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Medical Advisory Criteria for Evaluation Under 49 CFR Part 391.41
Unlike regulations which are codified and have a statutory base, the recommendations in this advisory are simply guidance established to help the medical examiner determine a driver's medical qualifications pursuant to Section 391.41 of the Federal Motor Carrier Safety Regulations (FMCSRs). The Office of Motor Carrier Research and Standards routinely sends copies of these guidelines to medical examiners to assist them in making an evaluation. The medical examiner may, but is not required to, accept the recommendations. Section 390.3(d) of the FMCSRs allows employers to have more stringent medical requirements.

391.41(b)(1) - A person is physically qualified to drive a commercial motor vehicle if that person:

Has no loss of a foot, leg, hand, or arm, or has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

For any loss of a foot, leg, hand, or arm, a person who is otherwise qualified under the Federal Motor Carrier Safety Regulations (FMCSRs) must apply for a Skill Performance Evaluation (SPE) certificate. The State Director will make the final determination whether the defect will interfere with the driver's ability to control and safely drive a motor vehicle.

With the advancement of technology, medical aids and equipment modifications have been developed to compensate for certain disabilities. The Skill Performance Evaluation (SPE) (formerly the Limb Waiver Program) was designed to allow persons with the loss of a hand, foot or limb to qualify under the FMCSRs by use of prosthetic devices or equipment modifications which enable them to safely operate a commercial motor vehicle. Since there are no medical aids equivalent to the original body limb, certain risks are still present, and thus restrictions may be included on individual SPE certificates when a State Director for the FMSCA determines they are necessary to be consistent with safety and public interest.

If the driver is found otherwise medically qualified (391.41(b)(3) through (13)), the examining physician must include the statement "medically unqualified unless accompanied by a SPE certificate" on the medical certificate issued pursuant to 391.43(g).

If a joint application is made, the letter of application must be submitted to the State Director in the Service Center in which the carrier's principal place of business is located. If a unilateral SPE application is filed, the application must be submitted to the State Director in the Service Center in which the driver has legal residence. The addresses for these service centers are found in Section 390.27 of the FMCSRs.

 391.41(b)(2)

A person is physically qualified to drive a commercial motor vehicle if that person has no impairment of:

(i) A hand or finger which interferes with prehension or power grasping;

or

(ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle;

or

Any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle;

or

Has been granted a Skill Performance Evaluation (SPE) certificate pursuant to Section 391.49.

If the examining physician determines that an impairment (e.g., partial hand or finger amputation, or paralysis) in any way interferes with the driver's ability to perform normal tasks associated with operating a commercial motor vehicle, then the driver becomes subject to the SPE certification program pursuant to Section 391.49. If the driver is found otherwise medically qualified (391.41(b)(3) through (13)), the examining physician must include the statement "medically unqualified unless accompanied by a SPE certificate" on the medical certificate issued pursuant to 391.43(g).

The driver and the motor carrier are subject to appropriate penalty if the driver operates a motor vehicle in interstate commerce without a current SPE certificate for his/her physical impairment.

If a joint SPE application is filed, it must be submitted to the State Director in the service center in which the carrier's principal place of business is located. If a unilateral SPE application is filed, it must be submitted to the State Director in the service center in which the driver has legal residence. The addresses for these service centers are found in Section 390.27 of the Federal Motor Carrier Safety Regulations.

 391.41(b)(3)

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

Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.   EXEMPTIONS NOW AVAILABLE

There is no provision in the Federal Motor Carrier Safety Regulations (FMCSRs) for an exemption from the minimum physical requirement with respect to the insulin-using diabetic. Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or orientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma, or insulin shock).

The administration of insulin is, within itself, a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related to long-haul commercial motor vehicle operations, such as fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the diabetic problem. Because of these inherent dangers, the FMCSA has consistently held that a diabetic who uses insulin for control does not meet the minimum physical requirements of the FMCSRs.

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule.  EXEMPTIONS NOW AVAILABLE

 391.41(b)(4)

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

Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis,

or

Any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure.

