant impact on driving ability for drivers as a group but may, on a case-by-case basis, interfere with

safe driving. You should not certify the driver until the etiology is confirmed, and treatment has been

shown to be adequate/effective, safe, and stable.

5+/%9 I3,%",%, <%:.$"+3'* O )0 QPRSOR^#_^P_

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with

his

/her ability to drive a commercial motor vehicle safely."

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d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the driver ability to operate a CMV safely.

This examination is for public safety determination and is considered by FMCSA to be a "medical fitness

for duty" examination.

As the medical examiner, your fundamental obligation during the medical assessment is to establish

wh

ether a driver has any disease or disorder that increases the risk for sudden death or incapacitation,

thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

["M)X'$%&( #'* F&;"* !$("0("(

The FMCSA Medical Examination Report form includes health history questions and physical

examination checklists. Additional questions should be asked, to supplement information requested on

the form, to adequately assess medical fitness for duty of the driver. You should ask about and document

any other conditions that might impact the ability to safely operate a CMV.

Regulations — You

must review and discuss with the driver any "yes" answers

• Any illness or injury in the last 5 years?

• Kidney disease, dialysis?

• Liver disease?

• Digestive problems?

Page 182

of 260

Recommendations — Questions that you may ask include

Does the driver have:

• Medical therapy that requires monitoring?

• Any current limitation?

Regulations — You

must evaluate

On examination, does the driver have:

• Abnormal urinalysis?

• Enlarged liver?

• Enlarged spleen?

• Masses?

• Bruits?

• Hernia?

• Significant abdominal wall muscle weakness?

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative history, including if available:

o On

set date, diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of medication use, including over-the-co

unter medications, while

driving.

• Any abnormal finding(s), noting:

o Ef

fect on driver ability to operate a CMV safely.

o

Necessary steps to correct the condition as soon as possible, particularly if the untreated

co

ndition could result in more serious illness that might affect driving.

• Any additional cardiovascular tests and evaluation.

REMEMBER: Me

dical fitness for duty includes the ability to perform strenuous labor. Overall

requirements for commercial drivers, as well as the specific requirements in the job description of the

driver, should be deciding factors in the certification process.

-7@3,'9=&)93+%93"FG.37"*6%

L"*%$0

The Medical Examination Report form physical examination section includes checking for hernia for both

the abdomen and viscera body system and the genitourinary system.

Page 183 of 260

If a hernia causes discomfort or the diagnosis suggests that the condition might interfere with the control

and safe operation of a commercial motor vehicle (CMV), further testing and evaluation may be required

to determine driver certification status.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the etiology is confirmed, and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

As the medica

l examiner, you believe that the nature and severity of the medical condition of the driver

does not endanger the safety and health of the driver and the public.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity

of the medical condition of the driver

endangers the safety and health of the driver and the public.

1'*3+'93*:F!%,+3*:

You may, on a case-by-case basis, obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

The driver must have at least biennial medical examinations.

c"P;*'P0&;M

Diabetic nephropathy accounts for a significant number of the new cases of end-stage renal disease. The

first sign of nephropathy commonly is the development of persistent proteinuria. End-stage renal disease

follows some time later. Whether nephropathy is a disqualifying factor should be determined on the basis

of the degree of disease progression and the associated impact on driver ability to function.

The prevalence of nephropat

hy is strongly related to the duration of diabetes mellitus. After 15 years of

living with diabetes mellitus, the frequency of nephropathy is higher among individuals who use insulin

than with individuals who do not use insulin.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the etiology is confirmed, and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 2 years

Page 184 of 260

Recommend to certify if:

The driver:

•

Meets all the physical qualification standards.

• Has a treatment plan that manages the disease and does not interfere with safe driving.

Recommend not to certify if:

As the medical examiner, you believe that the nature and severity of the medical condition of the driver

endangers

the safety and health of the driver and the public.

1'*3+'93*:F!%,+3*:

Urinalysis - An abnormal urinalysis, including but not limited to proteinuria, may indicate some degree

of renal dysfunction. You may, on a case-by-case basis, obtain additional tests and/or consultation to

adequately assess driver medical fitness for duty.

When requesting additional evaluation from a specialist, the specialist must understand the role and

fun

ction of a driver. Therefore, including copies of the Medical Examination Report form description of the

driver role and the applicable medical standard(s) and guidelines with the request is helpful.

0'$$'VU.A

The driver must have biennial medical examinations. You may require more frequent examinations, if

indicated, to adequately monitor the progression of the condition.

=*$%0/M($(

You are required to perform a urinalysis (dip stick) as a part of every driver certification and recertification

medical examination and to record test results for:

• Specific gravity.

• Protein.

•

Blood.

• Glucose.

Proteinuria, hematuria, or glycosuria may be an indication for further testing to rule out any underlying

med

ical problem.

You should advise the driver of any abnormal findings and when indicated, encourage the driver to seek

pri

mary care provider evaluation, particularly if an abnormal urinalysis could indicate the presence of a

medical condition that if left untreated could result in a serious illness that might affect driving.

When an abnormal urinalysis is indicative of a medical con

dition that endangers the safety and health of

the driver and the public, you should not certify the driver until the etiology is confirmed and treatment has

been shown to be adequate/effective, safe, and stable.

8,=6/'$':36"$ I3,'97%9, ^#_^P_

Safe and effective operation of a commercial motor vehicle (CMV) requires high levels of physical

strength, skill, and coordination as well as the ability to maintain adequate attention and react promptly

and appropriately to traffic, emergency situations, and other job-related stressors.

Page 185 of 260

Some psychological or personality disorders can directly affect memory, reasoning, attention, and

judgment. Somatic and psychosomatic complaints should be thoroughly examined when determining

overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of

development, may warrant disqualification.

Risk factors associated with personality disorders can interfere with driving ability by compromising:

• Attention, concentration, or memory

affecting information processing and the ability to remain

vigilant to the surrounding traffic and environment.

• Visual-spatial function (e.g., motor response latency).

•

Impulse control, including the degree of risk taking.

• Judgment, including the ability t

o predict and anticipate.

• Ability to problem solve (i.e., executive functioning), including the ability to respond to

sim

ultaneous stimuli in a changing environment when potentially dangerous situations could

exist.

The driver with:

• Active psychotic disorder may exhibit unpredictable behavior and poor judgment.

• Mood disorder may, during a

o Manic episode exhibit grandiosity, impulsiveness, irritability, and aggressiveness.

o

Depressive episode exhibit slowed reaction time and poor judgment.

•

Personality disorde

rs, depending on severity and type, may exhibit inflexible and maladaptive

behaviors and have an increased crash rate.

8,=6/'$':36"$ <%:.$"+3'* O )0 QPRSOR^#_^P_

"A person is physically qualified to drive a commercial motor vehicle if that person —

Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with

hi

s/her ability to drive a commercial motor vehicle safely."

W%"$+/&W3,+'9= "*7&8/=,36"$ >?"43*"+3'*

d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a CMV

safely. This examination is for public safety determination and is considered by the Federal Motor Carrier

Safety Administration (FMCSA) to be a "medical fitness for duty" examination.

As a medical examiner, your fundamental obligation during the psychological assessment is to establish

whe

ther a driver has a psychological disease or disorder that increases the risk for periodic, residual, or

insidious onset of cognitive, behavioral, and/or functional impairment that endangers public safety.

The examination is based on information provided by the

driver (history), objective data (physical

examination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical

assessment of overall health and informed

medical judgment about the impact of single or multiple conditions on the whole person.

Page 186 of 260

["M)X'$%&( #'* X(MB;'/'-$B0/ NO0+$%0&$'%

During the physical examination, you should ask the same questions as you would for any individual who

is being assessed for psychological concerns. The FMCSA Medical Examination Report form includes

health history questions and physical examination checklists. Additional questions should be asked to

supplement information requested on the form. You may ask about psychological symptoms and

screening tests when indicated by the driver's affect, behavior, or your interactions with the driver.

It is the degree of inappropriateness and the cumulative effect of driver presentation and interact

ion that

provide a cue that a driver may require more in-depth mental health evaluation.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver:

• Have a nervous or psychiatric disorder (e.g., severe depression)?

• Have loss of or altered consciousness?

•

Use medication for a nervous or psychiatric disorder?

• Use alcohol regularly and/or frequently?

• Use narcotic or habit-for

ming drugs?

Recommendations — You

should observe driver presentation and interaction

Does the driver dis

play any of the following:

• Inappropriate dress?

• Suspiciousness?

• Evasiveness?

• Threatening behavior?

• Hostility?

• Distractibility?

• Flat affect or no emotional expression?

• Unusual or bizarre ideas?

• Auditory or visual hallucinations?

• Dishonesty?

• Omission of

i

mportant information?

Recommendations — Ask

the driver

• Have you ever thought of hurting yourself?

• Have you ever thought of suicide?

• Have you ever attempted suicide, including using a vehicle like a car or truck?

• Do you ever get into fights?

• Have you ev

er

thought of hurting or killing other people?

Page 187 of 260

• Do you ever have problems with your concentration or memory?

• Have you ever heard voices that other people don't seem to hear or that weren't really there?

• Have you ever seen things that weren't really there?

• Have you ever been hospitalized for psychiatric problems?

• Are you taking any medication for nerves?

• Have you ever used medicines for a purpose other than what was prescribed?

Recommendations — In

a

ddition to health history, you may inquire about

• Work history.

•

Driving history.

• Drug and alcohol history.

• Military history, including type of discharge.

• Legal history.

Regulations — You

must evaluate

On examination, does the driver have:

• Tremor?

• Enlarged liver and/or spleen?

• Signs of alcoholism or problem drinkin

g?

• Drug abuse?

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative history, including if available:

o On

set date, diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of med

ication use, including over-the-counter medications, while

driving.

• Any abnormal finding(s), noting:

o Ef

fect on driver ability to operate a commercial vehicle safely.

o

Necessary steps to correct the condition as soon as possible, particularly if the untreat

ed

condition could result in more serious illness that might affect driving.

• Any additional psychological tests and evaluation.

REMEMBER: Med

ical fitness for duty includes the ability to perform strenuous labor and to have good

judgment, impulse control, and problem-solving skills. Overall requirements for commercial drivers as well

as the specific requirements in the job description of the driver should be deciding factors in the

certification process.

Page 188 of 260

-7@3,'9= )93+%93"FG.37"*6%

There are three categories of risk associated with psychological disorders.

• The mental disorder, including symptoms and/or disturbances in performance that are an

integral part of the disorder and may pose hazards for driving.

• Residual symptoms occurring after time-limited reversible episodes or initial presentation of the

full syndrome that can interfere with safe CMV driving.

• Psychopharmacology, as many psychotropic medications can compromise performance to the

degree

that CMV driving would be hazardous.

The recommendations do

not support automatic exclusion from CMV driving based solely on the

diagnosis. Typically, the more serious the diagnosis, the more likely it is that the driver will be medically

disqualified. Careful consideration should also be given to the side effects and interactions of medications

in the overall qualification determination.

Many of the medications used to treat psychological disorders have effects and/or side effects that render

dri

ving unsafe. The recommendations use the degree of impairment produced by a 0.04 percent blood

alcohol concentration as a benchmark. This standard was chosen based on the FMCSA exclusionary rule

related to alcohol usage.

C%&$>"P*"((0%& <;"*0PM

Guidelines recommend case-by-case assessment of drivers treated with antidepressant medication.

Evidence indicates that some antidepressant drugs significantly interfere with skills performance and that

these medications vary widely in the degree of impact. With long-term use of antidepressants, many

drivers will develop a tolerance to the sedative effects. Your evaluation must consider both the specific

medicine used and the pertinent characteristics of the patient.

First generation antidepressants have consistently been shown to interfere with safe driving. First

generat

ion antidepressants include tricyclics such as amitriptyline (Elavil) and imipramine (Tofranil).

Second generation antidepressants have fewer side effects and are generally safe; however, these

med

ications can still interfere with safe driving and require case-by-case evaluation. Second generation

antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and

sertraline (Zoloft); serotonin and norepinephrine reuptake modulators such as venlafaxine (Effexor); and

unicyclic aminoketones such as bupropion (Wellbutrin). You should consider the underlying reason for

treatment when determining certification.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the medication has been shown to be adequate/e

ffective, safe, and

stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

As the medical examiner, you believe:

• Nature and severity of the underlying condition does not interfere with safe driving.

Page 189 of 260

• Effects or side effects of medication use while operating a commercial motor vehicle do not

endanger the safety of the driver and the public.

Recommend not to certify if:

The driver:

• Uses a first generation antidepressant.

• Has treatment effects or side effects that interfere with saf

e

driving.

NOTE: Federal Motor Carrier Safety Administration recommendations favor not certifying the driver who

us

es a first generation tricyclic antidepressant stating that "only under exceptional circumstances would

continuous use of amitriptyline be acceptable for a commercial driver."

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving

to evaluate:

• Dose, plasma concentration, and duration of drug therapy.

• Severity of the underlying mental disorder.

0'$$'VU.A

The driver should have annual medical examinations.

C%&$P(MB;'&$B <;"*0PM

Antipsychotic drugs include typical and atypical neuroleptics. These agents are used to treat

schizophrenia, psychotic mood disorders, and some personality disorders. Some cases of nausea and

chronic pain are also treated with antipsychotic agents. Many of the conditions are associated with

behaviors and symptoms such as impulsiveness, disturbances in perception and cognition, and an

inability to sustain attention. Often the behaviors and symptoms are only partially corrected by

neuroleptics.

