Form Dlab-Cdl-1 - Medical Report Form (Page 4 of 4) in pdf

Form Dlab-Cdl-1 - Medical Report Form Page 4

PART III •

TO BE COMPLETED BY THE EXAMINING PHYSICIAN (CONTINUED)

PAGE 4

PART IV •

TO BE COMPLETED BY THE EXAMINING PHYSICIAN

D.) Examining Physician’s Comments, Recommendations, and Certi cation

1. In your professional opinion, can the applicant safely operate a commercial vehicle?

Yes

2. Do you recommend periodic medical evaluations for driver license purposes?

Yes

If yes, how often? _______________________________________________________________________________________________

3. Do you feel there should be limitations on the size or type of commercial vehicle to be operated?

Yes

If yes, specify: __________________________________________________________________________________________________

_______________________________________________________________________________________________________________

4. In your opinion, should there be any restrictions imposed such as: limitation of driving distance, daylight driving only,

or no interstate driving?

If yes, specify: _________________________________________________________________

Yes

_______________________________________________________________________________________________________________

5. Are there any other medical conditions not shown on this report which may a ect the applicant’s safe operation of

a commercial vehicle?

If yes, specify: __________________________________________________________________

Yes

_______________________________________________________________________________________________________________

Physician’s Name

Medical License

State Of Issue

(Please print in ink or type)

Number

Business

City

State

Zip

Address

Signature

Date

Telephone

(X)

(

)

Number

Form Dlab-Cdl-1 - Medical Report Form Page 4