teamcme - chirocredit · verifies your ability to conduct physical examinations with your state...

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National Registry Physician Training

TeamCME

TeamCMENational Network of DOT Medical Examiners

Accredited Training for the National Registry of

CertifiedMedical Examiners

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Michael Megehee, DC, President

Session 301 Hour 1

TeamCME Partners

has no relevant financial relationships in regard to the content of this presentation.

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Interstate Sleep SolutionsSensiCardiac Lifeloc TechnologiesTestVault EHR3bExams EHR

This ME training course conforms to FMCSA’s training curriculum modules and topics on regulations and guidelines for conducting CMV driver medical examinations.

FMCSA regulations and guidelines are reviewed regularly, and the training is updated as required. This course was last updated on January 21, 2019.

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TeamCME is recognized by the PACE program of the Federation of

Chiropractic Licensing Boards.

PACE is the Nationally Recognized Accredited Body for the TeamCME

Accredited National Registry Training









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• Safe, Accountable, Flexible, Effective, Transportation Equity Act- A Legacy for Users (SAFETEA-LU)

• Effective Date: May 21, 2012

• Compliance Date: May 21, 2014

• Preferably referred to as “The National Registry”

• Beginning May 21, 2014, all medical certificates issued to interstate truck and bus drivers must come from a National Registry Certified Medical Examiner.

The National Registry of Certified Medical Examiners (NRCME)

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National Registry Medical Examiner Requirements

Medical examiner Requirements

• Maintain a valid State license

• Complete Accredited Training

• Pass the NR Certification Test

• Complete periodic re-training and re-certification testing.

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How to Set up your NRCME Account:

Go to: https://www.fmcsa.dot.gov/regulations/national-registry/national-registry-certified-medical-examiners-become-medical-examiner

1. Click on the link to Register

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2. Follow the Instructions (6 pages)

Write down our NRCME #, your username and password!!

How to Sign Into your NRCME Account:

Go to: https://nr-1.fmcsa.dot.gov/ui/index.xhtml

1. Click on “Login”

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2. Click on “Sign In”

How to Sign Into your NRCME Account:

Go to: https://nr-1.fmcsa.dot.gov/ui/index.xhtml

3. You will need to enter a security code that will be sent to

your phone.

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4. Click on “Remember this browser or you will have to obtain a new security code every time you log in, but every month you will have to do this again

If you don’t have a phone that will receive a test message, Click here

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Your NRCME Account Page

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XXXXXXXXXX

Report Completed Exams & More

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XXXXXXXXXX

Your NRCME Profile

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Update your profession license expiration date every time you renew your license!!

Click here to see your profile

Manage Medical AssistantsMEAAs set up their own account in the NationalRegistry.

XXXXXXXXXX

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Resources & LogoutRecent FMCSA Emails to MEs

The National Registry Regulations

Examination Forms

Medical Examiner tools including the Medical Examiner Handbook

Information for Training Organizations

The National Registry Core Curriculum

Information for Testing Organizations

Driver Fact Sheet and Brochure

FAQs

Meeting and Conferences

Presentations and Webinars

Archived Webinars

The Administrator’s Podcast

Medical Review Board and Medical Reports

Rules and Regulations

Glossary

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ResourceCenter

Contacting FMCSA

https://www.fmcsa.dot.gov/regulations/national-registry/national-registry-certified-medical-

examiners

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This page has all kinds of information as well as contact information (phone and email) for the National Registry

FMCSA Medical Programs:202-366-4001

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Test Providers:

PSI, ComiraPrometric

600+ Test Sites

Cost: $79

Call the site and schedule the test during regular business hours

Eligibility# is your NR ID#

The certification test is offered by the testing organizations provided in the links below. Using these links, you will find the process and contact information necessary for you to contact the testing organization directly to schedule the examination.

Comira: http://www.comiratesting.com/Prometric: https://www.prometric.com/PSI: https://candidate.psiexams.com/

Once you have submitted the required information, FMCSA verifies your ability to conduct physical examinations with your state licensing board. Once they receive passing test results from the testing organization, FMCSA will conduct a final evaluation of your application. If approved, you will receive an email with an official certificate as a Medical Examiner listed on the National Registry. Medical Examiners are not permitted to conduct physical qualification examinations of interstate commercial motor vehicle drivers until the official certificate has been received via email.

NRCME Certification Test

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National Registry Certification Test• 120 computer multiple

choice questions

• 4 answers, select most correct

• 100 questions are graded. 20 are being evaluated for future tests. (Can’t tell the difference).

• Two hour time limit

• Paper test version available (if you have a disability)

• Learn the system before starting (up to 15 minutes)

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Certification Test

• Pass/Fail Score available immediately.

• Multiple Test versions Passing score 71.

• Those that fail must wait 30 days to re-take the test.

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• The certification test must be passed within 3 years of taking the accredited training course.

• Those that pass the exam will have their name added to the list of CMEs in the National Registry.

Recurrent Training

Re-current training every 5 yrs

Re-Certification every 10 years

After being Certified:

• Retaking training cannot

occur before 4 years

• Retaking the test cannot

occur before 9 years

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Reporting Completed CDL Medical Exams

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Click “CMV Driver Exams

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Must be “Certified”

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Exam Date

CDL or CLP?

Medically Qualified Interstate(across state lines)

Driving Status must be determined on the day of the exam

Intrastate Drivers(within State Only)

Determination PendingDisappears and is not available for intrastate drivers

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Reporting Completed Physical Exams

Report monthly, even if no exams were completed.

At the time of this update you are not required to report completed exams by the end of the month although it is highly recommened by FMCSA. However FMCSA will announce in the near future that CMEs must report completed exams by midnight on the calendar day following the exam.

CMEs may designate an Administrative Assistant to report completed exams. They must have their own National Registry account

From your CME account, put cursor over “My Profile” and click “ manage administration assistants.

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Reporting Completed Physical ExamsWhich exams must be reported:

CMEs must report exams perform on all drivers of a CMV that are medically certified to drive across state lines.

Includes:

1. Drivers with, or who will apply for, a Commercial Driver’s License (CDL) or Commercial Learner’s Permit (CLP)

2. Drivers without or who will not apply for a CDL or CLP:

• School bus drivers who are not exempted from the federal medical examiner regulation. (FMCSA is considering whether states may require medical examiners to report exams for school bus drivers under state jurisdiction.)

• Interstate Non CDL Drivers of vehicles that weigh/rated for over 10,000lbs but under 26,001lb.

Completed Physical Exam Data

• FMCSA will monitor/audit performed examinations for CME errors.

• CMEs who repetitively incorrectly determine driver status may be removed from the National Registry.

• CMEs must provide a copy of the examination form to FMCSA within 48 hours when requested.

• FMCSA is monitoring drivers who ‘doctor shop”.

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Medical Examiner Reference Materials

FMCSA On-line Medical Examiner handbook was removed from the FMCSA Website. However, you will receive a copy of the handbook in an email from TeamCME when you complete the training program.

Test Preparation:

Read/Study, highlight if-then” statements.

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Medpreps:Internet medical management/review of medical conditions

Mosby’s Nursing Video Skills:Internet: Physical Exam and Health assessment videos

Medical School Videos Available: Internet: Physical/Systems exam procedures, UCLA

Practice Tests: 1. You have on month’s FREE access to the TeamCME

Online Practice Test!!2. There is a preliminary practice test when you complete

this program to evaluate your knowledge/training.

Test Preparation Resources

Medication Resource

Epocrates:

• Free!