Neuroleptics can cause a variety of side effects that can interfere with driving, such as motor dysfunction

tha

t affects coordination and response time, sedation, and visual disturbances (especially at night).

E"3+3*: 8%93'7

No recommended time frame.

You should not certify the driver until the medication has been sho

wn to be adequate/effective, safe, and

stable.

I%63,3'*

Maximum certification — 1 year

Page 190 of 260

Recommend to certify if:

As the medical examiner, you believe:

• Nature and severity of the underlying condition does not interfere with safe driving.

• Effects of medicati

on use while operating a commercial motor vehicle does not endanger the

safety of the driver and the public.

Recommend not to certify if:

The driver has:

• Disqualifying underlying condition.

• Treatment side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving

to evaluate:

• Dose, plasma concentrati

on, and duration of drug therapy.

• Severity of the underlying mental disorder.

0'$$'VU.A

The driver should have annual medical examinations.

C%O$'/M&$B 0%> D">0&$A" LMP%'&$B <;"*0PM

Anxiolytic drugs used for the treatment of anxiety disorders and to treat insomnia are termed sedative

hypnotics. Studies have demonstrated that benzodiazepines, the most commonly used anxiolytics and

sedative hypnotics, impair skills performance in pharmacologically active dosages.

The effects of benzodiazepines on skills perf

ormance generally also apply to virtually all non-

benzodiazepines sedative hypnotics, although the impairment is typically less profound. However,

barbi

turates and other sedative hypnotics related to barbiturates cause greater impairment in

performance than benzodiazepines. Epidemiological studies indicate that the use of benzodiazepines and

other sedative hypnotics are probably associated with an increased risk of automobile crashes.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driv

er until the medication has been shown to be adequate/effective, safe, and

stable.

I%63,3'*

Maximum certification — 2 years

Page 191 of 260

Recommend to certify if:

The driver uses:

• Hypnotic, if the medication is:

o Sh

ort-ac

ting (half-life of less than 5 hours).

o The lowest effective dose.

o

Used for a short period of time (less than 2 weeks).

•

Non-sedating anxiolytic.

Re

commend not to certify if:

The driver:

• Uses a sedating anxiolytic.

• Has symptoms or side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, to adequately assess driver medical fitness for duty.

0'$$'VU.A

The driver should have at least biennial medical examinations or more frequently if indicated.

3"%&*0/ c"*A'.( DM(&"+ D&$+./0%& <;"*0PM

Psychiatric uses of central nervous system (CNS) stimulants (e.g., dextroamphetamine, methylphenidate,

and pemoline) include primary treatment of narcolepsy and adult attention deficit hyperactivity disorder

(ADHD), both of which are associated with psychomotor deficits related to sleepiness or hyperactivity.

CNS stimulants may also be used as adjuncts to antidepressants.

CNS stimulants improve performance on simple tasks, but not on tasks requiring complex intellectual

fun

ctions. For some conditions (e.g., fatigue, brain damage, adult ADHD), low doses of CNS stimulants

can enhance:

• Vigilance and attention.

• Performance of simple tasks (not complex intellectual functions).

Bef

ore qualifying a driver with ADHD who is using a CNS stimulant:

• Request evaluation fro

m the treating provider.

• Verify the diagnosis of adult ADHD.

• Use caution when determining the side effects of medication.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the medication has been shown to be adequate/effectiv

e, safe, and

stable.

Page 192 of 260

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver has:

• Non-disqualifying underlying condition (e.g., adult ADHD).

•

No drug-induced impairment.

•

No tendency to increase the dose.

Recommend not to certify if:

The driver has:

• Disqualifying underlying condition (e.g., narcolepsy).

• Treatment side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving

to evaluate:

• Dose, plasma concentration, and duration of drug therapy.

• Severity of the underlying mental disorder.

0'$$'VU.A

The driver should have annual medical examinations.

N/"B&*'B'%A./($A" <;"*0PM

Electroconvulsive therapy (ECT) is sometimes used to treat depression. ECT produces an acute organic

mental syndrome characterized by confusion, disorientation, and loss of short-term memory even with

low-dose, brief pulse, unilateral treatment. Clinical experience has shown that acute side effects usually

resolve rapidly and almost invariably within a few months.

E"3+3*: 8%93'7

Minimum — 6 months symptom free following a course of ECT

NOTE: If mo

re than one waiting period applies (because of multiple cardiac conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

Page 193 of 260

I%63,3'*

Recommend to certify if:

The driver:

• Completes the waiting period.

• Has a comprehensive evaluation from an appropriate mental health professional who

unders

tands the functions and demands of commercial driving.

• Is not undergoing maintenance ECT.

• Tolerates treatment without disqualifying side ef

fects (e.g., sedation or impaired coordination).

Recommend not to certify if:

The driver has:

• Maintenance ECT.

• Treatment side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist to adequately assess driver medical fitness for duty.

0'$$'VU.A

The driver should have annual medical examinations.

Z$&;$.+)<;"*0PM

Lithium (Eskalith) is used for the treatment of bipolar and depressive disorders. Studies suggest that there

is little evidence of lithium interfering with driver skill performance.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until etiology is confirmed and treatment has been

shown to be

adequate/effective, safe, and stable.

I%63,3'*

Recommend to certify if:

The driver:

• Is asymptomatic.

• Has lithium levels that are maintained in the therapeutic range.

• Has no impairment that interferes with safe driving.

Page 194

of 260

Recommend not to certify if:

The driver has:

• Disqualifying underlying condition.

• Disqualifying symptoms.

• Lithium levels that are not in the therapeutic range.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving

to evaluate:

• Dose, plasma concentration, and duration of drug therapy.

• Severity of the underlying mental disorder.

0'$$'VU.A

The driver should have annual medical examinations.

C>./& C&&"%&$'% !"#$B$& LMP"*0B&$A$&M)!$('*>"*

Children who had attention deficit hyperactivity disorder (ADHD) often continue to show signs of the

disorder into adulthood.

Essential features of adult ADHD include age-ina

ppropriate levels of inattention, impulsiveness, and

hyperactivity. Symptoms include mood lability, low frustration tolerance, and explosiveness.

Risks to safe driving associated with adult ADHD include comorbid antisocial or borderline personality

dis

order and/or other disorders, side effects of medication, and a high incidence of substance abuse;

however, a significant percentage of individuals with adult ADHD show a moderate to marked degree of

improvement on central nervous system stimulant medication.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver:

• Complies with treatment program.

• Tolerates treatment without disqualifying side effects (e.g., sedation or impaired coordination).

• Has a comprehensive evaluation fro

m an appropriate mental health professional who

understands the functions and demands of commercial driving.

Recommend not to certify if:

Page 195

of 260

The driver has:

• An active psychosis.

• Prominent negative symptoms, including:

o Su

bstantially compromised judgment.

o

Attentional difficulties.

o

Suicidal behavior or ideation.

o

Personality disorder that is repeatedly manifested by overt, inappropriate acts.

•

Side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, to adequately assess driver medical fitness for duty.

0'$$'VU.A

The driver should have annual medical examinations.

W$P'/0* ?''> !$('*>"*

Mood disorders are characterized by their pervasiveness and symptoms that interfere with the ability of

the individual to function socially and occupationally. The two major groups of mood disorders are bipolar

and depressive disorders. Bipolar disorder is characterized by one or more manic episodes and is usually

accompanied by one or more depressive episodes.

The onset of manic episodes may be sudden or gradual. Symptoms include excessively elevated,

expans

ive, or irritable moods. During a manic episode, judgment is frequently diminished, and there is an

increased risk of substance abuse. Some episodes may present with delusions or hallucinations.

Treatment for bipolar mania may include lithium and/or anticonvulsants to stabilize mood and

antipsychotics when psychosis manifests.

Symptoms of a depressive episode include loss of interest and motivation, poor sleep, appet

ite

disturbance, fatigue, poor concentration, and indecisiveness. A severe depression is characterized by

psychosis, severe psychomotor retardation or agitation, significant cognitive impairment (especially poor

concentration and attention), and suicidal thoughts or behavior. In addition to the medication used to treat

mania, antidepressants may be used to treat bipolar depression.

Other psychiatric disorders, i

ncluding substance abuse, frequently coexist with bipolar disorder.

NOTE: Cyclothymia is a mild form of bipolar disorder that causes brief episodes of depression or elevated

mo

od, but typically does not cause marked impairment. Treatment may include medication.

Determination is not based on diagnosis alone. The actual ability to drive safely and effectively

sho

uld not be determined solely by diagnosis but instead by an evaluation focused on function

and relevant history.

E"3+3*: 8%93'7

Minimum — 6 months symptom free following a nonpsychotic major depression unaccompanied by

suicidal behavior

Minimum — 1 y

ear symptom free following a severe depressive episode, a suicide attempt, or a manic

episode

Page 196 of 260

NOTE: If more than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver:

• Completes an appropriate symptom-fr

e

e waiting period.

• Complies with treatment program.

• Tolerates treatment without disqualifying side effects (e.g., sedation or impaired coordination).

• Has a comprehensive evaluation from an appropriate mental health professional who

unders

tands the functions and demands of commercial driving.

Recommend not to certify if:

The driver has:

• Active psychosis.

• Prominent negative symptoms, including:

o Su

bstantially compromised judgment.

o

Attentional difficulties.

o

Suicidal behavior or ideation.

o

Personality disorder that is

repeatedly manifested by overt inappropriate acts.

• Treatment side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

At least every 2 years the driver with a history of a major mood disorder should have evaluation and

clearance from a mental health specialist, such as a psychiatrist or psychologist, who understands the

functions and demands of commercial driving.

Advise the certified driver with a major mood disorder to report any manic or severe major depressive

epis

ode within 30 days of onset to the driver's employer, medical examiner, or appropriate health care

professional and to seek medical intervention.

0'$$'VU.A

The driver should have annual medical examinations.

?0J'* !"P*"(($'%

Major depression consists of one or more depressive episodes that may alter mood, cognitive functioning,

behavior, and physiology. Symptoms may include a depressed or irritable mood, loss of interest or

pleasure, social withdrawal, appetite and sleep disturbance that lead to weight change and fatigue,

restlessness and agitation or malaise, impaired concentration and memory functioning, poor judgment,

and suicidal thoughts or attempts. Hallucinations and delusions may also develop, but they are less

common in depression than in manic episodes.

Page 197 of 260

Most individuals with major depression will recover; however, some will relapse within 5 years. A

significant percentage of individuals with major depression will commit suicide; the risk is the greatest

within the first few years following the onset of the disorder.

Although precipitating factors for depression are not clear, many patients experience stressful events in

th

e 6 months preceding the onset of the episode. In addition to antidepressants, other drug therapy may

include anxiolytics, antipsychotics, and lithium. Prophylactic treatment may prevent or shorten future

episodes. Electroconvulsive therapy is also used to treat some cases of severe depression.

Determination is not based on diagnosis alone. The actual abi

lity to drive safely and effectively should not

be determined solely by diagnosis but instead by an evaluation focused on function and relevant history.

E"3+3*: 8%93'7

Minimum — 6 months symptom free following a nonpsychotic major depression unaccompanied by

suicidal behavior

Minimum — 1

year symptom free following a severe depressive episode, a suicide attempt, or a manic

episode

NOTE: If m

ore than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver:

• Completes an appropriate symptom-fr

ee waiting period.

• Complies with treatment program.

• Tolerates treatment wi

thout disqualifying side effects (e.g., sedation or impaired coordination).

• Has a comprehensive evaluation from an appropriate mental health professional who

under

stands the functions and demands of commercial driving.

Recommend not to certify if:

The driv

er has:

• Active psychosis.

• Prominent negative symptoms, including:

o Su

bstantially compromised judgment.

o At

tentional difficulties.

o Su

icidal behavior or ideation.

o Pe

rsonality disorder that is repeatedly manifested by overt, inappropriate acts.

• Treatment side

effects that interfere with safe driving.

Page 198

of 260

1'*3+'93*:F!%,+3*:

At least every 2 years the driver with a history of a major mood disorder should have evaluation and

clearance for commercial driving from a mental health specialist, such as a psychiatrist or psychologist,

who understands the functions and demands of commercial driving.

Advise the certified driver with a major mood disorder to report any manic or severe major depressive

epis

ode within 30 days of onset to the driver's employer, medical examiner or appropriate health care

professional and to seek medical intervention.

0'$$'VU.A

The driver should have annual medical examinations.

X"*('%0/$&M)!$('*>"*(

Any personality disorder characterized by excessive, aggressive, or impulsive behaviors warrants further

inquiry for risk assessment to establish whether such traits are serious enough to adversely affect

behavior in a manner that interferes with safe driving.

A person is medially unqualified if the disorder is severe enough to have repeatedly been manifested by

over

t acts that interfere with safe operation of a commercial vehicle.

NOTE: Alcohol and drug dependency and abuse are profound risk factors in the presence of personality

di

sorders.

Determination is not based on diagnosis alone. The actual ability to drive safely and effectively should not

be det

ermined solely by diagnosis but instead by an evaluation focused on function and relevant history.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the etiology is confirmed and treatment has been shown to be

adequate/

effective, safe, and stable.

I%63,3'*

Maximum certification — 1 year

Recommend to certify if:

The driver:

• Complies with treatment program.

• Tolerates treatment without disqualifying side effects (e.g., sedation or impaired coordination).

• Has a comprehensive evaluation fro

m an appropriate mental health professional who

understands the functions and demands of commercial driving.

Recommend not to certify if:

The driver has:

• An active psychosis.

