Form Ds-704 - Article 19-A Bus Driver'S Diabetic Follow-Up
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1ARTICLE 19-A BUS DRIVER’S DIABETIC FOLLOW-UP
NYS DMV COMMISSIONER’S REGULATION PART 6.10
the driver is not qualified to operate a bus if the bus
NOTE: If insulin is necessary to control a diabetic condition,
driver has an established medical history or clinical diagnosis of diabetes mellitus which has not been stabilized by
insulin therapy to the degree that his or her personal healthcare provider (physician, nurse practitioner, or physician
assistant) can certify that such person has not had an incident of hyperglycemic/hypoglycemic shock for a period of
two years. Where diabetes can be stabilized by a diet or hypoglycemic agent, the driver must be under adequate
medical supervision and follow-up.
shall consist of certification every six months by the driver’s
The follow-up for all drivers with diabetic conditions
personal healthcare provider that his or her condition has remained stabilized and that he or she has not had an
incident of hyperglycemic/hypoglycemic shock since the last certification.
This form may be used by a motor carrier to document the required 6-month diabetic follow-up by the driver’s
personal healthcare provider.
: ________________________________________________________
BUS DRIVER’S NAME
(Must correspond to name on driver’s license)
________________________________________________________
DATE OF BIRTH:
DRIVER
LICENSE ID NUMBER (9- digit number on driver license): ______________________________
I, ___________________________________________________________________, am acting as the above-named
(Print Personal Healthcare Provider’s Name)
bus driver’s personal healthcare provider. He/she is under my care and treatment for an existing diabetic condition.
His/her condition is stabilized by (indicate which):
¨
Diet
¨
¨
¨
Medication (identify):____________________________________________ Form of Insulin:
Yes
No
¨
Other means (explain):______________________________________________________________________
¨
¨
¨
¨
M.D.
D.O
PA (physician assistant)
NP (nurse practitioner)
Professional License or Certificate Number: ______________________________________ Issuing State: ________
Address: ______________________________________________________________________________________
_____________________________________________________________________________________
Phone: ________________________
I certify that he/she has not had an incident of hyperglycemic or hypoglycemic shock within the last six months.
Â
Personal Healthcare Provider’s Signature: __________________________________________________________
(Personal Healthcare Provider must sign)
Date
____________________________
DS-704 (5/15)
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