• Review Medications

• PDA, IPhone, Droid

• Other Services $

• Easy to Use

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The Driver Medical Exam

requires urinalysis for:

• Specific Gravity

• Protein

• Glucose

• Blood

When performed in-office, this constitutes a “laboratory test” according to the Federal Clinical Laboratory Improvement Amendment (CLIA).

Urinalysis is Required

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CLIA Certificate of WaiverFor those performing urinalysis in-office (own patients only)

A CLIA Certificate of Waiver is required to perform CLIA Waived/Exempted tests in your office.

CLIA is involved with testing of body fluids when used for evaluation or tx for health conditions.

Drug testing for forensic (occupation) reasons are not part of CLIA until the drug testing is used to monitor treatment.

CLIA not involved for any DOT drug

testing as all DOT drug testing is

performed in a lab.

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Non-Testable Material

CLIA Certificate of WaiverFor those performing urinalysis in-office (own patients only)

The CLIA application requires each “lab” to have a “Laboratory Director”

State lab regulations can

limit who may be a Laboratory Director even though CLIA has no such limitations.

State law may also require that you have a State laboratory licensed.

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CLIA Certificate of Waiver For DCs

• GA, NY does not allow DCs to be the Laboratory Director for their CLIA Certificate of Waiver:

• Options:

– Have someone else acceptable to your State to serve as your Laboratory Director

– Send sample/driver to lab

– Collect sample, dipstick performed by other provider

– Collect and test under direction of other provider

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Contact your State Laboratory Licensing Agencies for CLIA Applications for Certificates of Waiver.

States Agencies: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/CLIASA.pdf

Getting Your CLIA Certificateof Waiver

Call your State Laboratory Licensing Agency:

I am a ________, and I will be providing commercial driver physical exams and will begin performing a CLIA Waived Urinalysis Dipstick Test in my office for my patients.

I would like to apply for a CLIA Certificate of Waiver, and, if required by state laboratory regulations, I need to apply for a State Laboratory license for performing CLIA waived urinalysis dipstick tests in my office for my patients.

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The Federal Motor Carrier Safety Administration (FMCSA) was established on

January 1, 2000.

FMCSA is one of nine DOT Administrations. Services provided by Field Operations, Service

Centers and State level division offices

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11 Acres 7000 Workers 1.35 million Sq. Feet

Test Material Begins Here

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FMCSA Mission StatementFMCSA is focused on reducing crashes, injuries, and fatalities involving large trucks and buses.

• Develop and enforce data-driven regulations that balance Motor Carrier (MC) safety with industry efficiency.

• Harness safety information systems focusing on higher-risk carriers in enforcing safety regulations.

• Targets educational messages to MC, Drivers, and Public

• Partners with stakeholders (Federal, State, local enforcement agencies, MCs, Safety Groups, Organized Labor to reduce bus and truck related crashes.

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Mission Statement

To promote safety of America’s highways thru promulgation and implementation of medical regulations, guidelines and policies that ensure CMV drivers engaged in interstate commerce are physically qualified to do so.

Office of Medical Programs

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Office of Medical Programs• Oversee medical certification process for CMV drivers

operating in interstate commerce.

• Develops/Implement medical regs, policies, procedures

• Oversees the MRB (Federal Advisory Committee Act)

• Develops/Implement the National Registry Program

• Oversee Medical Exemption & Certificate Programs

• Lead Office/Agency for CMV driver health, safety, and conducts relevant medical research.

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National Registry Mission Statement

To improve highway safety by producing trained, certified medical examiners who can effectively

determine if a CMV driver’s health meets the FMCSA standards.

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ART prepares all economic, statistics, environmental analysis for rulemaking.

Truck Crashes can be catastrophic:

• Greater risk of loss of life, injuries to occupants in smaller vehicle

• Environmental risk involving hazardous materials

• Some commercial vehicles carry many members of the public

• Economic cost is exceedingly high

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Office of Analysis, Research, and Technology

Office of Analysis, Research, and Technology

Severity of injury is related to relative velocity change. A vehicle with twice the weight of the other vehicle equals a six-fold risk of death to person in other vehicle.

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CMVs may weigh 20X the mass of a SUV

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Driver Hours of Service (HOS)

Who Has to Comply?

Drivers operating a Commercial Motor Vehicle and: • is engaged in interstate commerce• is engaged in intrastate commerce where that state adopted and enforces the new HOS regulations.

https://www.fmcsa.dot.gov/regulations/hours-of-service

Note: Drivers with and without a CDL license must comply.

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Property-Carrying Drivers11-Hour Driving Limit: After 10 consecutive hours off duty, these drivers begin a new 11-Hour limit

14-Hour Limit: Can not drive beyond 14 hours after coming on duty following 10 consecutive hours off duty. Off-duty time does not extend the 14 hour period.

Rest Breaks: May drive if 8 hours of less have passed since the end of the driver’s last off-duty or sleeper berth period of at least 30 minutes. Does not apply to short-haul exceptions. Mandatory “in attendance” time may be included in break if no other duties are performed.

60-70 Hour Limited: May not driver at 60/70 hours of duty in 7/8 consecutive days. A 7/8 consecutive day period may restart after taking 34 or more consecutive hours off duty.

Work that is not driving must be included in “Duty” Hours

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Property-Carrying Drivers

After a suspension of enforcement of Hours of Service regulations has been restored. At the time of this update, FMCSA is again reviewing the Hours of Service regulation.

Drivers who use a sleeper must take at least 8 consecutive hours in the sleeper , please an additional 2 consecutive hours either in the sleeper, off duty, or any combination of the two.

Work that is not driving must be included in “Duty” Hours

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Passenger-Carrying Drivers

10-Hour Limit: May drive a maximum of 10 hours after 8 consecutive hours off duty

15-Hour Limit: Can not drive after having been on duty for 15 hours, following 8 consecutive hours off duty. Off-duty time is not included in the 15-hour period

60/70-Hour Limit: May not driver after 60/70 hours on duty in 7/8 consecutive days.

Drivers using a sleeper berth must take at least 8 hours in the sleeper berth, and may split the sleeper berth time into two periods provided neither is less than 2 hours.

Work that does not include driving must be included in “Duty” hours!

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“Floating” 7 and 8 Day Limit

Considered the “weekly” limit.

The limits are based on a “floating” 7 or 8 day period. The oldest day’s hours drops off at the beginning of the next day.

Drivers must carry documentation of the past 8 days of duty.

Counsel drivers who are not complying to follow the HOS regulations

Federal Motor Carrier Safety Administration Definition49CFR 390.5

Medical Examiner means:

• “a person who is licensed, certified, and/or registered, in accordance with applicable State laws and regulations to perform physical examinations. The term includes, but is not limited to, doctors of medicine and osteopathy, advanced practice nurses, physician assistants and chiropractors.”

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Motor Carrier/Driver Definition

Motor Carrier:

For-hire or private. Includes motor carrier’s agents, officers, and representatives as well as employees for hiring, supervising, training, assigning, or dispatching of drivers and employees concerned with installation, inspection, and maintenance of motor vehicle equipment and/or accessories.

Owner-Operator:

Independent driver of a commercial vehicle

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Interstate Commerce (Buy/Sell of Goods or Service)

• Drives or may drive a CMV involved in commerce, trade, traffic or transportation involving the crossing of a state boundary.

• From one State to another State or a foreign country;

• Between two places within a State, but during part of the trip, the CMV crosses into another State or foreign country; or

• Between two places within a State, but the cargo is part of a trip that began or will end in another State or country.

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Intrastate commerce is driving a CMV within a State that does not meet any of the descriptions for interstate

commerce.

• Involved in commerce, trade, traffic within a single state.

