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
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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
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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
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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.

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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."

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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

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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.

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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.

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