Page 199 of 260

• Prominent negative symptoms, including substantially compromised judgment, attentional

difficulties, suicidal behavior or ideation, or a personality disorder that is repeatedly manifested by

overt, inappropriate acts.

• Treatment side effects that interfere with safe driving.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consult with a mental health specialist,

such as a psychiatrist or psychologist, to adequately assess driver medical fitness for duty.

0'$$'VU.A

The driver should have annual medical examinations.

DB;$e'P;*"%$0 0%> ,"/0&"> X(MB;'&$B !$('*>"*(

Schizophrenia is the most severe condition within the spectrum of psychotic disorders. Characteristics of

schizophrenia include psychosis (e.g., hearing voices or experiencing delusional thoughts), negative or

deficit symptoms (e.g., loss of motivation, apathy, or reduced emotional expression), and compromised

cognition, judgment, and/or attention. There is also an increased risk for suicide.

Individuals with chronic schizophrenia should not be considered medically qualified for commercial

drivin

g.

Related conditions include:

• Schizophreniform disorder.

• Brief reactive psychosis.

• Schizoaffective disorder.

• Delusional disorder.

,$(G( #'* 3'++"*B$0/ !*$A$%-

Clinical experience shows that a person who is actively psychotic may behave unpredictably in a variety

of ways. For example, a person who is hearing voices may receive a command to do something harmful

or dangerous, such as self-mutilation. Delusions or hallucinations may lead to violent behavior. Moreover,

antipsychotic therapy may cause sedation and motor abnormalities (e.g., muscular rigidity or tremors) and

impair coordination, particularly as the medication is being initiated and doses are adjusted.

Except for a confirmed diagnosis of schizophrenia, determination may not be based on diagnosis alone.

The

actual ability to drive safely and effectively should not be determined solely by diagnosis but instead

by an evaluation focused on function and relevant history.

E"3+3*: 8%93'7

Minimum — 6 months symptom free if a brief reactive psychosis or schizophreniform disorder

Minimum — 1 y

ear symptom free if any other psychotic disorder

NOTE: If mo

re than one waiting period applies (because of multiple conditions or other comorbid

diseases), examine the driver for certification after the completion of the longest waiting period.

I%63,3'*

Maximum certification — 1 year

Page 200 of 260

Recommend to certify if:

The driver:

• Completes an appropriate sym

ptom-free waiting period.

• Complies with treatment program.

• Tolerates treatment without disqualifying side effects (e.g., sedation or impaired coordination).

• Has a comprehensive evaluation from an appropriate mental health professional who

unders

tands the functions and demands of commercial driving.

Recommend not to certify if:

The driver has:

• Diagnosis of schizophrenia.

• Active psychosis.

• Prominent negative symptoms, including:

o Su

bstantially compromised judgment.

o

Attentional difficulties.

o

Suicidal behavior

or ideation.

o Personality disorder that is repeatedly manifested by overt, inappropriate acts.

•

Treatment side effects that interfere with safe driving.

NOTE: Chronic schizophrenia is usually a clear-cu

t condition. Individuals with this condition tend to be

severely incapacitated and frequently lack the cognitive skills necessary for steady employment, may

have impaired judgment and poor attention, and have a high risk for suicide.

1'*3+'93*:F!%,+3*:

At least every 2 years, the driver with a history of mental illness with psychotic features should have

evaluation and clearance for commercial driving from a mental health specialist, such as a psychiatrist or

psychologist, who understands the functions and demands of commercial driving.

Advise the certified dri

ver with a major mood disorder to report any manic or severe major depressive

episode within 30 days of onset to the driver's employer, medical examiner, or appropriate health care

professional and to seek medical intervention.

0'$$'VU.A

The driver should have annual medical examinations.

I9.: -#.,% "*7&-$6'/'$3,4

There is overwhelming evidence that drug and alcohol use and/or abuse interferes with driving ability.

Although there are separate standards for alcoholism and other drug problems, in reality much substance

abuse is polysubstance abuse, especially among persons with antisocial and some personality disorders.

Alcohol and other drugs cause impairment through both intoxication and withdrawal. Episodic abuse of

sub

stances by commercial drivers that occurs outside of driving periods may still cause impairment during

withdrawal. However, when in remission, alcoholism is not disabling unless transient or permanent

neurological changes have occurred.

Page 201 of 260

Alcohol and other drug dependencies and abuse are profound risk factors associated with personality

disorders that may interfere with safe driving.

Even in the absence of abuse, the commercial driver should be made aware of potential effects on driving

abil

ity resulting from the interactions of drugs with other prescription and nonprescription drugs and

alcohol (e.g., alcohol enhances hypoglycemic effects of sulfonylureas).

The Office of Drug & Alcohol Policy & Compliance ov

ersees intermodal (e.g., Federal Motor Carrier

Safety Administration (FMCSA), Federal Railroad Administration, Federal Transit Administration, and

Federal Aviation Administration) drug and alcohol testing programs in accordance with the Omnibus

Transportation Employee Testing Act of 1991.

See the FMCSA Dru

g and Alcohol Program at http://www.fmcsa.dot.gov/safety-security/drug-

alcohol/index.aspx for more information about the regulations and guidelines governing CMV drivers.

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49 CFR 391.41(b)(12)i)(ii)(A)(B)

"A person is physically qualified to d

rive a commercial motor vehicle if that person —

Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an

amphetamine, a

narcotic, or any other habit-forming drug.

Exception. A driver may use such a substance or drug, if the substa

nce or drug is prescribed by a

licensed medical practitioner who:

Is familiar with the driver’s medical history and assigned duties; and

Has advised the driver that the prescribed substance or drug will not adversely affect the driver’s ability to

sa

f

ely operate a commercial motor vehicle."

49 CFR 391.41(b)(13)

"Has no current clinical diagnosis of alcoholism."

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The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely. This examination is for public safety determination and is

considered by FMCSA to be a “medical fitness for duty exam.”

As a medical examiner, your fundamental obligation is to medically evaluate a driver to ensure that the

dri

ver has no medical condition that interferes with the safe performance of driving tasks on a public road.

If a driver has a current drinking problem, clinical alcoholism, or uses a Schedule I drug or other

substance such as an amphetamine, a narcotic, or any other habit-forming drug, the effects and/or side

effects may interfere with driving performance, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Page 202 of 260

Medical certification depends on a comprehensive medical assessment of overall health and informed

medical judgment about the impact of single or multiple conditions on the whole person.

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During the physical examination, you should ask the same questions as you would for any individual who

is being assessed for psychological or behavior concerns. The FMCSA Medical Examination Report form

includes health history questions and physical examination check lists. Additional questions should be

asked to supplement information requested on the form. You may use drug and/or alcohol abuse

screening tests.

NOTE: A test for controlled substances is not requi

red as part of the medical certification process. The

FMCSA or the employer should be contacted directly for information on controlled substances and

alcohol testing under Part 382 of the FMCSRs.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver use:

• Alcohol, regularly and frequently?

• Narcotic or habit-for

ming drugs?

Recommendations — Que

stions that you may ask include

Does the driver who uses alcohol:

• Have a consumption pattern that indicates additional evaluation may be needed based on

quanti

ty per occasion or per day/week?

• Pass standardized screening questions (e.g., Alcohol Use Disorde

rs Identification Test (AUDIT),

CAGE, and T-ACE)?

• Have a history of driver and/or family alcohol-rel

ated medical and/or behavioral problems?

Does the driver who uses narcotic or habit-forming drugs have a:

• Therapeutic or habitual need?

• Goal to alter mood, af

fect, or state of consciousness?

• Goal to extend physical limits by use of stimulants?

• History of drug rehabilitation?

NOTE: Certification may require successful completion of a substance abuse professional (SAP)-re

quired

drug rehabilitation program.

• Participation in a self-hel

p program cannot be substituted for completion of a SAP-required drug

rehabilitation program.

• Voluntary, ongoing participation in a self-help

program to support recovery is not disqualifying.

Page 203 of 260

Regulations — You must evaluate

On examination, does the driver have signs of alcoholism, problem drinking, or drug abuse, including:

• Tr

emor

.

• En

larged liver

.

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Regulations — You must document discussion with the driver about

• Any affirmative history, including if available

:

o On

set date, di

agnosis.

o Medication(s), dose, and frequency

.

o Any current limitation(s)

.

• Po

tential negative effects of medication use, including over-the-co

unter medications, while

dr

ivi

ng.

• An

y abnormal finding(s), noting

:

o Ef

fect on driver ability to operate a CMV safel

y.

o Necessary steps to correct the condition as soon as possible, particularly if the untreate

d

co

ndition could result in more serious illness that might affect driving

.

• An

y additional drug abuse or alcohol screening tests and evaluation

.

RE

MEMBER: Th

e Me

dical Review Officer oversees the drug and alcohol testing process. Medical fitness

for duty includes the ability to perform strenuous labor and to have good judgment, impulse control, and

problem-solving skills. Overall requirements for commercial drivers as well as the specific requirements in

the driver role job description should be deciding factors in the certification process.

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The purpose of this part is to establish programs designed to help prevent crashes and injuries resulting

from the misuse of alcohol or use of controlled substances by drivers of commercial motor vehicles

(CMVs).

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Who must be tested?

• All drivers, including part-tim

e, holding a commercial driver's license (CDL) and operating CMVs

(g

reater than 26,000 combined gross vehicle weight rating, or transporting more than 1

6

pas

sengers, or placarded hazardous materials) on the public roadways must be U.S. Departm

ent

of

Transportation (DOT) drug and alcohol tested. This means any driver required to possess

a

CDL

, including

:

o Drivers employed by Federal, State, and local government agencies

.

o Owner operators

.

o Equivalently licensed drivers from foreign countries

.

o For-hi

re motor carriers.

NOTE: Drivers who only operate CMVs

on private property not open to the public do not require testing.

Page 204 of 260

When is drug and/or alcohol testing required?

• Pre-employment:

o

Drug testing is required; however, a driver may be exempted from testing if the driver was

in

a testing program within the last 30 days and tested within the last 6 months or in a

program for the previous 12 months.

o Alcohol testing is not re

quired; however, the employer may require alcohol testing before

the driver can perform safety-sensitive functions. The employer may make the job offer

contingent upon passing an alcohol test.

• Post-accident dr

ug and/or alcohol testing is required for all fatal crashes and when the driver is

cited for a moving traffic violation.

• Reasonable suspicion tes

ting is conducted when a trained supervisor or company official

observes behavior or appearance that is characteristic of drug and/or alcohol misuse.

• Random drug

and/or alcohol testing is conducted on a random, unannounced basis just before,

during, or just after performance of safety-sensitive functions.

• Return-to-duty and follow-up testing is conducted when an individual who has violated the

prohibited drug and/or alcohol conduct standards returns to performing safety-sensitive duties.

Employer responsibilities include:

• Implementing and conducting

drug and alcohol testing programs.

• Providing a list of substance abuse professionals (SAPs).

• Ensuring that the driver who is returning to a safety-se

n

sitive position has complied with SAP

recommendations.

• Conducting follow-up t

esting to monitor that the driver is compliant with DOT alcohol conduct

guidelines and abstaining from unauthorized drug use.

Employer responsibilities do not include:

• Providing SAP evaluations.

• Paying for driver SAP evaluation, education, or treatment.

For more information see Feder

al

Motor Carrier Safety Administration Web site

http://www.fmcsa.dot.gov/rules-reg

ulations/topics/drug/engtesting.htm.

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Except where absolute criteria exist (i.e., a current clinical diagnosis of alcoholism), as a medical

examiner, you make the final determination as to whether the driver meets the Federal Motor Carrier

Safety Administration (FMCSA) medical standards for driver certification.

Use whatever tools or additional assessments you feel are necessary. If the driver shows signs of

alc

oholism, have the driver consult a specialist for further evaluation.

If you believe immediate testing for alcohol is warranted, contact FMCSA or c

ontact the employer of the

driver directly for information on controlled substances and alcohol testing under Part 382 of the Federal

Motor Carrier Safety Regulations.

Page 205 of 260

A driver MUST submit to alcohol testing if there is reasonable suspicion that the U.S. Department of

Transportation (DOT) prohibitions concerning alcohol are violated. Suspicion MUST be based on specific

observations concerning driver behavior, speech, or body odor.

I%&"*P*"&0&$'% #'* 12 34, 52S71S

When an interstate driver tests positive for alcohol or controlled substances under Part 382, the driver is

not required to be medically re-examined or to obtain a new medical examiner’s certificate provided the

driver is seen by a SAP who evaluates the driver and does not make a clinical diagnosis of alcoholism.

The SAP provides the driver with documentation allowing the driver to return to work.

If the SAP determines that alcoholism exists, the driver is not qualified to drive a commercial motor

veh

icle in interstate commerce. The ultimate responsibility rests with the motor carrier to ensure the driver

is medically qualified and to determine whether a new medical examination should be completed.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver until the driver has succe

ssfully completed counseling and/or treatment.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The driver with a history of alcoholism has:

• No residual disqualifying physical impairment.

• Successfully completed counseling and/or tre

atment.

• No current disqualifying alcohol-rel

ated disorders.

Do not to certify if:

The driver has:

• A current clinical diagnosis of alcoholism.

• Signs of a current alcoholic illness and/or non-com

pliance with DOT alcohol conduct guidelines.

• An alcohol-rel

ated unstable physical condition, regardless of the time element.

• Not met return-to-duty

requirements.

NOTE: Ongoing voluntary attendance at self-hel

p groups (e.g., 12-step programs) for maintenance of

recovery is not disqualifying.