• Vehicle does not cross state lines

• Cargo does not originate or end up out of state

• Intent- No intent to cross state lines

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Intrastate Commerce

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States Regulate Intrastate commercial drivers who are not subject to Federal Regulations.

States are required to adopt the federal medical requirements to Interstate drivers, but may adopt additional, different, or more stringent requirements.

Exclusively intrastate drivers must comply with state regulations.

Medical Examiners are responsible for knowing the driver regulations for the State in which they practice

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Intrastate Only Driver Medical Exam Requirements

Commercial Motor Vehicle 49 CFR 390.5CMV Definition:

• Has a gross vehicle or gross combination weight or rated to transport 10,001 lbs or more

• Designed or used to transport more than 9 passengers (including the driver) for compensation or,

• Designed of used to transport more than 16 passengers (including the driver) not for compensation

• Transport requiring Placard for Hazardous Waste

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Commercial Driver Licenses Section 383.5States are required to issue the following license classifications:

Class A -- Any combination of vehicles with a GCWR of 26,001 or more lbs provided the GVWR of the vehicle(s) being towed is in excess of 10,000 lbs.

Class B -- Any single vehicle with a GVWR of 26,001 or more lbs, or any such vehicle towing a vehicle not in excess of 10,000 lbsGVWR.

Class C -- Any single or combination of vehicles, that does not meet the definition of Class A or B, but is either designed to transport 16 or more passengers, including the driver, or is placarded hazardous or is transporting any quantity of a material listed as a select agent or toxin in 42 CFR Part 73.

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State Driver Licensing Agencies (SDLA)

Until June 22, 2021 SDLAs are required to retain the original or a copy of the driver’s medical certificate

• Post the Medical Exam and Medical Variance information within 10 business days to CDLIS.

• Whether active or inactive, drivers without a current certificate will have their CDL license downgraded.

• Electronically tie a driver’s CDL license to a current CDL medical certificate and post that information on the Commercial Driver License Information System (CDLIS)

FYI Slide

State Licensing Agency Requirements

Within 10 calendar days of expiration/rescinded of the driver's medical certification/variance the State must:

• Update the CDLIS that driver as "not-certified”.

• Notify the CDL holder of their "not-certified“ status and that the CDL privilege will be removed unless the driver submits a current medical certificate and/or medical variance, or changes his or her self-certification to driving only in excepted interstate or intrastate commerce.

• Each State determines any additional requirements for reinstating the CDL/CLP driving privilege.

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FYI Slide

States Will Decide How to Comply Each State will decide how it will comply with downgrading and when/if to require re-testing of drivers to reinstate CDL License.

To Find How Your State will Comply go to the following link:

https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Med-Cert-State-Instructions-FINAL.pdf

This document includes phone numbers to contact commercial driver units at SDLAs.

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FYI Slide

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Self Certification- CDL drivers must disclose type of Commercial Operation: CFR 49 (383.71)

Non-Excepted Interstate: Operates or expects to in interstate commerce and is subject to qualification requirements under 49 CFR part 391. The license does not restrict the transport, origination, or destination of the load to be transported.

Non-Excepted Intrastate: Operates in “State”only. May only transport cargo that originates in and the final destination is in “State”. May not cross state or international borders.

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“When” is a Medical Certificate Required

Before first operating a Commercial Motor Vehicle. Drivers who are attending driving school have a commercial learner’s permit (CLP)

At least every 2 years, or more often as directed by the ME

Whenever a driver’s ability to drive has been impaired, a new medical certificate may be required. This decision is a shared responsibility of the driver and the motor carrier. CMEs are frequently contacted for guidance regarding whether the medical condition or injury warrants a new medical certificate to be issued

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License/Medical Certificate

CDL/CLP Drivers are not required to carry their medical certificate when they drive a CMV, with the exception of for the first 15 days after getting a new medical certificate.

• They are required to provide a copy to their SDLA and the motor carrier.

Non-CDL/CLP drivers are required carry their medical certificate when they driver a CMV.• They are not be required by Federal regulation to provide a copy to their

SDLA but may be required to provide a copy to their SDLA, employer/motor carrier.

Because many SDLAs have not fully complied with the reporting requirements, FMCSA is advising at this time that CDL drivers continue to

carry their medical certificate when they drive. Many law enforcement personnel continue to ask to see the driver’s medical certificate

FYI Slide

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Drivers of CMVs Who Need a Medical Certification“Excepted” and “Non-Excepted” Drivers

All (Non-Excepted) Interstate commercial and non-commercial driver’s licensed holders involved in commerce and who operate a “commercial motor vehicle” are required to maintain a current medical examiner’s certificate.

CMV Definition:• Has a gross vehicle or gross combination weight or rated for 10,001 lbs or more

• Designed or used to transport more than 9 passengers (including the driver) for compensation or,

• Designed of used to transport more than 16 passengers (including the driver) not for compensation

• Transport requiring Placard for Hazardous Waste

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Interstate Drivers That Do Not Need a Medical Exam

Excepted Interstate Driver:

• Transport school children/staff between home and school;

• Federal, State or local government employees;

• Transport human corpses or sick or injured persons;

• Fire truck/rescue vehicle driver during emergencies and other related activities;

• Transportation of propane winter heating fuel when responding to an emergency condition requiring immediate response such as damage to a propane gas system after a storm or flooding;

• Response to a pipeline emergency condition requiring immediate response such as a pipeline leak or rupture;

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• In custom harvesting on a farm or to transport farm machinery and supplies used in the custom harvesting operation to and from a farm or to transport custom harvested crops to storage or market;

• Beekeeper in the seasonal transportation of bees;

• Controlled and operated by a farmer, but is not a combination vehicle (power unit and towed unit), and is used to transport agricultural products, farm machinery or farm supplies (no placardable hazardous materials) to and from a farm and within 150 air-miles of the farm;

• As a private motor carrier of passengers for non-business purposes ; or

• To transport migrant workers.

If yes to the above activities as the only operation in which they drive, they operate in excepted interstate commerce.

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Intrastate Drivers and Medical Certificates

Intrastate Drivers That Do Not Need A Medical Exam

Excepted Intrastate Drivers:

• Drive a CMV only in intrastate commerce activities for which the State of licensure has determined they are not required to meet the State’s medical certification requirements.

Medical Examiners should know what intrastate drivers are excepted from the requirement to obtain a medical certificate (such as state workers).

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School Bus Operations

• Drivers of vehicles operating for picking up students or staff at home to school and back home regardless of whether the bus crosses state lines. (does not include sporting trips or field/activity trips)

• Drivers who are employees of a school district, city, county, or state government

The following School Bus Drivers are Exempted from the Federal Medical Exam requirement:

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State School Bus Driver Medical Exams

• Most if not all states require all School Bus Drivers to have a medical examination.

• School Bus Driver regulations may be regulated by the State Department of Education.

• Download your State’s School Bus Driver Handbook.

• Many States have additional physical requirements to be a school bus driver.

• Many States also have their own form rather than the Federal Medical Exam Form.

• Some states restrict who can perform a school bus driver physical. (DC restrictions in: Ohio, GA, MA, NY)

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FYI Slide

Medical Exams-Foreign Drivers

A driver licensed commercial driver a Canadian Province of the Mexican Licencia Federal is not required to have a US medical certificate.

Canadian or Mexican drivers who use insulin, have epilepsy, or are vision or hearing impaired are not qualified to drive a CMV in the U.S.

Canadian drivers who must wear a prosthesis to drive must wear the prosthesis while driving in the U.S. Canadian drivers can not apply for a U.S. SPE.

