Cdl Physical Examination Form (Page 4 of 8) in pdf

Cdl Physical Examination Form Page 4

NAME: ______________________________________________________

Note certification status here. See Instructions to the Medical Examiner for guidance.

I certify that ________________________________________________________________________________________________________

Name of Driver

Meets standards in 49 CRF 391.41-49; qualifies for 2 year certificate

Wearing corrective lenses

Wearing hearing aid

Does not meet standards

Accompanied by a______waiver/exemption

Skill Performance Evaluation (SPE) Certificate

Meets standards, but periodic evaluation required.

Driving within an exempt intra-city zone

Qualified by operation of 49 CFR 391.64

(vision or insulin dependent waiver program)

Due to ___________________________driver qualified only for:

3 months

1 year

6 months

Other

Temporarily disqualified due to (condition or medication): _____________________________________________________________

Return to medical examiner’s office for follow up on: ________________________________________________________________________

Name of medical examiner (print)

Signature of medical examiner

Address of medical examiner

Telephone number of medical examiner

If meets standards, complete a Medical Examiner’s Certificate (at the back of

this form) as stated in 49 CFR 391.43(h).

TO BE COMPLETED BY PATIENT

I hereby authorize and request the physician who has examined and whose signature appears above to release all information and findings

contained herein to the Louisiana Department of Public Safety and Corrections. The Louisiana Department of Public Safety and Corrections can

release this information to such individuals or groups as may be considered necessary and appropriate to determine my ability to safely operate

a commercial motor vehicle.

Date

Signature of Patient

OMV COMPLETES THIS SECTION

REVIEWED BY

DATE

FIELD OFFICE

APP. DATE

HEADQUARTER’S REVIEW

Cdl Physical Examination Form Page 4