1'*3+'93*:F!%,+3*:

You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver

medical fitness for duty.

0'$$'VU.A

No specific follow up is required.

Page 206 of 260

!*.-)CQ.("

All drug test results are reviewed and interpreted by a physician who is certified as a medical review

officer (MRO). When there is a positive result, the MRO contacts the driver and conducts an interview to

determine if there is an alternative medical explanation for finding drugs in the urine specimen. The MRO

notifies the employer only after determining that a positive test result was caused by unauthorized driver

use of a controlled substance.

All urine specimens are tested for:

• Marijuana.

• Cocaine.

• Amphet

amines.

•

Opiates.

• Phencyclidine (PCP).

A driver MUST be removed from safety-sen

sitive duty when the driver has a positive drug test result

caused by the unauthorized use of a controlled substance. To be returned to safety-sensitive duties the

driver MUST:

• Be evaluated by a substance abuse professional (SAP).

• Comply with recommended rehabilitation.

• Have a negative result on a return-to-duty

drug test.

E"3+3*: 8%93'7

No recommended time frame

You should not certify the driver for the duration of the prohibited drug(s) use and until a second

exam

ination shows the driver is free from the prohibited drug(s) use and has completed any recertification

requirements.

To be returned to safety-sen

sitive duties the driver MUST:

• Be evaluated by a SAP.

• Comply with recomme

n

ded rehabilitation.

• Have a negative result on a return-to-duty

drug test.

I%63,3'*

Maximum certification — 2 years

Recommend to certify if:

The driver with a history of drug abuse has:

• No residual disqualifying physical condition.

• Proof of successful com

pletion of return-to-duty requirements.

Page 207 of 260

Do not to certify if:

The driver uses:

• Schedule I controlled substances

.

• Am

phetamines

.

• Na

rcotics

.

• An

y other habit-form

ing drug for which the exception guidelines do not apply.

• Me

thadone (regardless of the reason for the

prescription).

• Ma

rijuana (even if in a State that allows medicinal use)

.

NO

TE: Ongoing voluntary attendance at self-help

groups (e.g., 12-step programs) for maintenance of

recovery is not disqualifying.

1'*3+'93*:F!%,+3*:

You have the option to certify for a period of less than 2 years if more frequent monitoring is required.

0'$$'VU.A

The driver should have at least biennial medical examinations or more frequently if indicated.

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The effects and/or side effects of medications may interfere with safe driving. The driver may experience

an altered state of alertness, attention, or even temporary confusion. Other medications may cause

physical symptoms such as hypotension, sedation, or increased bleeding that can interfere with task

performance or put the driver at risk for gradual or sudden incapacitation. Combinations of medications

and/or supplements may have synergistic effects that potentiate side effects, causing gradual or sudden

incapacitation.

The demands of com

mercial driving may complicate adherence to prescribed dosing intervals and

precautions. Irregular meal timing, periods of sleep deprivation or poor sleep quality, and irregular or

extended work hours can alter the effects of medicine and contribute to missed or irregular dosing.

Physical demands may increase pain and the need for medication.

Three types of medications may be used by the commercial driver:

• Prescription

.

• Over-the-cou

nter (OTC).

• Su

pplements and herbs

.

Ev

ery year, more medications are availa

ble

without prescription and provider supervision.

Nonprescription medications are not necessarily safe to use while driving

In the advisory criteria general information, you are instructed to discuss common prescriptions and OTC

medi

cations relative to the side effects and hazards of these medications while driving. In addition,

educate the driver to read warning labels on all medications.

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"A person is physically qualified to drive a commercial motor vehicle if that person —

Page 208 of 260

Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a

narcotic, or any other habit-forming drug.

Exception. A driver may use such a substance or drug, if the substance or drug is prescribed by a

lice

nsed medical practitioner who:

Is familiar with the driver’s medical history and assigned duties; and

Has advised the dri

ver that the prescribed substance or drug will not adversely affect the driver’s ability to

safely operate a commercial motor vehicle."

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The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the ability of the driver to operate a

commercial motor vehicle (CMV) safely. This examination is for public safety determination and is

considered by the Federal Motor Carrier Safety Administration (FMCSA) to be a "medical fitness for duty"

examination.

As the medical examiner, your fundamental obligation is to establish whether a driver uses one or more

medic

ations and supplements that have cognitive or physical effects or side effects that interfere with safe

driving, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical

exam

ination), and additional testing requested by the medical examiner. Your assessment should reflect

physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

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During the physical examination, you should ask the driver to provide a complete history of medication

use, including OTC medications and food and herbal supplements. The FMCSA Medical Examination

Report form includes health history questions and physical examination checklists. Additional questions

should be asked to supplement information requested on the form. You may ask questions to ascertain

the level of knowledge regarding appropriate use of the medication while driving.

Regulations — You

must review and discuss with the driver any "yes" answers

Does the driver use medications to:

• Treat cardiovascular disease?

• Reduce hypertension?

• Control blood glucose level?

o Or

al hypoglycemics?

o

Insulin (regardless of route)?

•

Control seizures or treat epilepsy?

• Treat nervous or psychiatric disorders?

Did the driver list all medications (including OTC medications) used regularly or recently?

Page 209

of 260

Recommendations — Question that you may ask include

Does the driver experience:

• Dizziness or light-headednes

s?

• Hypotension?

• Sedation?

• Depressed mood?

• Cognitive deficit?

• Decreased reflex responses?

• Unsteadiness?

Regulations — Yo

u must evaluate

On examination,

does the medication have:

• The desired effect on the underlying disease (e.g., blood pressure is lowered)?

• Side effects that interfere with safe driving (e.g., uncontrollable tremor or orthostatic

hy

potension)?

Important considerations for medication use

while driving

Does the medication:

• Indicate the presence of underlying disqualifying disease or injury?

• Effectively treat the disease or medical condition?

• Exhibit side effects that interfere with safe driving?

• Have side effects that interfere with lifest

yle functions such that the driver may cease to comply

with treatment (e.g., decreased libido).

• Have potential for gradual or sudden incapacitation, or exacerbation of underlying medical

condition, due to missed dose (e.g., seizure, psychosis)?

• Require moni

toring to maintain a therapeutic dose or prevent toxicity (e.g., Coumadin)?

• Interact with other drugs, food, and/or alcohol, interfering with the ability to drive?

Do

es the driver:

• Understand and comply with medication plan, including monitoring?

• Know what

warning signs might indicate medication toxicity, interaction, etc.?

• Store medications properly when driving long haul or cross country?

• Read and understand warning labels on medications and supplements?

• Consult the treating healthcare professional and/

or a pharmacist before using new medication or

combining medications while driving.

Page 210

of 260

,"B'*>

Regulations — You must document discussion with the driver about

• Any affirmative history, including:

o On

set date, diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of medication use, including OTC medications, while driving.

• Any abnormal finding(s), noting:

o Effect on driver ability to operate a CMV safely.

o

Necessary steps to correct the condition if appropriate, or

reasons for disqualification.

• Any additional tests and evaluation.

REMEMBER: Med

ical fitness for duty includes the ability to perform strenuous labor and to have good

judgment, impulse control, and problem-solving skills. Overall requirements for commercial drivers as well

as the specific requirements in the driver role job description should be deciding factors in the certification

process.

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49 CFR 391.41(b)(12) identifies driver use of Schedule I drugs as medically disqualifying. The 1970

Comprehensive Drug Abuse Prevention and Control Act provides the framework for the current Drug

Enforcement Administration (DEA) drug schedules.

There are five schedules of controlled sub

stances, I, II, III, IV, and V. The drug schedules are based on

addiction potential and medical use but not on side effects. The lists are updated annually.

NOTE: The advisory criteria first directs you to 21

CFR 1308.11 TITLE 21— FOOD AND DRUGS

CHAPTER 13 — DRUG ABUSE PREVENTION AND CONTROL SUBCHAPTER I — CONTROL AND

ENFORCEMENT Part B — Authority To Control; Standards and Schedules. This regulation describes the

rules and procedures used to establish and maintain the 21 USC Sec. 812 controlled substance lists.

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26/%7.$%&H

These drugs have no currently accepted medical use in the United States, have a high abuse potential,

and are not considered safe, even under medical supervision. These substances include many opiates,

opiate derivatives, and hallucinogenic substances. Heroin and marijuana are examples of Schedule I

drugs. The exception criteria of 49 CFR 41(b)(12)(ii) does not apply to any Schedule I substance.

NOTE: The driver taking medical marijuana cannot be certified.

26/%7.$%&HH

These drugs have currently accepted medical uses but have a high abuse potential that may lead to

severe psychological or physical dependence. Schedule II drugs include opioids, depressants, and

Page 211 of 260

amphetamines. The opioids in Schedule II include natural opioids (e.g., morphine) and synthetic opioids

(e.g., OxyContin).

NOTE: Interpretation for 49 CFR 391.41- Me

thadone is a habit-forming narcotic which can produce drug

dependence and is not an allowable drug for operators of commercial motor vehicles (CMV).

26/%7.$%, HHH U J

These drugs have decreasing potential for abuse than preceding schedules. Abuse may lead to moderate

or low physical dependence or high psychological dependence. Schedule III drugs include tranquilizers.

Schedule IV drugs include drugs such as chlorhydrol and phenobarbital. Schedule V drugs have the

lowest potential for abuse and include narcotic compounds or mixtures.

Side effects are not part of the DEA schedule rating criteria. Therefore, a substance can have little risk for

addic

tion and abuse but still have side effects that interfere with driving ability.

See About 49 CFR 382 Alcohol and Drug Rules section of this handbook.

Page 212 of 260

Appendix A: Medical Examination Report Form

To print a sample Medical Examination Report form, visit:

http://www.fmcsa.dot.gov/documents/safetyprograms/Medical-Rep

ort.pdf

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The first page of the Medical Examination Report form is for recording Driver Information and Health

History. The driver completes these sections.

I93@%r H*('94"+3'*

A complete physical examination is required for new certification and recertification. Verify that the date of

the examination is accurate because this is used to calculate the expiration date.

Any individual can request and be given a Federal Motor Carrier Safety Administration physical

exam

ination. A person must be at least 21 years of age to operate a commercial motor vehicle (CMV) in

interstate commerce. A person operating a CMV in interstate commerce must be medically examined,

carry an original or copy of the medical examiner’s certificate while driving, and be currently licensed

(commercial or noncommercial).

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The health history is an essential part of the driver physical examination. Are there limitations resulting

from a current or past medical condition? Are there symptoms that indicate additional testing or

evaluation is needed? Discuss the safety implications of effects and/or side effects of prescription and

over-the-counter medications, supplements, and herbs.

Ensure that the driver signs and dates the Medical Examination Report form. By signing the form, the

dri

ver certifies that the information and history are “complete and true.” The driver signature also

acknowledges that providing inaccurate or false information or omitting information could invalidate the

medical examiner’s certificate. A civil penalty may be levied under 49 U.S.C. 521(b)(2)(b) against the

driver who provides a false or intentionally incomplete medical history. Everything above the driver

signature should be completed by the driver.

As a medical examiner, you must clarify yes answers. Document the significant findings of the health

histo

ry in the comments section below the signature of the driver.

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The results of the four required tests: vision, hearing, blood pressure/pulse, and urinalysis are recorded

on the second page of the Medical Examination Report form. Abnormal test results may disqualify a

driver or indicate that additional evaluation and/or testing are needed.

Drug and alcohol testing are not required for the driver physical examination unless findings indicate they

are

needed to determine medical fitness for duty.

J3,3'*

The medical examiner or a licensed ophthalmologist or optometrist can examine and certify vision test

results.

Page 213 of 260

Visual acuity is measured in each eye individually and both eyes together:

• Distant visual acuity of at lea

st 20/40 (Snellen) in each eye, with or without corrective lenses.

• Distant binocular visual acuity of at least 20/40 (Snellen) in both eyes, with or without corrective

len

ses.

• Field of vision of at least 70° in the horizontal meridian in each eye.

Color

vision must be sufficient to recognize and distinguish traffic signals and devices showing the

st

andard red, amber, and green colors.

When corrective lenses are used to meet vision qualification requirements, the corrective lenses must be

used

while driving.

A driver with monocular vision, who is otherwise medically qualified, may apply for a Federal vision

exem

ption. The driver with a Federal vision exemption may be certified for up to 1 year.

You may certify the driver who meets vision qualification requir

ements, with or without the use of

corrective lenses, for up to 2 years.

W%"93*:

To qualify, the driver must meet the hearing requirement of either the forced whisper test or the

audiometric test in one ear.

The requirement for the:

• Forced whisper test i

s to first perceive a forced whispered voice, in one ear, at not less than five

feet.

• Audiometric test is to have an average hearing loss, in one ear, less than or equal to 40 decibels

(dB

).

The driver who wears a hearing aid to meet the hearing qualific

ation requirement must wear a hearing aid

while driving.

L$''7&89%,,.9%F8.$,%

Record pulse rate and rhythm on the Medical Examination Report Form.

The cardiovascular recommendations for certification using the JNC-6 s

tages of hypertension are

summarized in the Medical Examination Report form table. Blood pressure (BP) readings are defined as:

• 140-159/90-99

= Stage 1 hypertension.

• 160-179/100-109

= Stage 2 hypertension.

• Greater than or equal to 180/110 = Stage 3 hypertension.

The driver with hypertens

i

on and BP less than or equal to 139/89 may be certified for up to 1 year.