If a Foreign driver goes to work for a U.S. based motor carrier, the motor carrier frequently requires them to obtain a medical certificate from a

national registry medical examiner. The medical examiner is not required to report the exam to FMCSA.

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Codified Federal Regulations

49 CFR 391 . 41

49 = Title 49: Transportation

CFR= Codified Federal Regulation

391= Part 391- Qualifications of Drivers

41= Section 41- Physical qualifications for drivers

CFRs are laws that must be followed.

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Medical Regulations Summary

49 CFR 391.41 Medical Standards:

• 13 Legal requirements, Must be followed

Advisory Criteria:

• Hypertension, ME Role, Driving duties

Medical Guidelines:

• Assist in the evaluation of drivers and based on expert review and considered “best practice”.

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Standard vs GuidelineStandard: 49 CFR 391.4 (b)(5):

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of a respirator dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely.

Guideline: Pulmonary Tuberculosis

Waiting Period: No recommended time frame

Certify If: Driver is determined not to be contagious. Etiology is confirmed and treatment has been shown to be adequate/effective, safe and stable.

Maximum Certification: 2 years.

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Not Conforming to Medical Guideline Guideline: Myasthenia Gravis:

Do not Certify if: Diagnosis of Myasthenia Gravis

Documentation to Certify a Driver with Myasthenia Gravis:• Outdated guideline • Current treatment and medications allow most to live nearly

normal lives and lifespan. • Driver treatment is effective, safe, and stable and he has no

deficits in ocular movement, torso, or extremity strength that affect safe driving.

When the certification decision does not conform with the guidelines, the reason must be noted on the medical exam form.

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Medical Standard Summary49CFR 391.41 Physical Qualifications and Examinations

Physical Qualifications 13 standards:

• 10 discretionary

• 3 non-discretionary: vision, hearing, epilepsy

49CF 391.43 Medical Examiner Duties, driver tasks, performing the exam, advisory criteria, forms

49CFR 391.45 Describes who must have the medical exam

49 CFR Part 381 Waivers/Exemptions/Pilot Programs

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Medical Standard Summary49CFR 391.47 • Conflict resolution between ME/Driver/MC/PCP

49CF 391.49 • Skill Performance Evaluation

49CFR 391.62• Intra-city zone drivers

49CFR 391.64• Grandfather clause for old vision waiver

21 USC Sec. 812 • U.S Drug Enforcement Administration

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Physical Examination (49 CFR 391.41 and 391.43)

• Eyes-Head (391.41(b) (10), 391.42

• Ears (391.41 (b) (11)

• Mouth and throat (391.41 (b)(5)

• Neck (391.41 (b)(7))

• Heart (391.41(b)(4)(6)

• Lungs, chest, thorax (391.41(b)(5))

• Abdomen (391.41 (a)(3)(I), 391.43(f))

• Spine (391.41 (b)(7))

• Extremities and trunk (391.41(b)(l),(b)(4), (b)(9)).

• Neurologic status (391.41(b)(7),(b)(8), (b)(9))

• Mental status (391.41(b)(9)).

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Session 301 Hour 1

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Session 301 Hour 2

CDL Driver Qualifications Motor Carrier Responsibility

• Be at least 21 Years Old (follow State procedure to determine whether to issue an interstate or intrastate medial certificate if medically qualified to drive interstate)

• Speak and Read English well enough to• Converse with general public• Understand highway/traffic signals• Respond to official questions• Make legible entries on records

• Capable to safely operate CMV• Perform Driving Tasks• Current Medical Certificate• Only one valid CDL License• Provide background/violation background• Not currently subject to disqualification 49CFR 391.15• Disqualified drivers can’t drive, No Marijuana Use & No alcohol use

when driving.• Completed driver road test of equivalent

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Profile of Average Truck or Bus Driver1. Male2. Over 40 years old- Aging population3. Sedentary4. Overweight- Obesity5. Smoker6. Poor eating habits7. Less healthy than average person8. More than two medical conditions9. Cardiovascular disease prevalent

Are at a higher risk for chronic disease, fixed deficits, gradual or sudden incapacitation and comorbidity

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Medical Examiner Role 49 CFR 391.43

Medical examiners shall:

1. Be knowledgeable of the specific physical and mental demands associated with operating a commercial motor vehicle and the requirements of this subpart, including the medical advisory criteria prepared by the FMCSA as guidelines to aid the medical examiner in making the qualification determination; and

2. Be proficient in the use of and use the medical protocols necessary to adequately perform the medical examination required by this section.

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Medical Examiner Role 49 CFR 391.43Section 43 that defines the role of the ME refers to Section 41 in that the ME must be familiar with 49 CFR 391.41, Physical qualifications for drivers.

In the interest of public safety, the medical examiner is required to certify that the driver does not have any physical, mental, or organic condition that might affect the driver's ability to operate a commercial motor vehicle safely.

**Your fundamental obligation is to establish whether a driver has a disease, disorder, or injury in a higher than acceptable likelihood for gradual or sudden incapacitation or sudden death, thus endangering public safety

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Medical Examiner Responsibilities 391.43Determine Driving Status and Issue ME’s Certificate (when appropriate):

FMCSA relies on the ME to determine driver certification.– Consulting specialists may not know medical standards. Clearance to

drive from a consulting provider is an opinion with which the ME may or may not concur.

– The ME is responsible for determination of CMV driver medical certification status on every examination.

Driving Duties Considered “Hard Work”Medical Examiners can not allow “work” limitations: • No light duty, can not limit driving to daytime

When issuing a medical certificate, all those being examined must be treated as if they were driving an 18 wheeler loaded with 110,000 lbs.

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Medical Examiner Responsibilities 391.43Determining Driving Status:

Medical Examiners are not responsible to determine whether a driver can understand or speak English well enough to drive. That is the motor carrier’s duty.

Medical Examiners are not expected to be lie detectors. The driver is responsible for providing complete, truthful information to the Medical Examiner.

Medical Examiner Responsibilities

• Does the Driver Pose a Risk to Public Safety? Yes? Do not Certify Driver

• Determining “acceptable risk” is a medical/societal decision

– 1%, 2%

For drivers needing exemptions:

The role of the medical examiner is to determine if the driver is “otherwise qualified”.

Medical Examiners DOsAs the ME, you are not diagnosing or treating personal medical conditions.

Treating medical conditions is allowable, but is outside the ME role.

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The medical exam is described as a “medical fitness for duty”examination. The Federal regulation does not address the issue of doctor-patient relationships. Consult your State regulation regarding establishment of a doctor-patient relationship.

MEs have the responsibility to educate and refer the driver for further evaluation if needed.

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Medical Examiner DOsAdditional Testing vs Testing for Diagnosis

MEs order tests to determine if the standard/guidelines for a particular medical condition is met. For some guidelines, these tests may determine the severity of the medical condition which may indicate disqualification.

Testing for the purpose of Diagnosis is typically performed by the driver’s PCP. The testing required for diagnosis may not include the testing required to determine the risk to driving.

Example: Ordering a Test not used for Diagnosis:

A driver with a diagnosis of COPD must meet PFT testing minimums. A ME might order spirometry to help make that determination.

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• Comply with FMCSA Regulations

• Perform the exam in accordance with instructions

• Seek Further testing/evaluation for conditions you are not sure about

• Perform the exam only in the state(s) you are licensed to practice in.

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Medical Examiners DOs

Medical Standards, & Motor Carriers

Motor Carriers can have additional medical requirements, such as a lifting capability.

Drivers could fail a M/C pre-placement examination and still meet the federal physical qualification requirements to obtain a medical examiner’s certificate.

