Fillable Medical Examination Report Form (Page 4 of 4) in pdf

Medical Examination Report Form Page 4

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MEDICAL EXAMINER’S CERTIFICATE

I certify that I have examined

In accordance with the Federal Motor Car-

rier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified; and, if applicable, only when:

wearing corrective lenses

driving within an exempt intracity zone (49 CFR 391.62)

wearing hearing aid

accompanied by a Skill Performance Evaluation Certificate (SPE)

accompanied by a

waiver exemption

Qualified by operation of 49 CFR 391.64

The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findings

completely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER

TELEPHONE

DATE

MEDICAL EXAMINER’S NAME (PRINT)

Chiropractor

Advanced

Practice

Physician

Nurse

Assistant

MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO./ISSUING STATE