Confirm an elevated BP by a second elevated BP later in the examination. The driver with stage 1 or

stage 2 hypertension may be certified in accordance with the cardiovascular recommendations, which

take into consideration known hypertension history. Disqualify a driver with stage 3 hypertension.

]93*"$=,3,

Record the test results of the required dipstick urinalysis (UA) in the Laboratory and Other Medical Test

Findings section of the Medical Examination Report form. The dipstick urinalysis must measure specific

Page 214 of 260

gravity and test for protein, blood, and glucose in the urine. Positive test results may indicate that

additional evaluation is needed.

Attach copies of additional test res

ults and interpretation reports to the Medical Examination Report form.

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Record the physical examination and certification status on the third page of the Medical Examination

Report form.

8/=,36"$ >?"43*"+3'*

The physical examination should be as thorough as described in the Medical Examination Report form, at

a minimum. Note any abnormal finding, including the safety implication, even if not disqualifying. Inform

the driver of any abnormal findings and as needed advise the driver to obtain follow-up evaluation.

Physical examination may indicate the need for additional evaluation and/or tests. Specialists, such as

car

diologists and endocrinologists, may perform additional medical evaluation, but it is the medical

examiner who decides if the driver is medically qualified to drive. Document the certification decision,

including the rationale for any decision that does not concur with the recommendations.

)%9+3(36"+3'* "*7&I'6.4%*+"+3'*

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Document the certification decision in the space provided for certification status. There are two possible

outcomes: the driver is certified and issued a medical examiner's certificate or the driver is disqualified

and is not issued a medical examiner's certificate.

• Certify the driver

o

The driver meets all the standards — Th

e maximum length of time a driver can be

medically certified is 2 years. The driver who must wear corrective lenses, a hearing aid,

or have a Skill Performance Evaluation certificate may be certified for up to 2 years when

there are no other conditions that require periodic monitoring.

o The driver meets the standards but has a condition that requires frequent

mo

nitoring (and certification) — Certify for less than 2 years as needed to monitor

continued medical fitness for duty. Federal exemptions and some Federal Motor Carrier

Safety Administration guidelines specify annual medical examinations.

• Disqualify the driver

o Th

e driver does not meet the standards — Do

not issue a medical examiner's

certificate.

o Discuss the disqualification decision with the driver, including what the driver can do to

me

et the Federal qualification requirements for commercial drivers.

Certification and recertification occur only when the

medical examiner determines that the driver is

medically fit for duty in accordance with Federal qualification requirements for commercial drivers.

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Provide the medical examiner's certificate to the qualified driver. Ensure that the date entered is the date

of the physical examination. The expiration date should be consistent with the Medical Examination

Report form certification status and cannot exceed 2 years from the date of the examination. The driver

Page 215 of 260

must sign the medical examiner's certificate. The certificate expires at midnight on the date of expiration.

There is no grace period.

The driver must carry a valid medical examiner's certificate when operating a commercial vehicle. The

mot

or carrier is also required to maintain a copy of the medical examiner's certificate.

The certificate can be the original or a photocopy, and can be reduced in size (usually wallet-size

d).

Lamination is prohibited in some States.

12 34, 52S715 ,Nd=ZC<IFc)C?Nc!?Nc< h5 4, h5SUhH !"B7 SH)U66f

There are now two paragraphs in 49 CFR 391.43(g):

(g)(1) If the medical examiner finds that the person examined is physically qualified to operate a

com

mercial motor vehicle in accordance with §391.41(b), the medical examiner should complete a

certificate in the form prescribed in paragraph (h) of this section and furnish the original to the person who

was examined. The examiner may provide a copy to a prospective or current employing motor carrier

who requests it.

(g)(2) For all drivers examined, the m

edical examiner should retain a copy of the Medical Examination

Report at least 3 years from the date of the examination. If the driver was certified as physically qualified,

then the medical examiner should also retain the medical certificate as well for at least 3 years from the

date the certificate was issued.

Page 216 of 260

Appendix B: Federal Exemption Programs

OP )0< QfRSQaa&E/"+ 3, "* %?%4A+3'*h

"(a) An exemption is temporary regulatory relief from one or more FMCSR given to a person or class of

persons subject to the regulations, or who intend to engage in an activity that would make them subject to

the regulations.

(b) An exemption provides the person or class of persons with relief from the regulations for up to two

yea

rs, and may be renewed.

(c) Exemptions may only be granted from one or more of the requirements contained in the following

par

ts and sections of the FMCSRs ...

(c)(3) Part 391 — Qua

lifications of Drivers."

0%7%9"$ J3,3'*&>?%4A+3'*&89':9"4

The FMCSA Vision Exemption Program is for monocular vision. The vision exemption is issued for a

maximum of 2 years and is renewable.

The driver must be otherwise qualified under 49 CFR 391.41(b)(1-13) or

hold another valid medical

exemption to legally operate a commercial motor vehicle in interstate commerce. Provisions of the vision

exemption include an annual medical examination and an eye examination by an ophthalmologist or an

optometrist.

At the annual recertification examination, the driver should present the current vision exemption and a

cop

y of the specialist eye examination report. Certify the qualified driver for 1 year and issue a medical

examiner's certificate with the "accompanied by" exemption checkbox marked and write "vision" to

identify the type of Federal exemption.

The motor carrier is res

ponsible for ensuring that the driver has the required documentation before driving

a commercial vehicle. The driver is responsible for carrying both the vision exemption and the medical

examiner's certificate while driving and keeping both current.

Z."$3(3%7&#y 5A%9"+3'*&'( OP )0R QPRScO[ YG9"*7("+/%9%7Y

Prior to the implementation of the Federal Vision Exemption Program, FMCSA conducted an initial vision

study program that ran from 1992 to 1996. At the conclusion of that study, 2,656 drivers received a one-

time letter confirming participation in the study and granting a continued exemption from the monocular

vi

s

ion requirement, as long as the driver is otherwise medically fit for duty and can meet the vision

qualification requirements with the one eye. The driver who was grandfathered must have an annual

medical examination and an eye examination by an ophthalmologist or optometrist. There are very few

remaining drivers from that program.

At the annual medical examination, the driver should present to the

medical examiner the letter identifying

the driver as a participant in the vision study program and a copy of the specialist eye examination report.

Certify the qualified driver for 1 year and issue a medical examiner's certificate with the "Qualified by

operation of 49 CFR 391.64" checkbox marked.

Page 217 of 260

0%7%9"$ I3"#%+%, >?%4A+3'*&89':9"4

-#'.+ +/% 0%7%9"$ I3"#%+%, >?%4A+3'* 89':9"4

W0BG-*'.%>

Prior to the implementation of the Federal Diabetes Exemption Program, the Federal Motor Carrier Safety

Administration (FMCSA) conducted a waiver study program concerning commercial motor vehicle (CMV)

operation by drivers with insulin-controlled diabetes. A small number of the drivers who participated in the

study and were participants in good standing on March 31, 1996, were provided a letter from FMCSA that

grandfathered them an exemption from standard 49 CFR 391.41(b)(3), by operation of 49 CFR 391.64(a),

as long as they were in compliance with the requirements. These drivers are governed by 49 CFR

391.64(a) and must provide the letter from FMCSA as proof of their grandfathered status before you issue

a Medical Examiner's Certificate to the driver.

On September 3, 2003, FMCSA published a Notice of Final Disposition announcing the decision to issue

exem

ptions to the diabetes mellitus prohibition under 49 CFR 391.41(b)(3). This program allows some

drivers who meet all medical standards and guidelines, other than the use of insulin, to be medically

certified and operate a CMV if the driver also meets the parameters for issuance of a Federal diabetes

exemption.

The 2003 Notice explained that in considering exemptions, FMCSA must ensure that the issuance of

diabet

es exemptions will not be contrary to the public interest, and that the exemption achieves an

acceptable level of safety.

,"(P'%($Q$/$&$"(

As a medical examiner, you are responsible for determining if the driver is otherwise medically fit for duty

and issuing a Medical Examiner's Certificate that indicates the driver is certified ONLY IF the driver has a

diabetes exemption.

The Federal Diabetes Exemption Program is responsible for determining if the driver meets program

req

uirements and for issuing the diabetes exemption.

The motor carrier is responsible for ensuring that the driver has a current medical examiner's cer

tificate

and diabetes exemption before allowing the driver to operate a commercial vehicle.

The driver is responsible for carrying both the Medical Examiner's Certificate and the diabetes exemption

whi

le driving and keeping both certificates current. The Federal diabetes exemption must be renewed

every 2 years. The driver must also comply with program requirements that include:

• Annual:

o CMV driver medical qualification examination.

o

Endocrinologist evaluation.

o

Ophthalmologist/optometrist evaluation.

o

Diabet

es mellitus education.

• Monitoring blood glucose.

NOTE: Although you, as a medical examiner, are not involved in the Diabetes Exemption Program

mo

nitoring, it is helpful for you to understand the requirements. The driver must provide a quarterly

evaluation checklist from his/her endocrinologist throughout the 2-year period or risk losing the

exemption.

Page 218 of 260

The Safe, Accountable, Flexible, Efficient Transportation Equity Act — A Legacy for Users (SAFETEA-

LU), August 10, 2005, eliminated the driving experience requirement.

For more information, review the Di

a

betes Exemption Application at

http://www.fmcsa.dot.gov/documents/safetyprograms/Diabetes/diabetes-exem

ption-package.pdf. Please

direct questions concerning Driver Exemption Programs to medicalexemptions@dot.gov or call 1-703

-

448-3094.

<%$%@"*6%&+o I93@3*:

The Center for Disease Control and Prevention (CDC) 2007 National Diabetes Fact Sheet

(http://www.cdc.gov/features/dsdiabetes/) reports that in adults, type 1 diabetes accounts for 5–10% of al

l

diagnosed cases of diabetes. Individuals with type 1 diabetes mellitus:

•

Are distinguished by a virtual lack of insulin production and often severely compromised counter-

regulatory mechanisms

.

• Must have insulin replacement therapy.

• May lack blood glucose control counter-regulatory mechanisms.

Although hypoglycemia can occur in non-insulin-treated diabetes mellitus, it is most often associated with

insulin-treated diabetes mellitus. Mild hypoglycemia causes rapid heart rate, sweating, weakness, and

hunger, while severe hypoglycemia causes headache and dizziness. FMCSA defines a severe

hypoglycemic reaction as one that results in:

•

Seizure.

• Loss of consciousness.

• Need of assistance from another person.

• Period of impaired cognitive function that occurs without warning.

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d"%"*0/ X.*P'(" '# L"0/&; L$(&'*M)0%> X;M($B0/ NO0+$%0&$'%

The general purpose of the history and physical examination is to detect the presence of physical, mental,

or organic conditions of such character and extent as to affect the driver ability to operate a CMV safely.

This examination is for public safety determination and is considered by FMCSA to be a “medical fitness

for duty" examination.

As a medical examiner, your fundamental obligation during the assessment of a driver with diabetes

mel

litus who uses insulin is to establish whether the driver meets all medical standards and guidelines in

accordance with 49 CFR 391.41(b)(1-13), other than the use of insulin to treat diabetes.

The examination is based on information provided by the driver (minimum 5-yea

r history), objective data

(physical examination), and additional testing requested by the medical examiner. Your assessment

should reflect physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed

med

ical judgment about the impact of single or multiple conditions on the whole person.

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This physical examination starts the Federal Diabetes Exemption Program application process. The

medical examiner evaluation guidelines (http://nrcme.fmcsa.dot.gov/documents/DMCertLet.pdf) stipulate

Pa

ge 219 of 260

that the medical examiner review the 5-year medical history of the driver. The driver must provide a 5-

year medical history for your review before you determine certification status.

The FMCSA Medical Examination Report form includes health history questions and physical

ex

amination checklists. Additional questions should be asked to supplement information requested on the

form. You should ask about and document diabetes mellitus symptoms, blood glucose monitoring, insulin

treatment, and history of hypoglycemic episodes.

It is your responsibility to determine if the driver meets all medi

cal standards and guidelines, other than

diabetes, in accordance with 49 CFR 391.41(b)(1-13). Any other medical problems or conditions that

prevent a driver being certified by the medical examiner must be corrected BEFORE the driver submits

an application to the Federal Diabetes Exemption Program.

Regulations — Yo

u must review and discuss with the driver any "yes" answers

Does the driver have diabetes mellitus or elevated blood glucose controlled by:

• Diet?

• Pills?

• Insulin?

o Do

sage?

o Ro

ute?

o Fr

equency?

Recommendations — Qu

estions that you may ask include

Does the driver:

• Newly started on insulin have documentation of completion of minimum waiting period?

• With a valid Federal diabetes exemption have documentation of compliance with program

re

quirements for specialist evaluation?

• Routinely monitor blood glucose level and have device record for review?

• Use over-th

e-counter medications and/or supplements?

• Use an

incretin mimetic?

• Have a history of fainting, dizziness, or loss of consciousness?

• Have a history of hypoglycemic reactions that resulted in:

o Se

izure?

o Los

s of consciousness?

o Ne

ed of assistance from another person?

o Pe

riod of impaired cognitive function that occurred without warning?

• Carry rescue glucose while driving?

NOTE: Wh

en the driver has a positive history for severe hypoglycemic reactions, ask about occurrences,

including has the driver had:

• One or more occurrences within last 12 months?

• Two or mor

e occurrences within last 5 years?

Page 220

of 260

Regulations — You must evaluate

On examination, does the driver have:

• Glycosuria (dip stick urinalysis)?

• Signs of target organ damage associated with dysfunction of the senses, including:

o Retinopathy?

o

Macular degenerati

on?

o Peripheral neuropathy?