ME would certify the driver and inform the company that the driver does not meet their requirements.

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Medical Exam FormsME:• Commercial Driver Medical Examination Report (MER-5875)• Medical Examiner’s Certificate (MEC 5876) (Self Laminating Versions

available)• Application forms for Federal Exemptions or State Exemptions/Waiver• Insulin-Treated Diabetes Mellitus (MCSA-5870)• MEs should make a copy of letters brought in by the driver

Driver:• Special Performance Evaluation (SPE) Letter• Hearing/Vision/Seizure/Implanted Defibrillator, other Federal Exemption Letter• State Exemption/Waiver Letter• Intra-City Zone Driver Letter

Drivers can request replacement copies of the MER and MEC from the ME or the Motor Carrier. On June 22, 2021, Motor carriers will no longer be required to keep a copy of their drivers’ medical certificate or verify that driver’s medical exams were performed by a National Registry CME.

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Record RetentionMedical Examiners are required to retain the original copy of the Exam Form and a copy of the ME Certificate and related health records for three years (electronic records accepted). The original copy of the MEC goes to the driver.

If the medical exam establishes a doctor/patient relationship keep the records for the period required by state law.

MEs may download the exam report and certificate for use.

https://www.fmcsa.dot.gov/medical/driver-medical-requirements/medical-applications-and-forms

Types of Driver Exams

Once a medical examiner’s certificate has been issued, that medical exam has been closed and can not be amended. To issue another medical certificate to that driver, medical examiners must perform a complete new full exam, using new forms.

Medical Examiners must determine the driving status of a driver on the day of the exam with one exception call Determination Pending driving status. This will be covered in more detail later, however, when a medical examiner can not determine the driving status of a driver during an exam, the medical examiner can delay making the driving status decision for up to 45 days as long as the driver does not have a disqualifying condition making them unsafe to drive. When using Determination Pending, the driver is not issued a medical certificate on the day of the exam and therefore that exam is not closed until the needed information is received or 45 days have past.

Expiration dates of MEC are always based on the date the MEC was signed! 15

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Medical Examination Report Form MCSA-5875Composed of 5 Pages:

1. Driver’s information, Health Hx specifically medications, and past surgeries.2. Continued Health History, Driver’s signature area, ME Hx Review3. Upper Half: Vision, Height, Weight, Hearing, BP, Pulse Rate, Heart

Rhythm, UA, other testing results,

Lower Half: Physical Examination Findings. It is generally acceptedthat the majority of the page’s lower half is performed by the CME.

4. Certification for Interstate Drivers5. Certification for Intrastate Drivers6. Instructions on use of the forms

Commonly referred to as the “Long Form”, MER 5875 is required for use in all states. The Federal instructions must be used for interstate drivers, however instructions for use of the MER 5875 for intrastate drivers in certain States (MT, CA) are different from the federal instructions. Training videos for those states are available at TeamCME.com

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Medical Examination Report 5875 (Long Form)

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MER 5875 Page 1 Upper Half

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Expires 11/30/2021

Your office Record# if applicable

Picture, Gov ID

Johnson Jack D 12/3/80 36

13579 OR 541-276-0001 X

X

X

Permanent Address Pendleton OR 97801

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MER 5875 Page 1 Lower Half

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Driver’s forget to mark “No” if theyhaven’t had surgery or are nottaking any medications. If the driverdid not make any comments, make Sure “No” has been checked in bothupper and lower section.

To provide a copy of the exam report form (HIPPA Protected) to an employer the ME should have a signed release from the driver.

X

Lisinopril 10mg twice a day, Dr. Jeff Carlson, Pendleton, OR#7

MER 5875 Page 2

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MER 5875 Page 2 Upper Half

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XXXXX

X

XXX

XX

XXXX

X X

XXXXXX

XXXXXXXXX

X

Johnson Jack 12/3/1980 10/31/16

#7

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#7 I have high blood pressure but it’s under control, treated by Dr. Carlson

#7 HTN PCP Dr. Jeff Carlson, Pendleton, OR 541-276-0001

Jack Johnson 10/31/16

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X

#7 From Upper Page 2

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MER 5875 Page 3

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MER 5875 Page 3

Johnson Jack 12/3/1980 10/31/16

85 X 6 1 210

145 92 1.020 None NEG TR

140 90

20 90

20 90 20

X

X X X

X

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20 30 40 40 50 60 30 50

10/15/16 A1c = 7.5

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X XX XX XX XX XX XX X

#11: Missing 5th digit on left hand, driver has sufficient grasp strength and prehension

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MER 5875 Page 4 & 5

Page 4 Interstate Drivers Page 5 Intrastate Drivers

FMCSA does not require the driver’s employer to keep a copy of their drivers’ Medical Exam Report form, but does not prohibitemployers from obtaining copies.

If transmitting a copy of the Exam Report to the employer, get the driver’s signature for HIPPA release of medical information.

When requested by a federal/state authority, regulatory requirements take precedence over HIPPA, and MEs must provide a copy within 48 hours.

What information must or can be turned over to the carrier is a legal issue, and if in doubt, the examiner should obtain a legal opinion.

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Medical Exam Report Request

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Medical Examiner’s Certificate 5876 (Short Form)

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Johnson Jack

Restrictions: Corrective lenses, hearing aid, exemptions, SPE, Exempt Intracity Zone

X

Jeffrey Carlson, DC 541-276-0001 10/31/2016

Jeff Carlson, DC X

12376 OR 123456778

Jack Johnson 985344 OR

Permanent Address Pendleton OR 97801 X

10/31/2018

(Up to) 2 Year Medical Certification

The maximum certification period is two years, however drivers may be certified for less than 2 years for any of the following reasons. Medical Examiner Certificates expire at midnight on the date of expiration.

• More frequent monitoring may be indicated by medical history or physical examination to ensure safety. Many Medical condition guidelines recommend a period of less than 2 years. (aproximately 40%+ of drivers)

• Drivers with a Federal Exemption are required to have annual recertification.

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Medical Examiner’s Certificate MCSA-5876

Medical Certificate Expiration dates ARE ALWAYS based on the date of the certificate was signed by the Medical

Examiner.

Medical Examiners Certificates ARE NOT issued to disqualified drivers

Medical Certificates ARE NOT issued to drivers who are in the Determination Pending driving category

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Michael Megehee, DC President

Teamwork makes the Dream work!Get on the Team!

541-276-6032www.TeamCME.com

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Accredited Training for the National Registry of Certified

Medical Examiners

Session 301 Hour 3

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ME Required Health Education Counseling

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Advise a Driver:• Consequences: Non-compliance with treatment plan or

required PCP or medical specialist monitoring• Fatigue, lack of sleep, diet, emotional, stress, affects

safe driving• Seek intervention: non-disqualifying conditions (serious,

future risk)• Carry a pair of glasses while driving if using contact

lenses• Carry a spare power source while driving if using

hearing aids• With deep vein thrombosis regarding inactivity,

intervention can prevent future thrombotic event

Pending Determination or Disqualification

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Record & Inform the driver of rationale for delaying or potentially disqualifying certification which may include:

• A post-operative waiting period needs to be completed• Additional testing or medical records needed• Vision disorder • Cardiac event (MI, coronary insufficiency)• Chronic pulmonary exacerbation (emphysema, fibrosis• Uncontrolled hypertension• Endocrine dysfunction (diabetes)• Musculoskeletal Disease (arthritis, neuromuscular disease• Neurologic event (seizure, stroke, TIA)• Sleep disorder (OSA)• Mental/emotion health (depression, schizophrenia)• Mental health dysfunction (depression, bipolar)• A medical condition requiring clearance f/ treating provider

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Medication Use History QuestionsAre you currently taking medications (prescription, over-the-

counter, herbal remedies, diet supplements)?:

• Is the driver compliant with medication instructions?