The term "has no current clinical diagnosis of" is specifically designed to encompass (1) a current cardiovascular condition; and/or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit. The term "known to be accompanied by" is defined to include a diagnosis of a cardiovascular disease which is (1) accompanied by symptoms of syncope, dyspnea, collapse, or congestive cardiac failure; and/or which is (2) likely to cause syncope, dyspnea, collapse, or congestive cardiac failure.

It is the intent of the Federal Motor Carrier Safety Regulations to render unqualified, a driver who has a current cardiovascular disease which is accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure. The subjective decision of whether the nature and severity of an individual's condition will likely cause symptoms of cardiovascular insufficiency is on an individual basis and qualification rests with the medical examiner and the motor carrier.. In those cases where there is an occurrence of cardiovascular insufficiency (myocardial infarction, thrombosis, etc.), it is suggested that, before a driver is certified, he/she have a normal resting and stress EKG, no residual complications, no physical limitations, and is taking no medication likely to interfere with safe driving.

Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus not necessarily unqualifying. However, the final determination must be based on functional assessment. A pacemaker recipient should be followed by a center specializing in this field.

Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver.

 391.41(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 respiratory dysfunction likely to interfere with his/her ability to control and drive a commercial motor vehicle safely.

To function adequately the cells of the body require a continuous supply of oxygen and removal of carbon dioxide. Proper functioning of the respiratory system ensures this adequate gaseous exchange. Any interruption in respiration for more than a few minutes will result in irreversible brain damage and, ultimately death.

Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving.

There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, that in any way is likely to interfere with the driver's ability to safely control and drive a motor vehicle, the driver must be referred to a specialist for further evaluation and therapy. Once the driver meets the minimum physical requirements of the Federal Motor Carrier Safety Regulations, a certificate can be issued.

Anticoagulation therapy for deep vein thrombosis and/or pulmonary thromboembolism is not unqualifying once optimum dose is achieved, provided lower extremity venous examinations remain normal and the treating physician gives a favorable recommendation.

 391.41(b)(6)

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

Has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability to operate a commercial motor vehicle safely.

Hypertension alone is unlikely to cause sudden collapse; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. This regulatory criteria is based on FMCSA's Cardiac Conference recommendations, which used the report of the 1984 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.

Mild Hypertension is considered an initial BP of 140-159 systolic and/or 90-99 diastolic.

If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosed with Stage 1 hypertension (BP is 140/90-159/99) may be certified for one year. At recertification, an individual with a BP equal to or less than 140/90 may be certified for one year; however, if his or her BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued.

Moderate Hypertension is considered an initial BP of greater than 160 systolic and/or greater than 100 diastolic.

An individual diagnosed with Stage 2 (BP is 160/100-179/109) should be treated and a one-time certificate for 3-month certification can be issued. Once the driver has reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter.

Severe Hypertension is considered an initial BP of greater than 180 systolic and/or greater than 110 diastolic.

An individual diagnosed with Stage 3 hypertension (BP equal to or greater than 180/110) should not be certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months.

 

Commercial drivers who present for certification with a normal BP reading, but who are taking medication for hypertension should be certified on the same basis as individuals who present with BPs in the mild to moderate range.

An elevated BP finding should be confirmed by at least two subsequent measurements on different days. Inquiry should be made regarding smoking, cardiovascular disease in relatives, and immoderate use of alcohol. An electrocardiogram (ECG) and blood profile, including glucose, cholesterol, HDL cholesterol, creatinine and potassium, should be made. An echocardiogram and chest x-ray are desirable in subjects with moderate or severe hypertension.

Since the presence of target organ damage increases the risk of sudden collapse, group 3 or 4 hypertensive retinopathy, left ventricular hypertrophy not otherwise explained (echocardiography or ECG by Estes criteria), evidence of severely reduced left ventricular function, or serum creatinine of greater than 2.5 warrants the driver being found unqualified to operate a commercial motor vehicle in interstate commerce.

Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors. Most antihypertensive medications also have side effects, the importance of which must be judged on an individual basis. Side effects of somnolence or syncope are particularly undesirable in commercial drivers. Commercial drivers should be informed of the side effects of drug therapy and the interaction of these drugs with other prescription drugs, nonprescription drugs, and alcohol.