•

Signs of target organ damage that can cause gradual or sudden incapacitation, including:

o Coronary heart disease?

o

Cerebrovascular disease, including:



Transient ischemic attack?

 Embolic or thrombotic stroke?

 Peripheral vascular disease?

o Autonomic neuropathy?

o Nephropathy?

State-issued Medical Waivers and Exemptions

It is important that as a medical examiner you distinguish between intrastate waivers/exemptions and

Federal diabetes exemptions for insulin-treated diabetes mellitus.

,"B'*>

Regulations — You must document discussion with the driver about:

• Any affirmative history, including if available:

o On

set date, diagnosis.

o

Medication(s), dose, and frequency.

o

Any current limitation(s).

•

Potential negative effects of medication use, inc

luding over-the-counter medications, while

driving.

• Any abnormal finding(s), noting:

o Effect on driver ability to operate a CMV safely.

o

Advice to take the necessary steps to correct the condition as soon as possible

par

ticularly if the condition, if neglected, could result in more serious illness that might

affect driving.

• Any additional medical tests and evaluation.

When documenting the certification of the driver with diabetes mellitus who uses insulin, ensure that the

Me

d

ical Examination Report form periodic monitoring interval and the Medical Examiner's Certificate

expiration date agree and do not exceed 1 year. When the driver has or must obtain a Federal diabetes

exemption:

• Mark the "accompanied by a ______________" exemption checkbox.

• Write "Federal diabetes" on the line.

•

Circle "exemption."

Page 221

of 260

Figure 24 - Medical Examination Report: Federal Diabetes Exemption

In the case of the driver who has documentation of having been a participant in good standing in the

Federal diabetes study on March 31, 1996, mark the "Qualified by operation of 49 CFR 391.64"

checkbox.

NOTE: Pr

oof of grandfathered status is the original letter from 1996 granting the right to continue to drive

as long as the driver can meet physical qualification requirements. If a letter is not provided, you may

verify driver participation in the study program—and the driver can obtain a new copy of the letter—by

calling the FMCSA Exemption Program Office at 703-448-3094.

Figure 25 - Medical Examination Report: Grandfathered Status

REMEMBER: The diabetes qualification standard parameter is use of insulin, not the diagnosis of

diabetes mellitus.

Page 222

of 260

Appendix C: Skill Performance Evaluation

03?%7&I%(363+ '( "* >?+9%43+=

When the loss of (hand, foot, leg, or arm) or a fixed impairment to an extremity may interfere with the

ability of the driver to operate a commercial motor vehicle (CMV) safely, you are responsible for

determining if the driver is otherwise medically fit to drive. A driver may be allowed to drive if the

qualification requirements for a Skill Performance Evaluation (SPE) certificate under 49 CFR 391.49 are

met.

NOTE: As a medical examiner, you determine if the severity of a fixed deficit that is less than the whole

hand

is medically disqualifying unless the driver has an SPE certificate pursuant to 49 CFR 391.49. The

SPE is applicable only for fixed deficits of the extremities.

In order to legally operate a CMV, the driver must carry an SPE certificate and a valid medical examiner's

cer

tificate. The driver is responsible for ensuring that both certificates are renewed prior to expiration.

E"3+3*: A%93'7

No recommended time frame

The driver must be otherwise medically fit for duty before certification or recertification in accordance

with

49 CFR 391.49.

I%63,3'*

Maximum certification period — 2 years

Recommend to certify (accompanied by an SPE) if:

The driver has:

• A fixed deficit of an extremity and is otherwise medically qualified at physical examination (required

for both certification and recertification).

• A valid SPE certificate and documentation of compliance with medical requirements (required for

recertification with a current SPE certificate).

NOTE: The SPE applies only to fixed deficits of the extremities, not those caused by a progressive

disease. To be certified, the driver with a deficit of an extremity caused by a progressive disease must

meet 49 CFR 391.41 requirements, including adequate range of motion, strength, grip, and prehension to

safely operate a CMV.

Recommend not to certify if:

The driver has:

•

An impairment that affects the torso.

• Not provided proof of compliance with SPE certification requirements.

• A disqualifying limb impairment caused by a progressive disease (e.g., multiple sclerosis).

NOTE: The SPE applies only to fixed deficits of the extremities, not those caused by a progressive

disease. The driver with a deficit of an extremity caused by a progressive disease must not be certified if

the driver cannot meet 49 CFR 391.41 requirements.

Page 223 of 260

Recommend not to certify if:

1'*3+'93*:F!%,+3*:

SPE initial and renewal applications also require a medical evaluation summary completed by either a

board qualified or board certified physiatrist or orthopedic surgeon. You should review the report at

recertification for any medical changes before determining driver certification status.

0'$$'VU.A

The driver should have at least biennial physical examinations or more frequently when indicated. The

driver is responsible for maintaining current medical and SPE certification.

Page 224

of 260

Appendix D: Cardiovascular Recommendation Tables

The first publication of the Cardiovascular Recommendation Tables occurred in

the October 2002, Cardiovascular Advisory Panel Guidelines for the Medical

Examination of Commercial Motor Vehicle Drivers, FMCSA-MCP-02-002. To review this publication,

visit:

http://www.fmcsa.dot.gov/facts-rese

arch/research-technology/publications/cardio.htm

89%("6%

The Federal Motor Carrier Safety Administration (FMCSA) has an ongoing process for reviewing all

Federal medical standards and guidelines used to determine driver medical fitness for duty.

These tables will be updated when

changes are made to FMCSA medical standards and guidelines. All

proposed changes to the medical standards are subject to public notice-and-comment rulemaking.

As part of its review process, FMCSA considers medical evidence reports, medical expert panel (M

EP)

opinion, and Medical Review Board (MRB) recommendations. FMCSA also considers other factors such

as feasibility and impact.

These tables do not include recommendations that have been submitted to FMCSA for consideration but

not adopted

by FMCSA. However, FMCSA posts copies of the medical evidence report executive

summaries and MEP recommendations on the FMCSA Web page Reports - How Medical Conditions

Impact Driving found at

http://www.fmcsa.dot.gov/rules-regu

lations/topics/mep/mep-reports.htm

Reports of MRB proceedings are posted on the MRB Web site at

http://www.mrb.fmcsa.dot.gov/proceedings.aspx, and the MRB public meeting schedule at

http://www.mrb.fmcsa.dot.gov/.

Medical examiners may submit questions or comments to the FMCSA Office of Medical Programs by

send

ing an email to fmcsamedical@dot.gov.

Page 225

of 260

ANEURYSMS

2002 Cardiovascular Conference Report Recommendation Tables, Page 145

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Abdominal Aortic

Aneurysm (AAA)

Evaluate for associated

cardiovascular diseases.

Aneurysm < 4.0 cm.

Aneurysm 4.0 to <5.0 cm.

Ultrasound to identify

change in size.

Aneurysm > 5.0 cm.

Yes, if asymptomatic.

Yes if:

Asymptomatic;

Cleared by vascular

specialist.

No, if:

Symptomatic; Surgery

recommended by

vascular specialist.

Yes if:

At least 3 months after

surgical repair. Cleared

by cardiovascular

specialist.

No.

Yes if:

At least 3 months after

surgical repair. Cleared

by cardiovascular

specialist.

Annual

Ultrasound for change in

size.

Annual

Thoracic Aneurysm

Evaluate for associated

cardiovascular diseases.

No, if >3.5cm.

Yes if:

At least 3 months after

surgical repair. Cleared

by cardiovascular

specialist.

Annual

Aneurysms of other

Assess for risk of rupture

No

vessels

and for associated

cardiovascular diseases.

Yes if:

At least 3 months after

surgical repair. Cleared

by cardiovascular

specialist.

Annual

Page 226 of 260

AORTIC CONGENITAL HEART DISEASE

2002 Cardiovascular Conference Report Recommendation Tables, Page 122

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Bicuspid Aortic Valve

May result in aortic

stenosis or regurgitation

(see section on Valvular

Diseases), aortic root

enlargement, aortic

aneurysm formation and

aortic rupture.

See section on Valvular

Diseases.

No if:

Aortic transverse

diameter > 5.5 cm.

Yes if:

Surgical intervention

successfully performed.

See section on Valvular

Diseases.

Annual

Subvalvular Aortic

Mild = favorable

Yes if:

Annual

Stenosis

Has potential for

progression.

Moderate or severe =

unfavorable.

No valvular abnormality

or hypertrophic

cardiomyopathy.

No if:

Symptomatic and mean

pressure gradient >30

mm Hg.

Yes if:

At least 3 months after

successful surgical

resection when cleared

by cardiologist

knowledgeable in

congenital heart disease.

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

is require.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required, including

echocardiogram.

Discrete Supravalvular

Unfavorable prognosis

No, unless surgery.

Aortic Stenosis

due to associated

coronary and aortic

disorder.

Yes if:

At least 3 months post

surgical intervention;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

is recommended.

Page 227 of 260

AORTIC CONGENITAL HEART DISEASE (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 122

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Marfan Syndrome

Cardiovascular disorders

are the major cause of

morbidity and mortality

including risk of sudden

death.

Yes if:

No cardiovascular

involvement.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required including aortic

root imaging and

echocardiography.

No if:

Any aortic root

enlargement; moderate or

more severe aortic

regurgitation; > mild mitral

regurgitation related to

mitral valve prolapse; LV

dysfunction with EF <40%

and no associated valve

disease.

Page 228 of 260

AORTIC REGURGITATION

2002 Cardiovascular Conference Report Recommendation Tables, Page 79

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Mild Aortic Regurgitation

Yes, if

asymptomatic.

Annual

Echocardiogram every 2

to 3 years.

Moderate Aortic

Yes if:

Annual

Regurgitation

Normal LV function;

No or mild LV

enlargement.

Echocardiogram every 2

to 3 years.

Severe Aortic

Regurgitation

Yes if:

Asymptomatic;

Normal LV function (EF =

50%);

LV dilatation (LVEDD <

60mm, LVESD < 50mm).

If LVEDD = 60mm or

LVESD = 50mm.

No if:

Symptoms,

Unable to complete Bruce

protocol Stage II,

Reduced EF < 50%,

LV dilatation

LVEDD > 70mm or

LVESD

> 55mm.

Yes if:

Valve surgery and at least

3 months post surgery.

Asymptomatic; cleared by

cardiologist.

Every 6 months.

Echocardiogram every 6

to 12 months.

Every 4 - 6 months.

Echocardiogram every 4

-

6 months if no surgery

performed.

Annual

EF=Ejection fraction

LVESD=Left ventricular end-systolic dimension

LVEDD=Left ventricular end-diastolic dimension

Page 229 of 260

AORTIC STENOSIS

2002 Cardiovascular Conference Report Recommendation Tables, Page 78

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Mild Aortic Stenosis

If symptoms are

consistent with aortic

Yes, if

asymptomatic.

Annual

Echocardiogram every 5

(AVA > 1.5 cm

2

)

stenosis but calculated

valve area suggests mild

aortic stenosis, the

severity of the stenosis

and an alternative

explanation for symptoms

needs to be reassessed.

years.

Moderate Aortic Stenosis

(AVA >1.0-1.5 cm

2

)

Yes, if

asymptomatic.

Yes if:

At least 3 months after

surgery.

No if:

Angina, Heart failure,

Syncope;

Atrial fibrillation;

LV dysfunction with EF

<50%;

Thromboembolism.

Annual

Echocardiogram every 1

to 2 years.

Annual

Severe Aortic Stenosis

No, irrespective of

symptoms or LV function.

(AVA <1.0 cm

2

)

Yes, if at least 3 months

after surgery.

Annual

AVA = aortic valve area

Page 230 of 260

ATRIAL SEPTAL DEFECTS

2002 Cardiovascular Conference Report Recommendation Tables, Page 124

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Atrial Septal Defect

(ASD): Ostium Secundum

Small ASD = favorable.

Moderate to large ASD =

unfavorable.

Yes if:

Asymptomatic.

No if:

Symptoms of dyspnea,

palpitations or a

paradoxical embolus;

Pulmonary hypertension;

Right-to-left shunt; or

Pulmonary to systemic

flow ratio > 1.5 to 1.

Yes if:

At least 3 months after

surgery or at least 4

weeks after device

closure; asymptomatic

and clearance by

cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in

congenital heart disease

including

echocardiogram.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

every 2 years.

Page 231 of 260

ATRIAL SEPTAL DEFECTS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 125

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Atrial Septal Defect

(ASD): Ostium Primum

Small ASD = favorable

prognosis.

Moderate to large ASD =

unfavorable prognosis

Yes, if:

Asymptomatic.

No if:

Symptoms of dyspnea,

palpitations or a

paradoxical embolus;

Echo-Doppler

demonstrates pulmonary

artery pressure > 50%

systemic; Echo-Doppler

demonstrates right-to-left

shunt;

Pulmonary to systemic

flow ratio greater than 1.5

to 1; Heart block on an

electrocardiogram; More

than mild mitral valve

regurgitation; Left

ventricular outflow tract

obstruction with a

gradient >30 mm Hg.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required including

echocardiogram.

Yes if:

At least 3 months after

surgical intervention if

none of the above

disqualifying criteria; No

symptomatic arrhythmia

and no significant residual

shunt;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

Page 232 of 260

ATRIAL SEPTAL DEFECTS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 126

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Sinus Venosus Atrial

Septal Defect

Usually associated with

anomalous pulmonary

venous connection.

Prognosis depends on

size of atrial septal defect.