• Experiencing effects or side effects such as:

– Dizziness or light headedness, Hypotension

– Sedation, Depressed Mood

– Cognitive deficit

– Decreased Reflex response

– Unsteadiness

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Review of Medications :• Effectiveness- therapeutic range Effects- Side Effects

• Synergistic effect

• Interactions with other drugs, food, supplements

• Reactions to a new medication

• Reaction to a single late or missed dose

• Reaction from discontinued use

• Advise driver where to find and how to read warning labels

• Carry extra medication so that doses are not missed

• Method for refilling medications when away from home

• Educate driver on proper storage, exposure to heat, light, cold, moisture

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Medication Counseling

Prescription and OTC Medication UseIrregular meals, sleep deprivation, poor sleep quality, irregular or extended work hours can alter the effects of medication and contribute to missed or irregular dosing. OTC medications are not necessarily safe

Drivers cannot take a controlled substance or prescription medication WITHOUT A PRESCRIPTION from a licensed practitioner.

Drivers cannot take an amphetamine, a narcotic, or any other habit-forming drug WITHOUT A PRESCRIPTION AND CLEARANCE from the prescribing physician who is familiar with the duties or driving and the driver’s health history.

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Prescription, Herbal, OTC Medication Use

Schedule 1 Drugs are ALWAYS disqualifying:

Including: 1. Marijuana, (includes legal recreational & medical use)

2. Peyote (includes religious use)

All Other Medications:

Acceptable Use: 1. MEs should consider medical guidance where provided by

FMCSA for specific classifications or medications, and/or effects and side effects on a Case by Case Basis.

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Medication Use Determination

1. Case by Case Review to Include the following:

– Drug Classification

– Relative Dose

– Medication’s Half Life

– Timing of administration

– Length of time driver has been taking the medication

– Adverse side effects and General Effects?

– Is driver is experiencing any side effects?

– Clearance from Prescribing provider required?

2. When in doubt, request a “clearance” letter

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FMCSA’s Answer Regarding Medication Use

Medical Examiner’s Question:

Is Clonazepam a disqualifying medication? Can a driver be certified while taking Clonazepam if accompanied by the prescribing doctor’s note that the condition (anxiety) is controlled and the driver does not take the medication before driving?

FMCSA Answer:

Unless being used to treat seizures, FMCSA does not specifically identify benzodiazepines as absolute disqualifiers. The 2009 Medical Expert Panel rendered an opinion that benzodiazepine use should be disqualifying, however the FMCSA has not adopted this to mean that this class of medication is an absolutedisqualifier.

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FMCSA’s Answer to Medication UseFMCSA Answer Continued:

The agency relies on the ME, in collaboration with the prescribing practitioner to determine whether use of a certain medication may impact a driver’s ability to safely operate a CMV.

392.3 does not permit a driver to drive “while the driver’s ability or alertness is so impaired, or so likely to become impaired, through fatigue, illness, or any other cause, so to make it unsafe…”

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Duties and Rigors of Commercial Driving

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Drivers must be able to:

• Coordinate/Shift thru several (up to 20) gears using a manual transmission

• Use of mirrors for backing up, traffic awareness• Climb ladders, bending, stooping, crouching; enter and exit the

cab, (requires 3pts of contact, hip flexion 90 degrees)• Perform precision prehension and power grasping• Use arms, feet and legs during CMV operation• Cognitive ability to:

• Stay Alert, Communicate• Plan a travel route• Inspect operating condition of tractor and/or trailer• Monitor and adjust to a complex driving situation• Maneuver thru crowded areas

The Duties and Rigors of Commercial Driving

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Driver’s Must be able to Perform “Hard Work” (ETT 6 METS)(Used for Functional Analysis-Physiatrist)

All Drivers must be able to perform all duties regardless of the duties of their current employment

Consider a driver’s ability to:

• Perform vehicle checks, detect changes: engine, brakes, tires• Couple and uncouple trailers, raising/lowering• Connect/Disconnect Cables, Install/Remove 80 lb tire chains• Secure/Load/Unload several 1000 pounds of freight• Manipulate and secure tarps

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Assessment

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2. If a driver has a disability (such as a work comp or social security disability, or rated to have a certain % of disability, can they be qualified to drive?

Probably not because the driver would not expected to be able to perform “hard duty”.

1. Can an injured driver who has been returned to “light” duty be medically certified to drive?

FMCSA Answer: Yes, the driver could be qualified to drive if they can perform hard duty. The medical examiner must make a functional assessment of the person’s ability to operate a commercial motor vehicle safely and perform the duties of driving. If qualified, this may affect the status of the driver’s disability

Health Risk Assessment

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Consider general health and wellness factors such as:

• Long-term effects of fatigue from extended work hours without breaks

• Risk factors from eating patterns/dietary choices available to drivers

• Stressors likely from extended time away from driver’s social support

• Short/long-term effects of stress from tight pickup/deliveries, changing/varying/rotating/ schedules

• Irregular rest periods, sleep and work schedule• Adverse road, weather, and traffic conditions• Exposure to temperature extremes, vibration, and noise• Transporting passengers or hazardous products

Medical Condition Risk Assessment

Symptoms: Does a benign condition with excellent prognosis have symptoms to interfere with the ability to drive?• Rapid onset• Duration• Frequency• Severity

Behavior: Appropriate interactions, responsible, non-violent?

Incapacitation: So rapid to interfere with safe driving or can the driver stop before becoming incapacitated? Or, so gradual that the driver is unaware of diminished capacity?

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Medical Condition Risk Assessment

Mental: Can the driver process environment cues rapidly and make appropriate responses, solve problems, respond to an emergency and function in a dynamic situation?

Medical Treatment: Does treatment allow the driver to perform tasks safer than without treatment

Medication Effects: Even if effective, do side effects interfere with safe driving (drowsiness, dizziness, hypotension, blurred vision, change in mental status)?

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Health Risk Assessment Summary

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• For Documented Conditions: is the medical condition safe, stable, and well controlled

• Document all of your observations, abnormal findings including non-disqualifying medical conditions in your reports and effect on driving

• Distinguish optimal treatment, prognosis and risk to safety for drive medical conditions

Risk Assessment Outcomes

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Certification Outcomes and Intervals:

1. Apply certification standards to determine driving status2. If appropriate, Certify a driver for an appropriate interval3. Indicate additional requirements when required:

• Waiver/exemption• Wearing Corrective Lenses• Wearing a Hearing Aid• Skill Performance Evaluation Certificate

4. Advise a driver certified with a limited interval to return for recertification with the appropriate documentation

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Medical Examiner Procedure

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Perform a complete examination as described on the Medical Exam Report form and complete the MER-5875 form when possible. If the exam was not completed, the ME fills in the form with all of the available information and marks the box indicating the examination was incomplete.

Ensure the driver signs the medical exam report form

For those qualified to drive, the driver signs and the ME issues the driver the original copy of the medical examiner’s certificate.

With the exception of instances where a skill performance evaluation or exemption is required, there is no requirement to issue a copy of the medical exam report to the driver although it is advised.

