Fillable Massdot Cdl Self-Certification Form (Page 2 of 2) in pdf

(Please either print clearly or type)

COMMERCIAL DRIVER INFORMATION

DRIVER NAME

(last)

(first)

(middle)

BIRTHDATE (mm/dd/yyyy)

Medical Examiner’s Certificate Information

Please clearly enter the information from your medical certificate in the fields below. If you are required to hold a medical

certificate, you will need to provide the RMV with a copy as part of your self-certification. Filling out the information below

assists us with data processing, but does not replace the requirement to also provide a copy.

1. Wearing corrective lenses

4. Driving within an exempt intracity zone (49 CFR 391.62)

2. Wearing hearing aid

5. Accompanied by a Skill Performance Evaluation

Certificate (SPE)

3. Accompanied by a waiver (variance)

exemption

6. Qualified by operation of 49 CFR 391.64

Condition #6 only applies to a very limited number of drivers who fall under a federal grandfather clause that limits them to

a one year medical certificate. If condition #6 is selected on your medical certificate and you do not fall under the

grandfather clause, condition #6 was most likely chosen by the medical examiner in error. You should return to the medical

examiner to request a revised medical certificate.

Telephone #

Issue Date

Medical Examiner’s Name

Specialty Code (MD, DO, PA, CH, AN, or Other)

License #

Issuing State

Suffix

Medical Examiner’s National Registry # (new requirement)

Medical Certification Expiration Date

If #3 is checked: Exemption Effective Date

Expiration Date

If #5 is checked: SPE Effective Date

Expiration Date

Definitions of Self-Certification Categories

Non-excepted Interstate (NI) –

All Class A, B, or C privately or self-employed commercial drivers who operate or expect to operate in interstate

commerce, and are subject to meet the federal medical standard and, therefore, are required to obtain a medical

•

examiner’s certificate

All Class A, B, or C drivers who do not fall under any other category or who have been granted a federal vision or

diabetes exemption or a Skill Performance Evaluation (SPE)

•

Excepted Interstate (EI) –

Drivers who operate or expect to operate in interstate commerce but engage exclusively in transportation or

operations that are not required to meet all or parts of the federal qualification requirements and are, therefore, not

•

required to obtain a medical examiner’s certificate

Examples of EI Drivers include:

City, municipal, or state employed Commercial Driver's License holders

Non-excepted Intrastate (NA) –



All Class A, B, or C privately or self-employed commercial drivers who only operate in intrastate commerce and are

subject to state driver qualification requirements

•

Examples of NA Drivers include:

Drivers 18-21 years of age with a K restriction associated with their license to operate

Drivers 21 and over with a W Restriction associated with their license to operate



Excepted Intrastate (EA) –



Drivers who operate in intrastate commerce but engage exclusively in transportation or operations that are not

required to meet all or parts of the state driver qualification requirements and are, therefore, not required to obtain

•

a medical examiner’s certificate

Examples of EA Drivers include:

City, municipal, or state employed Commercial Driver's License holders



Massdot Cdl Self-Certification Form Page 2

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