Commonly associated

with sinus node

dysfunction, particularly

after surgery.

Yes if:

Small shunt and

hemodynamically

insignificant.

No if:

Symptoms of dyspnea,

palpitations or a

paradoxical embolus;

Echo-Doppler

examination

demonstrating pulmonary

artery pressure greater

than 50% systemic; Echo-

Doppler examination

demonstrating a right-to

-

left shunt; A pulmonary to

systemic flow ratio

greater than 1.5 to 1;

Heart block or sinus node

dysfunction on an

electrocardiogram.

Yes if:

At least 3 months after

surgical intervention;

Hemodynamics are

favorable;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease,

including Holter Monitor.

Page 233 of 260

BUNDLE BRANCH BLOCKS AND HEMIBLOCKS

2002 Cardiovascular Conference Report Recommendation Tables, Page 100

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Bundle Branch Block

Progression of disease in

Yes if:

Every 2 years.

Axis Deviation

the conduction system

can lead to third degree

heart block with total loss

of electrical connection

between the atria and

ventricles causing

syncope or sudden death.

Asymptomatic.

(Depends on risk from

underlying heart disease.)

Yes, if treated for

symptomatic disease (see

pacemaker); No

disqualifying heart

disease; Cleared by

cardiologist.

Annual

No, if symptomatic.

Page 234 of 260

CARDIOMYOPATHIES AND CONGESTIVE HEART FAILURE (CHF)

2002 Cardiovascular Conference Report Recommendation Tables, Page 82

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Hypertrophic

Cardiomyopathy

No

Idiopathic Dilated

Cardiomyopathy and

Congestive Heart Failure

No, if

symptomatic CHF.

No if: Asymptomatic;

Ventricular arrhythmias

present; and

LVEF <50%.

No if:

Asymptomatic;

No ventricular

arrhythmias; LVEF <

40%.

Yes if:

Asymptomatic;

No ventricular

arrhythmias;

and

LVEF 40% to 50%.

Annual

Requires annual

cardiology evaluation

including

Echocardiography and

Holter monitoring.

Restrictive

cardiomyopathy

No

Page 235 of 260

COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD)

2002 Cardiovascular Conference Report Recommendation Tables, Page 36

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Post Myocardial Infarction

(MI)

Risk of recurrent major

cardiac event highest

within the first months

post-MI;

Drivers in a rehabilitation

program can receive

comprehensive

secondary prevention

therapy.

No if:

Recurrent angina

symptoms;

Post-MI ejection fraction

<40% (by

echocardiogram or

ventriculogram);

Abnormal ETT

demonstrated

prior to planned work

return;

Ischemic changes on rest

ECG;

Poor tolerance to current

cardiovascular

medications.

Yes if:

At least 2 months post-

MI;

Cleared by cardiologist;

No angina;

Post-MI ejection fraction

>40% (by

echocardiogram or

ventriculogram);

Tolerance to current

cardiovascular

medications.

Annual

Biennial ETT at minimum

(If test positive or

inconclusive, imaging

stress test may be

indicated);

Cardiologist examination

recommended.

Angina Pectoris

Lower end of spectrum

among CHD patients for

risk of adverse clinical

outcomes.

Condition usually implies

at least one coronary

artery has

hemodynamically

significant narrowing.

Yes, if asymptomatic.

No if:

Rest angina or change in

angina

pattern within 3 months of

examination;

Abnormal ETT;

Ischemic changes on rest

ECG;

Intolerance to

cardiovascular therapy.

Annual

Biennial ETT at minimum

(If test positive or

inconclusive, imaging

stress test may be

indicated).

Cardiologist examination

recommended.

Page 236 of 260

COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 37

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Post Percutaneous

Coronary Intervention

(PCI)

Rapid recovery for

elective PCIs for stable

angina.

Delayed re-stenosis is the

major PCI limitation and

requires intensive

secondary prevention.

Yes if:

At least 1 week after

procedure; Approval by

cardiologist; Tolerance to

medications.

ETT 3 to 6 months after

PCI.

No if:

Incomplete healing or

complication at vascular

access site; Rest angina;

Ischemic ECG changes.

Annual

Recommend Cardiologist

examination.

Biennial ETT at minimum

(If test positive or

inconclusive, imaging

stress test may be

indicated).

Post Coronary Artery

Delay in return to work to

Yes if:

Annual

Bypass Surgery (CABG)

allow sternal incision

healing. Because of

increasing risk of graft

closure over time, ETT is

obtained.

At least 3 months after

CABG; LVEF > 40% post

CABG; Approval by

cardiologist;

Asymptomatic; and

tolerance to medications.

After 5 years: Annual

ETT. Imaging stress test

may be indicated.

Page 237 of 260

COMMERCIAL DRIVERS WITHOUT KNOWN CORONARY HEART DISEASE (CHD)

2002 Cardiovascular Conference Report Recommendation Tables, Page 35

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Asymptomatic, healthy

Low CHD event risk.

Assess for clinically

apparent risk factors.

Use, when possible,

Framingham risk score

model to predict 10-year

CHD event risk;

Increasing age is a

surrogate marker for

increasing atherosclerotic

plaque burden.

Yes, if asymptomatic.

Rarely disqualifying

alone.

Biennial

Asymptomatic, high risk

Sub-clinical coronary

Yes, if asymptomatic.

Annual

person (as designated by

atherosclerosis is a

CHD risk-equivalent

concern.

No if:

condition)*

High-risk status requires

Abnormal ETT;**

Ischemic changes on

Asymptomatic, high risk

close physician follow-up

ECG; †

person > 45 years with

and aggressive

Functional incapacitation

multiple risk factors for

comprehensive risk factor

by one of conditions.

CHD

management.

*CHD risk equivalent is defined as presence of diabetes mellitus, peripheral vascular disease, or

Framingham risk score predicting a 20% CHD event risk over the next 10 years.

** Abnormal Exercise Tolerance Test (ETT) is defined by an inability to exceed 6 METS (beyond

completion of Stage II, or 6 minutes) on a standard Bruce protocol or the presence of ischemic symptoms

and/or signs (e.g., characteristic angina pain or 1 mm ST depression or elevation in 2 or more leads),

inappropriate SBP and/or heart rate responses (e.g., inability in the maximal heart rate to meet or exceed

85% of age-predicted maximal heart rate), or ventricular dysrhythmia.

† Ischemic ECG changes are defined by the presence of new 1 mm ST-seg

ment elevation or depression

and/or marked T wave abnormality.

Page 238 of 260

CONGENITAL HEART DISEASE

2002 Cardiovascular Conference Report Recommendation Tables, Page 128

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Patent Ductus Arteriosus

Small = favorable.

Yes, if small shunt.

Annual

(PDA)

Moderate to large =

unfavorable.

No if:

Symptoms of dyspnea or

palpitations;

Pulmonary hypertension;

Right to left shunt;

Progressive LV

enlargement or

decreased systolic

function.

Yes if:

At least 3 months after

surgery or 1 month after

device closure;

None of above

disqualifying criteria;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Should have evaluation

by cardiologist

knowledgeable in adult

congenital heart disease.

Coarctation of the Aorta

Mild = favorable.

Moderate or severe =

unfavorable prognosis.

Yes if:

Mild and unoperated;

BP controlled; and

No associated

disqualifying disease.

No

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

recommended.

Coarctation of the Aorta

Unfavorable prognosis

Yes, if

Annual

after intervention

with persistent risk of

cardiovascular events.

perfect repair (see text p.

115 and 116).

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required.

Page 239 of 260

CONGENITAL HEART DISEASE (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 129

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Pulmonary Valve

Stenosis

(PS)

Mild and moderate =

favorable.

Yes, if

mild or moderate.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

Severe PS may be

unfavorable, associated

with arrhythmias and

rarely sudden death.

No if

Symptoms of dyspnea,

palpitations or syncope;

Pulmonary valve peak

gradient >50 mm Hg with

normal output;

RV pressuve >50%

systemic pressure;

>mile RVH;

>mild RV dysfunction;

>moderate pulmonary

valve regurgitation;

or main pulmonary artery

>5cm.

Yes if:

3 months after surgical

valvotomy or 1 month

after balloon

valvuloplasty;

None of above

disqualifying criteria;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Recommend evaluation

by cardiologist

knowledgeable in adult

congenital heart disease.

Other causes of right

Double chambered right

Yes if:

Annual

ventricular outflow

ventricle.

Hemodynamic data and

Recommend evaluation

obstruction in persons

Infundibular pulmonary

criteria similar to

by cardiologist

with congenital heart

stenosis.

individuals with isolated

knowledgeable in adult

disease.

Supravalvar pulmonary

stenosis.

Pulmonary artery

stenosis.

pulmonary valve stenosis

who are eligible for

certification.

congenital heart disease.

Page 240 of 260

CONGENITAL HEART DISEASE (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 130

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Ebstein anomaly

Mild = favorable.

Yes if:

Mild;

Asymtomatic;

No intracardiac lesions;

No shunt;

No symptomatic

arrhythmia or accessory

conduction; Only mild

cardiac enlargement;

Only mild RV dysfunction.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

Moderate and severe

variants = unfavorable.

No if:

(see text, p. 117)

Yes if:

At least 3 months post-

surgical intervention;

None of above

disqualifying features.

Annual

Echocardiogram and

evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required.

Tetralogy of Fallot

Unfavorable in the

unrepaired state.

No, if uncorrected.

Repaired = variable

prognosis.

Yes if:

Excellent result obtained

from surgery;

Asymptomatic;

No significant pulmonary

or tricuspid valve

regurgitation;

No pulmonary stenosis;

No history of arrhythmias;

No residual shunt.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

required, including EKG,

24 hour Holter Monitor,

exercise testing, Doppler

Echocardiogram.

Page 241 of 260

CONGENITAL HEART DISEASE (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 131

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Transposition of the Great

Vessels

Unfavorable if

uncorrectable.

No

Atrial switch repair

(Mustard or Senning

procedures). Unfavorable

long-term prognosis.

No

After Rastelli repair.

Yes if:

Asymptomatic and

excellent result obtained

from surgery (see text).

No if:

(see text p. 119).

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

After arterial switch

repair, prognosis appears

favorable.

No (Data currently not

sufficient to support

qualification in this

group).

Page 242 of 260

CONGENITAL HEART DISEASE (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 132

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Congenitally corrected

transposition

95% have associated

intracardiac lesions.

Conduction system is

inherently abnormal.

Yes if:

None of below

disqualifying criteria.

Annual

Required annual

evaluation by cardiologist

knowledgeable in adult

congenital heart disease,

includes

echocardiography and 24

hour Holter Monitor.

No if:

Symptoms of dyspnea,

palpitations, syncope or

paradoxical embolus;

Intracardiac lesion such

as VSD;

>moderate pulmonary

stenosis with a pulmonary

ventricular pressure

>50% systemic;

>mild RV or LV

enlargement or

dysfunction;

Moderate or greater

tricuspid valve (systemic

atrioventricular valve)

regurgitation; History of

atrial or ventricular

arrhythmia; ECG with

heart block; or Right-to

-

left shunt or significant

residual left-to-right shunt.

Yes if:

At least 3 months after

surgery;

None of above

disqualifying criteria;

Prosthetic valve - must

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease.

meet requirements for

that valve;

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Page 243 of 260

HEART TRANSPLANTATION

2002 Cardiovascular Conference Report Recommendation Tables, Page 154

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Heart Transplantation

Special attention to:

Accelerated

atherosclerosis,

transplant rejection,

general health.

Yes if:

At least 1 year post-

transplant;

asymptomatic;

stable on medications;

no rejection;

Consent from cardiologist

to drive commercially.

Biannual

Clearance by cardiologist

required.

Page 244 of 260

HYPERTENSION

2002 Cardiovascular Conference Report Recommendation Tables, Page 55

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Essential Hypertension

Evaluate for other clinical

CVD including TOD†;

Presence of TOD, CVD or

diabetes may affect

therapy selected.

Yes, if asymptomatic.

Rarely disqualifying

alone.

Stage 1

Usually asymptomatic;

Yes

Annual

(140-159/90-99 mm Hg)

Low risk for near-term

incapacitating event.

Rarely disqualifying

alone.

BP <140/90 at annual

exam; If not, but

<160/100, certification

extended one time for 3

months.

Stage 2

Low risk for incapacitating

Yes

(160-179/100-109 mm

event; risk increased in

One time certification for

Hg)

presence of TOD;

Indication for

pharmacologic therapy.

3 months.

Yes, at recheck if:

BP <140/90mmHg Certify

for 1 year from date of

initial exam.

Annual

BP <140/90.

Stage 3

High risk for acute

No

(>180/110 mm Hg

hypertension-related

event.

Immediately disqualifying;

Yes, at recheck if:

Every 6 months;

BP <140/90 mm Hg;

Treatment is well

tolerated. Certify for 6

months from date of initial

exam.

BP <140/90.

Secondary Hypertension

Evaluation warranted if

persistently hypertensive

on maximal or near-

maximal doses of 2-3

pharmacologic agents;

May be amenable to

surgical/specific therapy.

Based on above stages.

Yes if:

Stage 1 or

nonhypertensive.

At least 3 months after

surgical correction.

Annual

BP <140/90

† TOD – Target Organ Damage – Heart Failure, Stroke or Transient Ischemic Attack, Peripheral

Artery Disease, Retinopathy, Left Ventricular Hypertrophy, Nephropathy. Examiner may

disqualify a driver if TOD significantly impairs driver’s work capacity. Driver should have no

excess sedation or orthostatic change in BP.