Physical Examination

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Ensure the driver is properly clothed for the exam(Minimum Clothing is underwear and a gown)

Testing:

Urinalysis- Note: SG, Protein, Blood, GlucoseDistant Visual Acuity, Horizontal Field, Color BlindnessBlood Pressure, Pulse, Rhythm, AmplitudeHearing; Whisper Test or Audiometric

Measurement:

Height and weight, Note: BMI, over or under weight

Physical Exam and Evaluation Page 3

Four Specific TESTsare required as part of the examination:

• Vision

• Hearing

• Blood Pressure/Pulse

• Urinalysis (dipstick)

(they all appear on page 3)

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Record Additional TestResults here

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Physical Examination Overview

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• General: Over/Under Weight, Tremor, Alcoholism, Drug Abuse, Cognition, Communication

• Eyes: Pupil Equality, Accommodation, muscle imbalance, extraocular movement, motility, imbalance, Rx to Light,

• Ears: Scarring, occlusion, perforation• Mouth/Throat: breathing, speaking, swallowing• Heart: Murmurs, Sounds, Enlargement, Pacemaker, Defib• Lung/Chest: excludes breast, Resp Rate, Sounds, cyanosis• Abdomen: Liver/Spleen Enlarge, Masses, AAA, Hernia/bruits• Vascular: Carotid, Post Tibial, Varicose• Genito-Urinary: Hernia • Extremities: Impairment, missing, grasp prehension, mobility• Spine: Surgery, deformity, limited motion, tenderness• Neurological: Equilibrium, coordination, DTRs, Patellar,

Babinski’s, sensory loss

Federal Exemptions for Drivers who Don’t Meet the Standard

FMCSA has four medical exemption programs for Interstate drivers of commercial vehicles:

1. Vision Exemption

2. Seizure/Epilepsy Exemption (January 15, 2013)

3. Hearing Exemption (January 15, 2013)

4. Implanted Defibrillator

Other exemptions may be granted by FMCSA

Medical Examiners cannot issue an exemption, however when applicable, the option for applying for a federal or stateexemption should be discussed with the driver.

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Federal and State Exemptions

Federal Exemptions: Because each driver must be listed in the Federal Register, the Federal Exemption process takes up to 6 months to be approved.

Drivers with a Federal Exemption can drive across state lines.

State Exemptions:

Each State determines if they have a waiver, exemption or program. Most of the time, these are much faster and easier to obtain. Therefore, a driver may with to apply for a State exemption first while waiting for their Federal Exemption to be approved.

Drivers with a State Exemption can only drive within the State.24

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Drivers Applying a Federal Exemption

Medical Examiner Should:

1. Ask the Driver if they want to apply for a Federal exemption.

2. Complete the exam just like any other exam.

3. Certify the driver for up to one year if otherwise qualified.

4. Check “Accompanied by a ________ waiver/exemption” on the MER and MEC and write Federal or State and the exemption name in the blank on both forms such as vision, or hearing.

5. Give a copy of the exam report form, and the original medical examiner’s certificate to the driver.

6. Inform the driver they can not drive until they have their exemption.

7. Give the Federal or State phone number to call or print the application to the waiver or exemption program and give it to the driver

Federal Phone #:

Vision: (703) 448-3094,

Hearing, Seizures, Implanted Defibrillator: (202) 366-400125

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Drivers Applying for a State Exemption

Medical Examiners should be familiar with and follow the procedure as required by the State Waiver/Exemption Program

Some states have discontinued their waivers/exemptions and depend entirely on the federal exemption programs. Remember Federal Exemptions are only available to drivers of commercial vehicles who drive or intend to drive across state lines.

Some States have a process for an intrastate driver to follow rather than require the driver to obtain a waiver/exemption. (Vision: FL, NJ)

In most States, use Page 5 of the MER and check the second oval on the Medical Examiner’s certificate indicating “intrastate only” driving and give the original copy to the driver. (CA, MT and some states use a different process such as requiring Page 4 to be used and to disqualify the driver for the State to issue a restricted MEC to the driver)

Remember, State regulations apply to intrastate drivers.

Alternative Standard for Limb Loss/ Impairment

Special Performance Evaluation (SPE):

Allows a driver with a fixed deficit or loss of fingers, toes, hand, foot, arm or leg to drive a CMV.

Medical Examiners cannot issue an SPE, however when applicable, the option for applying for a SPE should be discussed with the driver.

SPEs are performed by FMCSA representatives or an assigned State representative.

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Vision 49 CFR 391.41 (b) (10) – Non Discretionary

There is increased demand on visual perception with driving a CMV:

Decreased maneuverability Increase size of blind spots

Dependence on Mirrors Longer acceleration/stopping

Safety is maintained thru a constant stream of decisions that require a high rate of accurate visual information.

Because most examiners do not have specialized diagnostic devices found in ophthalmological specialty settings, MEs are to “ask about” the following eye conditions:

Aphakia Macular Degeneration

Glaucoma Retinopathy, Cataracts

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Drivers must meet the standard in each eye and when using both eyes.

Distant acuity:

– 20/40, each eye (individually w/wo corrective lenses)

– 20/40, both eyes (binocular), w/wo corrective lenses)

– No double vision

– When corrective lenses are used to meet the requirements, corrective lenses must be used while driving

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• Field of Vision:

– 70 degrees, horizontal meridian each eye (peripheral)

• Color Vision:

– Can distinguish between Traffic Signal Green, Red and Amber

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Driver History Questions Related to Vision Driver History:

Eye disorders or impaired vision (except corrective lenses)

• Ask any changes, diagnosis, glare, any near crashes (indications of beginning eye conditions)

• Any symptoms related to or cause by eye disease, tolerance to contacts

• Use of ophthalmic preparations with burning, irritation, itching, blurring, night vision?

• Any history of Macular Degeneration, Aphakia, Glaucoma, Cataracts, Retinopathy

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Color BlindnessColor Blindness is rarely disqualifying.

• To identify those with color deficiencies, the color bars on Snellen charts and Ishihara charts are designed to be difficult for those with color deficiencies to differentiate.

• Traffic Signal Red, Green and Amber are specifically designed to be easy to differentiate by those with color deficiencies.

• True color perception is not required.

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Can the Driver Identify the colors from a traffic signal?

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Vision Screening TestsVision evaluation can be performed by an ophthalmologist or optometrist and reported to the Medical Examiner

The ME should check the box for the referral and when receiving a report from an eye specialist and attach received reports.

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Vision Screening TestsUse the Snellen chart and report in Snellen-comparable values. The chart distance should be 20 feet and illuminated with white light.

Trained assistive personnel may perform the vision screening test and record results.

Drivers who wear corrective lenses for driving, should wear corrective lenses for testing. (some may pass without their lenses)

Evaluate drivers wearing contact lenses for good tolerance and adaptation to contact usage.

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Vision Screening TestsSnellen Test Suggestions:

• Reverse reading of the lines forward and backward to avoid memorization

• Ask the driver which is the smallest numbered line they can read

• Use an eye occluder, instruct driver to keep both eyes open when testing individual eyes

• Note smallest line that driver can read while missing only one letter. Could be reported at 20/40-1

• Drivers that are 20/50 in your office may benefit from evaluation in a specialist office using more precise equipment Other versions of

Snellen charts are allowable.

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• Monovision: Lasik surgery or contacts for distance acuity in 1 eye, and near acuity in the other is disqualifying (may affect depth perception). Can be resolved by having another contact lens or glasses for distance acuity in both eyes.

• Monocular Vision: One eye does not meet the standard is disqualifying (391.43) unless accompanied by a Federal or State vision exemption.

• Telescopic lenses: Disqualifying (significantly decrease field of vision, used for uncorrectable low acuity from macular degeneration, tunnel vision from glaucoma, retinal detachment, diabetic retinopathy)

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Vision Acuity Continued

Required use of corrective lenses should be marked on the medical examiner’s certificate.