Surgically Corrected Hypertension:

A commercial driver who has normal blood pressure 3 or more months after a successful operation for pheochromocytoma, primary aldosteronism (except when a bilateral adrenalectomy has been performed), renovascular disease, or unilateral renal parenchymal disease, and who shows no evidence of target organ damage may be qualified. Hypertension that persists despite surgical intervention with no target organ disease should be evaluated and treated following the guidelines set forth above.

 

 391.41(b)(7)

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

Has no established medical history or clinical diagnosis of a rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease which interferes with his/her ability to control and operate a commercial motor vehicle safely.

Certain diseases are known to have acute episodes of transient muscle weakness, poor muscular coordination (ataxia), abnormal sensations (paresthesia), decreased muscular tone (hypotonia), visual disturbances and pain which may be suddenly incapacitating. With each recurring episode, these symptoms may become more pronounced and remain for longer periods of time. Other diseases have more insidious onsets and display symptoms of muscle wasting (atrophy), swelling and paresthesia which may not suddenly incapacitate a person but may restrict his/her movements and eventually interfere with the ability to safely operate a motor vehicle. In many instances these diseases are degenerative in nature or may result in deterioration of the involved area.

Once the individual has been diagnosed as having a rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease, then he/she has an established history of that disease. The physician, when examining an individual, should consider the following:

  1. the nature and severity of the individual's condition (such as sensory loss or loss of strength);
  2. the degree of limitation present (such as range of motion);
  3. the likelihood of progressive limitation (not always present initially but may manifest itself over time); and
  4. the likelihood of sudden incapacitation.

If the medical examiner determines that the disease or condition is likely to interfere with a driver's ability to safely operate a motor vehicle, the driver cannot be certified and must be sent to a specialist. In cases where more frequent monitoring is required, a certificate for a shorter time period may be issued.

 391.41(b)(8)

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

Has no established medical history or clinical diagnosis of epilepsy;

or

any other condition which is likely to cause the loss of consciousness; or any loss of ability to control a commercial motor vehicle.

Epilepsy is a chronic functional disease characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control which may lead to loss of consciousness and/or seizures. Therefore, the following drivers cannot be qualified:

  1. a driver who has a medical history of epilepsy: or
  2. a driver who has a current clinical diagnosis of epilepsy; or
  3. a driver who is taking antiseizure medication.

If an individual has had a nonepileptic seizure or an episode of loss of consciousness of unknown cause which did not require antiseizure medication, the decision as to whether that person's condition may result in the loss of consciousness or loss of ability to control a motor vehicle is made on an individual basis by the medical examiner in consultation with the treating physician. Before certification is considered, it is suggested that a 6-month waiting period elapse from the time of the episode. Following the waiting period, it is recommended that the individual have a complete neurological examination. If the results of the examination are negative and antiseizure medication is not required, then the driver may be qualified.

In those individual cases where a driver had a nonepileptic seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration, or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition, has no existing residual complications, and is not taking antiseizure medication.

 391.41(b)(9)

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

Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with the driver's ability to drive a commercial motor vehicle safely.

Emotional or adjustment problems contribute directly to an individual's level of memory, reasoning, attention, and judgment. These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness, or paralysis that may lead to incoordination, inattention, loss of functional control and susceptibility to accidents while driving. Physical fatigue, headache, impaired coordination, recurring physical ailments, and chronic "nagging" pain may be present to such a degree that certification for commercial driving is inadvisable. Somatic and psychosomatic complaints should be thoroughly examined when determining an individual's overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification.

Many bus and truck drivers have documented that "nervous trouble" related to neurotic, personality, emotional or adjustment problems is responsible for a significant fraction of their preventable accidents. The degree to which an individual is able to appreciate, evaluate and adequately respond to environmental strain and emotional stress is critical when assessing an individual's mental alertness and flexibility to cope with the stresses of commercial motor vehicle driving.

When examining the driver, it should be kept in mind that individuals who live under chronic emotional upsets may have deeply ingrained maladaptive or erratic behavior patterns. Excessively antagonistic, instinctive, impulsive, openly aggressive, paranoid or severely depressed behavior greatly interfere with the driver's ability to drive safely. Those individuals who are highly susceptible to frequent states of emotional instability (schizophrenia, affective psychoses, paranoia, anxiety or depressive neuroses) may warrant disqualification.

Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination.

 391.41(b)(10)

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

Has a distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses;

and

distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses;

and

field of vision of at least 70 degrees in the horizontal meridian in each eye;

and

the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

The term "ability to recognize the colors of" is interpreted to mean if a person can recognize and distinguish among traffic control signals and devices showing standard red, green, and amber, he/she meets the minimum standard, even though he/she may have some type of color perception deficiency. If certain color perception tests are administered (such as Ishihara, Pseudoisochromatic, Yarn, etc.), and doubtful findings are discovered, a controlled test using signal red, green, and amber may be employed to determine the driver's ability to recognize these colors.

Contact lenses are permissible if there is sufficient evidence to indicate that the driver has good tolerance and is well adapted to their use. Use of a contact lens in one eye for distant visual acuity and another lens in the other eye for near vision is not acceptable, nor are telescopic lenses acceptable for driving commercial motor vehicles.

If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only if wearing corrective lenses".

 391.41(b)(11)

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

First perceives a forced whispered voice in the better ear at not less than five feet with or without the use of a hearing aid,

or

if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to the American National Standard [formerly American Standard Association (ASA)] Z24.5--1951.

There are two organizations that set forth frequently used audiometric calibration standards, the American National Standards Institute (ANSI, S3, 6-1969) and the International Standards

Organization (ISO, 1964). Since the prescribed standard under the Federal Motor Carrier Safety Regulations is the ANSI, it may be necessary to convert the audiometric results:

  1. at 500 Hz subtract 14 dB from the ISO reading to get the ANSI reading,
  2. at 1,000 Hz subtract 10 dB from the ISO reading, and
  3. at 2,000 Hz subtract 8.5 dB from the ISO reading.

The final figure is derived by averaging the readings of the three frequencies (e.g., If the loss reading at 500 Hz is 30 dB, at 1,000 Hz is 30 dB, and at 2,000 Hz is 52 dB, the average of the three readings is 37 dB, and the driver should be qualified).

If an individual meets the criteria by using a hearing aid, the driver must wear that hearing aid and have it in operation at all times while driving. Also, the driver must be in possession of a spare power source for the hearing aid.

If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner's Certificate "Qualified only when wearing a hearing aid".

 391.41(b)(12)

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

Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who is familiar with the driver's medical history and assigned duties; and has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle.

This exception does not apply to the use of methadone.

The intent of the medical certification process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit-forming drug, it may be cause for the driver to be found medically unqualified. Motor carriers are encouraged to obtain a practitioner's written statement about the effects on transportation safety of the use of a particular drug.

A test for controlled substances is not required as part of this biennial certification process. The FMCSA or the driver's employer should be contacted directly for information on controlled

substances and alcohol testing under Part 382 of the FMCSRs.

The term "uses" is designed to encompass instances of prohibited drug use determined by a physician through established medical means. This may or may not involve body fluid testing. If body fluid testing takes place, positive test results should be confirmed by a second test of greater specificity. The term "habit-forming" is intended to include any drug or medication generally recognized as capable of becoming habitual, and which may impair the user's ability to operate a motor vehicle safely.

The driver is medically unqualified for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use. Recertification may involve a substance abuse evaluation, the successful completion of a drug rehabilitation program, and a negative drug test result. Additionally, given that the certification period is normally two years, the examiner has the option to certify for a period of less than two years if this examiner determines more frequent monitoring is required.

This is contingent on the treating/prescribing medical practitioner making a good faith judgment, with notice of the driver's assigned duties and on the basis of available medical history, that use of the substance by the driver at the prescribed or authorized dosage level is consistent with the safe performance of the driver's duties. Finally, the substance's use must be at the dosage prescribed or authorized.

 391.41(b)(13)

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

Has no current clinical diagnosis of alcoholism.

The term "current clinical diagnosis" is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition has not fully stabilized, regardless of the time element. If an individual shows signs of having an alcohol-use problem, he or she should be referred to a specialist trained to deal in such matters. After this individual has been treated and/or undergone appropriate counseling, he or she may be considered for certification.

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