Medical Examination Report Form for Commercial Drivers
This file is used for the medical examination of commercial drivers. It contains sections for personal information, health history, and medical examination results. The form helps to ensure that drivers are medically fit to operate commercial vehicles safely.
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How do I fill this out?
To fill out this form, start with Section 1 by providing your personal information, including name, date of birth, and address. Next, complete the Driver Health History section by answering all relevant questions about your medical history. Finally, sign the form and submit it to your medical examiner for review.
How to fill out the Medical Examination Report Form for Commercial Drivers?
1
Provide personal information.
2
Answer health history questions.
3
Sign the form.
4
Submit to medical examiner.
5
Medical examiner completes the examination section.
Who needs the Medical Examination Report Form for Commercial Drivers?
1
Commercial drivers who need to renew their medical certification.
2
New commercial driver's license (CDL) applicants.
3
Drivers who have been diagnosed with a new medical condition.
4
Drivers returning to work after a medical leave.
5
Drivers required to undergo periodic medical assessments.
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1
Open the PDF in PrintFriendly's editor.
2
Enter your personal information and health history.
3
Make any necessary changes to the text and checkboxes.
4
Use the signature tool to sign the form.
5
Save and download the edited PDF.
What are the instructions for submitting this form?
Submit the completed form to your medical examiner. You can either email or fax it to the examiner's office or submit it physically during your appointment. Always ensure that every section is accurately filled out and signed.
What are the important dates for this form in 2024 and 2025?
Key dates for this form include the expiration date of your current medical certificate and the date of your next required medical examination in 2024 or 2025.
What is the purpose of this form?
The purpose of this form is to assess the medical fitness of commercial drivers. It ensures that drivers meet the necessary health standards to operate commercial vehicles safely. By completing this form, drivers and medical examiners contribute to the overall safety of road transportation.
Tell me about this form and its components and fields line-by-line.
- 1. Last Name: The driver's last name.
- 2. First Name: The driver's first name.
- 3. Middle Initial: The driver's middle initial.
- 4. Date of Birth: The driver's date of birth.
- 5. Street Address: The driver's street address.
- 6. City: The city where the driver resides.
- 7. State/Province: The state or province where the driver resides.
- 8. Driver's License Number: The driver's license number.
- 9. Issuing State/Province: The state or province that issued the driver’s license.
- 10. Phone: The driver's phone number.
- 11. E-mail (optional): The driver's email address.
- 12. CLP/CDL Applicant/Holder: Indicates whether the driver is a CLP/CDL applicant or holder.
- 13. Driver ID Verified By: The type of photo ID used to verify the driver's identity.
- 14. Medical Record Number: The medical record number, if applicable.
- 15. Age: The driver's age.
- 16. Zip Code: The zip code of the driver's residence.
- 17. Gender: The driver's gender.
- 18. Driver Health History: Section for the driver to provide information about their health history.
- 19. CMV Driver's Signature: The driver's signature certifying the accuracy of the information provided.
- 20. Exam Date: The date the medical examination was conducted.
- 21. Pulse Rate: The driver’s pulse rate.
- 22. Pulse Rhythm Regular: Indicates whether the driver's pulse rhythm is regular.
- 23. Height: The driver's height.
- 24. Weight: The driver's weight.
- 25. Blood Pressure: The driver's blood pressure readings.
- 26. Urinalysis: Results of the driver’s urinalysis.
- 27. Vision: Results of the driver’s vision test.
- 28. Hearing: Results of the driver’s hearing test.
- 29. Physical Examination: Details of the physical examination conducted by the medical examiner.
What happens if I fail to submit this form?
If you fail to submit this form, you may be unable to obtain or renew your medical certification, which is required to operate commercial vehicles.
- Medical Certification: Without this form, you cannot receive your medical certification.
- Employment Impact: Your employment may be affected if you are unable to operate a commercial vehicle.
- Legal Compliance: Failure to submit the form may result in non-compliance with federal regulations.
How do I know when to use this form?
- 1. New CDL Application: For new applicants seeking a commercial driver's license.
- 2. CDL Renewal: For current CDL holders renewing their medical certification.
- 3. Medical Condition Update: For drivers reporting a new medical condition.
- 4. Post-Medical Leave: For drivers returning to work after a medical leave.
- 5. Periodic Assessment: For drivers required to undergo regular medical evaluations.
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