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Failing the Acuity Standard

If a driver has at least one eye that satisfies the vision standard (acuity, field of vision, color), the ME should inform the driver of the Federal Vision Exemption program.

If both eyes fail the vision standard the driver will not be approved for a Federal vision exemption.

Many States have a similar State vision exemption but may have different/less requirements

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Federal Vision Exemption Program 49 CFR 381

1. Ask the driver if they want to apply for a Federal or State vision exemption.

2. If “No”, disqualify the driver, complete the exam form, mark “does not meet standards”, and do not issue ME’s certificate.

3. If “Yes” continue to step #4 if the driver has 3 yrs of driving experience of a CMV (w/wo a CDL license)

4. Complete the exam

5. If otherwise qualified to drive, qualify the driver for 1 yr. by checking the box “Meets Standards”…write in “Vision”, and check box for “1 year” (or less) on the exam report form.

6. Check the box “When Accompanied by (write in “Vision”) on the Report Form and ME Certificate:

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Federal Vision Exemption Program 49 CFR 3817. Give the driver a copy of the physical exam form and the

original medical examiner’s certificate.

8. Tell the driver they can not drive until they have an

exemption

9. Tell the driver to:

• Contact the Federal Vision Exemption Program: 1-703-448-3094 Email: [email protected]

• Return to your office when he has his exemption

• Bring their exemption and an annual specialist eye exam report by an optometrist or ophthalmologist with them for review by the ME before driving. Note: drivers rarely comply with this request!

• The Federal Vision Exemption is good for 2 years.

• Requires drivers to have a yearly DOT medical exam.

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State Vision Exemptions

If the driver does not meet the 3 year driving experience requirement, wants to drive a cmv in his state to apply for a federal exemption, or plans to only drive within the state, they can usually obtain a state vision exemption.

1. If the driver says Yes to pursue a state vision exemption.

2. Follow the procedure outlined by your state licensing agency which may follow a similar procedure as the federal vision program.

3. If they say No, the medical examiner disqualifies the driver, completes the medical exam report form, marks the box Does not meets standards on the exam report form and does not issue a medical examiner’s certificate.

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Vision Waiver Program 49 CFR 391.64A small # of drivers in a vision study in the 1990’s are “grand-fathered” and may drive if they meet vision requirements in one eye and are otherwise medically fit. Drivers must provide the Waiver program letter and a copy of the yearly eye exam.

If “Otherwise” medically qualified, The Medical Examiner:

1. Completes the exam

2. Qualifies the driver for one year by checking the box “Meets Standards but periodic monitoring required due to” writes Vision Waiver in the space and marks the 1 year box

3. Checks the box “Qualified by operation of 49 CFR 391.64” on both the Medical Examiners Certificate and the Report Form.

4. Gives the driver a copy of the Report form and original ME Certificate

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Eye Preparation Side Effects

May cause temporary eye discomfort or difficulty with vision.

Allergic Conjunctivitis:– transient burning/stinging when applied, corneal change, keratitis,

chills, edema, fever

– may cause drowsiness and fatigue, headache dizziness, drowsiness, blurred vision, dry eyes

Glaucoma: – red itchy eyes (minor), dizziness, depression, rash, drowsiness, blurred

vision, lacrimation, GI upset, may affect safe driving

Bacterial Conjunctivitis: – oral and topical antibiotics

Macular Degeneration: – may increase risk for stroke in drivers with predisposing health

conditions.

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Eye Examination (Page 3 )

Check for:

• Pupillary equality, size, round

• Reaction to light, individually and consensual

• Motility, accommodation, muscle imbalance, extraocular movement

• Nystagmus

• Exophthalmos

• Note abnormal findings. Advise driver that early detection of eye disease is important giving value to regular vision exams.

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Ocular Motility, Accommodation, Convergence

Driver’s eye follow the examiner’s penlight movement thru the H pattern, and then focuses on the penlight when moved close and distant.

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Convergence: shifting to a close object causes constriction.

Field of Vision- Right Eye Confrontational TestSit approximately two feet in front of the driver so

that your eyes are at about the same level. Driver

uses the palm of the left hand to cover the left eye.

Ask the driver to fixate on your right eye. Extend your arms forward and position your hands halfway between yourself and the driver. Position your right hand one foot to the right of the straight-ahead axis and six inches above the horizontal plane. Position your left hand one-and-a-half feet to the left of the straight-ahead axis and six inches above the horizontal plane. Ask the driver to confirm when a moving finger is detected. Repeat the procedure with your hands positioned six inches below the horizontal meridian. Reverse for right eye.

When test results are inconclusive, obtain specialist evaluation for precise measurement of peripheral vision.

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Ocular Conditions-When to Refer Ask if there is a history of Macular Degeneration, Aphakia, Glaucoma, Cataracts, Retinopathy and refer to a specialist if appropriate.

The Visual Disorders and Commercial Drivers Medical Expert Panel in November 1991 included the following statement:

These conditions should be brought to the attention of the applicant so that treatment…can be sought. Disqualification should not be made on the task of noting one of these conditions. Instead, applicants should be disqualified for visual reasons only. AlI pathologies noted on the checklist will eventually have consequences for vision…This recommendation appears consistent with current practice.

Ocular Medications: Determine if the treatment is having the desired effect of preserving vision that meets qualification requirements without any visual and/or systemic side effects that interfere with safe driving

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Eye Examination (Page 3 )Fundoscopic exam is not required unless indicated and may be referred to a specialist.

• Note abnormal findings and discuss the value of regular vision exams in early detection of eye diseases

• Refer a driver who EXHIBITS EVIDENCE of retinopathy, macular degeneration, glaucoma, Aphakia, cataracts to a specialist.

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OPHTHALMOSCOPIC EXAM

Basic Components of a Fundoscopic Examination:

• Normal variations

• Evidence:

– Glaucoma

– Hypertension

– Diabetes

– Macular degeneration

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CataractsBlurry vision at any distance in all fields) is a common symptom.

Accelerated by smoking, diabetes, gout, injury, radiation, and steroid medications.

Glare, particularly at night f/ oncoming headlights may be an early sign. Decreased contrast and color resolution

Close vision may be improved temporarily.

Cataracts appear as white obstruction in pupil area

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Surgery involves replacement of the lens (aphakia)“Cat Eye” reflection from otoscope.

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Glaucoma

Glaucoma causes decreased

peripheral vision.

• Painless and progressive.

• Decreased night vision and color vision.

• Acuity may not be affected and will probably not be detected by vision acuity testing.

• Lost vision can not be restored. Advise strict compliance with medications is required for effective treatment.

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Glaucoma Signs: Optic cup/disk ration > 6/10 Suspect Glaucoma

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Affects the macula and detailed central vision.

Usually slowly progressive

Increase prevalence with age after 30% by age 70.

Peripheral vision usually spared.

Macular Degeneration

Decreased central visual acuity, increased time required for recovery from bright lights

Telescopic lenses redirect central images to areas of the eye for peripheral vision but is not acceptable for commercial driving.

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Most common cause: Diabetes

Micro aneurisms/hemorrhagesin any vision field leads to vision loss.

Unstable Proliferative Retinopathy is disqualifying

Fluid leakage can lead to partial scotomas in central vision, gross hemorrhage can obscure vision, retinal detachment, and blindness. Subtle contrast sensitivity, flicker fusion frequency, color discrimination also affected

Retinopathy

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Retinopathy-Hypertension (A-V nicking)

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Michael Megehee, DC President

Teamwork makes the Dream work!Get on the Team!

541-276-6032www.TeamCME.com

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