Page 245 of 260

IMPLANTABLE DEFIBRILLATORS

2002 Cardiovascular Conference Report Recommendation Tables, Page 104

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Primary prevention

Patient has high risk for

death and sudden

incapacitation.

No

Secondary prevention

Patient demonstrated to

have high risk for death

and sudden

incapacitation.

No

Page 246 of 260

MITRAL REGURGITATION

2002 Cardiovascular Conference Report Recommendation Tables, Page 77

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Mild Mitral Regurgitation

Yes if:

Asymptomatic;

Normal LV size and

function;*

Normal PAP.

Annual

Annual echo not

necessary.

Moderate Mitral

Yes if:

Annual

Regurgitation

Asymptomatic;

Normal LV size and

function; * Normal PAP.

Annual Echocardiogram.

Severe Mitral

Regurgitation

Yes, if

asymptomatic.

Yes if:

At least 3 months post-

surgery. Asymptomatic;

cleared by cardiologist.

Annual

Echocardiogram every 6

-

12 months. Exercise

testing may be helpful to

assess symptoms.

Annual

No if:

Symptomatic;

Inability to achieve > 6

METS on Bruce protocol;

Ruptured chordae or flail

leaflet;

Atrial fibrillation;

LV dysfunction;*

Thromboembolism;

Pulmonary artery

pressure 50% of systolic

arterial pressure;

EF = Ejection fraction; LVESD = Left ventricular end-systolic dimension

LVEDD = Left ventricular end-diastolic dimension;

PAP = Pulmonary artery pressure

*Measures include: LVEF <60%; LVESD ≥45mm; LVEDD ≥70mm

Page 247 of 260

MITRAL STENOSIS

2002 Cardiovascular Conference Report Recommendation Tables, Page 76

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

*Mild Mitral Stenosis

In the presence of

Yes, if asymptomatic.

Annual

MVA >1.6 cm

2

symptoms consistent with

moderate to severe mitral

stenosis but a calculated

valve area suggesting

mild mitral stenosis, the

severity of the stenosis

should be reassessed

and an alternative

explanation for symptoms

should be considered.

Moderate Mitral Stenosis

MVA 1.0 to 1.6 cm

2

Yes, if

asymptomatic.

Annual

Severe Mitral Stenosis

MVA < 1.0 cm

2

No if:

NYHA Class II or higher;

Atrial fibrillation;

Pulmonary artery

pressure >50% of

systemic pressure;

Inability to exercise for >6

Mets on Bruce protocol

(Stage II).

Yes if:

At least 4 weeks post

percutaneous balloon

mitral valvotomy; or

At least 3 months post

surgical commissurotomy;

Clearance by cardiologist.

Annual

Annual evaluation by a

cardiologist.

MVA = mitral valve area

*See text p.61 for additional echocardiogram criteria.

Page 248 of 260

PACEMAKERS

2002 Cardiovascular Conference Report Recommendation Tables, Page 101

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Sinus node dysfunction

Variable long term

prognosis depending on

underlying disease, but

cerebral hypoperfusion

corrected by support of

heart rate by pacemaker.

No

Yes if:

1 month after pacemaker

implantation; and

documented correct

function by pacemaker

center.

Underlying disease is not

disqualifying.

Annual

Documented pacemaker

checks.

Atrioventricular (AV) block

Variable long term

prognosis depending on

underlying disease, but

cerebral hypoperfusion

corrected by support of

heart rate by pacemaker.

No

Yes if:

1 month after pacemaker

implantation and

documented correct

function by pacemaker

center; Underlying

disease is not

disqualifying.

Annual

Documented pacemaker

checks.

Page 249 of 260

PACEMAKERS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 102

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Neurocardiogenic

Excellent long-term

No, with symptoms.

Syncope

survival prognosis but

there is risk for syncope

that may be due to

cardioinhibitory (slowing

heart rate) or

vasodepressor (drop in

blood pressure)

components, or both.

Pacemaker will affect only

cardioinhibitory

component, but will

lessen effect of

vasodepressor

component.

Yes if:

3 months* after

pacemaker implantation;

Documented correct

function by pacemaker

center; Absence of

symptom recurrence.

Annual

Documented pacemaker

checks;

Absence of symptom

recurrence

*Three months recommended due to possible vasodepressor component of syndrome not necessarily

treated by pacing.

Page 250 of 260

PACEMAKERS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 103

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Hypersensitive carotid

sinus with syncope

Excellent long-term

survival prognosis but

there is risk for syncope

that may be due to

cardioinhibitory (slowing

heart rate) or

vasodepressor (drop in

blood pressure)

components, or both.

Pacemaker will affect only

cardioinhibitory

component, but will

lessen effect of

vasodepressor

component.

No, with symptoms.

Yes if:

3 months* after

pacemaker implantation;

and documented correct

function by pacemaker

center; Absence of

symptom recurrence.

Annual

Documented regular

pacemaker checks; and

Absence of symptom

recurrence

*Three months recommended due to possible vasodepressor component of syndrome not necessarily

treated by pacing.

Page 251 of 260

PERIPHERAL VASCULAR DISEASE

2002 Cardiovascular Conference Report Recommendation Tables, Page 146

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Peripheral Vascular

Disease

(PVD)

Evaluate for associated

cardiovascular diseases.

Yes, if no other

disqualifying

cardiovascular condition.

Annual

Intermittent Claudication

Most common presenting

manifestation of occlusive

arterial disease.

Rest pain.

Yes if:

At least 3 months

after surgery;

Relief of symptoms;

No other disqualifying

cardiovascular disease.

No, if symptoms.

Yes if:

At least 3 months

after surgery;

Relief of symptoms and

signs;

No other disqualifying

cardiovascular disease.

Annual

Page 252 of 260

SUPRAVENTRICULAR TACHYCARDIAS

2002 Cardiovascular Conference Report Recommendation Tables, Page 96

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Atrial Fibrillation

Lone Atrial Fibrillation

Atrial fibrillation as cause

of or a risk for stroke

Atrial fibrillation following

thoracic surgery

Good prognosis and low

risk for stroke.

Risk for stroke decreased

by anticoagulation.

Good prognosis and

duration usually limited.

Yes

Yes if:

Anticoagulated

adequately for at least 1

month;

Anticoagulation monitored

by at least monthly INR;

Rate/rhythm control

deemed adequate

(Recommend

assessment by

cardiologist).

In atrial fibrillation at time

of return to work;

Yes if:

Anticoagulated

adequately for at least 1

month;

Anticoagulation monitored

by at least monthly INR;

Rate/rhythm control

deemed adequate

(Recommend

assessment by

cardiologist).

Annual

Page 253 of 260

SUPRAVENTRICULAR TACHYCARDIAS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 97

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Atrial flutter

Same as for atrial

fibrillation.

Same as for atrial

fibrillation.

Yes if:

Isthmus ablation

performed and

at least 1 month after

procedure;

Arrhythmia successfully

treated;

Cleared by

electrophysiologist.

Same as for atrial

fibrillation.

Annual

Multifocal Atrial

Tachycardia

Often associated with

comorbidities, such as

lung disease, that may

impair prognosis.

Yes if:

Asymptomatic;

Unless associated

condition is disqualifying.

Annual

No, if

symptomatic.

Yes if:

Symptoms controlled and

secondary cause is not

exclusionary.

Annual.

Atrioventricular Nodal

Reentrant Tachycardia

(AVNRT)

Atrioventricular Reentrant

Tachycardia (AVRT) and

Wolff-Parkinson-White

(WPW) Syndrome

Atrial Tachycardia

Prognosis generally

excellent, but may rarely

have syncope or

symptoms of cerebral

hypoperfusion.

For those with WPW, pre

-

excitation presents risk

for d

eath or syncope if

atrial fibrillation develops.

No if:

Symptomatic; or

WPW with atrial

fibrillation.

Yes if:

Asymptomatic;

Treated and

asymptomatic for at least

1 month and

Annual

Recommend consultation

with cardiologist

Junctional Tachycardia

assessed and cleared by

expert in cardiac

arrhythmias.

Page 254 of 260

VALVE REPLACEMENT

2002 Cardiovascular Conference Report Recommendation Tables, Page 80

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Mechanical Valves

Yes if:

At least 3 months post-

op; Asymptomatic;

Cleared by cardiologist.

Annual

Recommend evaluation

by cardiologist.*

No if:

Symptomatic; LV

dysfunction-EF < 40%;

Thromboembolic

complication post

procedure; Pulmonary

hypertension; Unable to

maintain adequate

anticoagulation (based on

monthly INR checks).

Prosthetic valve

No

dysfunction.

Yes if:

Surgically corrected; At

least 3 months post-op;

Asymptomatic; Cleared

by cardiologist.

Annual

Recommend evaluation

by cardiologist.*

* Role of annual echocardiography in stable patients is controversial.

Page 255 of 260

VALVE REPLACEMENT (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 81

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Atrial fibrillation.

Yes if:

Anticoagulated

adequately for at least 1

month and monitored by

at least monthly INR,

rate/rhythm control

adequate; Cleared by

cardiologist.

Annual

Biologic Prostheses

Antiocoagulant therapy

not necessary in patients

in sinus rhythm (after

initial 3 mo0nths), in

absence of prior emboli or

hypercoagulable state.

Yes if:

At least 3 months post-

op; Asymptomatic; None

of above disqualifying

criteria for mechanical

valves; Cleared by

cardiologist.

Annual

Recommend evaluation

by cardiologist.*

Page 256 of 260

VENOUS DISEASE

2002 Cardiovascular Conference Report Recommendation Tables, Page 147

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Acute Deep Vein

Thrombosis (DVT)

No, if symptoms.

Yes if:

No residual acute deep

venous thrombosis;

If on Coumadin:

Regulated for at least 1

month;

INR monitored at least

monthly.

Annual

Superficial Phlebitis

Yes if:

DVT ruled out;

No other disqualifying

cardiovascular disease.

Biennial

Pulmonary Embolus

No, if symptoms.

Yes if:

No pulmonary embolism

for at least 3 months;

On appropriate long-term

treatment.

If on Coumadin:

Regulated for at least 1

month;

INR monitored at least

monthly;

No other disqualifying

cardiovascular disease.

Annual

Chronic Thrombotic

Venous Disease

Yes, if no symptoms.

Biennial

Varicose veins

Yes, if no complications.

Biennial

Coumadin

Use of INR required.

Yes if:

Stabilized for 1 month;

INR monitored at least

monthly.

Annual

Page 257 of 260

VENTRICULAR ARRHYTHMIAS

2002 Cardiovascular Conference Report Recommendation Tables, Page 98

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Coronary Heart Disease

(CHD)

Sustained VT:

Poor prognosis and high

risk.

NSVT, LVEF < 0.40:

Unfavorable prognosis.

NSVT, LVEF >0.40:

Generally considered to

have good prognosis.

No

No, if symptomatic.

Yes if:

Asymptomatic.

At least 1 month after

drug or other therapy is

successful;

Cleared by cardiologist.

Annual

Cardiology examination

required.

Dilated Cardiomyopathy

NSVT (LVEF < 0.40).

Sustained VT, any LVEF.

Syncope/near syncope,

any LVEF: High risk.

No

Hypertrophic

Cardiomyopathy

Variable but uncertain

prognosis.

No

Page 258 of 260

VENTRICULAR ARRHYTHMIAS (Continued)

2002 Cardiovascular Conference Report Recommendation Tables, Page 99

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Right Ventricular Outflow

VT

Favorable prognosis and

low risk for syncope.

No, if

symptomatic.

Yes, if asymptomatic.

Yes if:

At least 1 month after

drug or other therapy

successful;

Asymptomatic; Cleared

by electrophysiologist.

Annual

Recommend evaluation

by cardiologist.

Annual

Evaluation by cardiologist

required.

Idiopathic Left Ventricular

VT

Favorable prognosis and

low risk for syncope.

No, if

symptomatic

Yes, if asymptomatic.

Yes if:

At least 1 month after

successful drug therapy

or ablation;

Cleared by

electrophysiologist.

Annual

Recommend evaluation

by cardiologist.

Annual

Evaluation by cardiologist

required.

Long QT Interval

Syndrome

High risk for ventricular

arrhythmic death.

No

Brugada Syndrome

High risk for ventricular

arrhythmic death.

No

Page 259 of 260

VENTRICULAR SEPTAL DEFECTS

2002 Cardiovascular Conference Report Recommendation Tables, Page 127

DIAGNOSIS

PHYSIOLOGY/

FUNCTIONAL

CERTIFICATION

RE-CERTIFICATION

Ventricular Septal Defect

Small = favorable.

Yes, if small shunt.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease

recommended.

Moderate to large VSD

has effect on pulmonary

pressure and ventricular

size and function.

No if:

Moderate to large VSD;

Symptoms of dyspnea,

palpitations or syncope;

Pulmonary artery

hypertension;

Right-to-left shunt, left

ventricular enlargement

or reduced function;

Pulmonary to systemic

flow ratio greater than 1.5

to 1.

Yes if:

At least 3 months after

surgery;

None of above

disqualifying criteria;

No serious dysrhythmia

on 24 hour Holter

Monitoring;

QRS interval <120 ms;

(If right ventricle

conduction delay >120

ms on ECG, can be

certified if invasive HIS

bundle studies show no

infra-His block or other

serious electrophysiologic

disorder);

Cleared by cardiologist

knowledgeable in adult

congenital heart disease.

Annual

Evaluation by cardiologist

knowledgeable in adult

congenital heart disease,

including 24 hour Holter

Monitoring.

Page 260 of 260