Medical Examiners Certificates - Free Download
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Medical Examiners Certificates
Medical Examiner’s Certificates
2 Examples of the most commonly submitted medical examiners certificates
Example 1 a one part medical examiner’s certificate
MEDICAL EXAMINER’S CERTIFICATE
(A)
I certify that I have examined ______________ in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391 41-391.49) and with
knowledge of the driving duties, I find this person is qualified; and , if applicable only when:
(B) wearing corrective lenses driving with an exempt intracity zone (49 CFR 391.62)**
wearing hearing aid accompanied by a Skill Performance Evaluation Certificate (SPE)*
accompanied by a ___waiver/exemption* qualified by operation of 49 CFR 391.64**
Signature of Medical Examiner
(C)
Telephone
(D)
Date
(E)
Medical Examiner’s Name (Print)
(F)
(G)
MD DO Chiropractor
Physician’s Assistant Advance Practice Nurse
Medical Examiner’s License Certificate No./Issuing State
(H)
Signature of Driver
(I)
Driver’s License NO.
(J)
Address of Driver
(L)
Medical Certificate Expiration Date
(M)
Example 2 a two part medical examiner’s certificate both parts must be submitted to be valid
MEDICAL EXAMINER’S CERTIFICATE
(A)
I certify that I have examined ______________ in accordance with the Federal
Motor Carrier Safety Regulations (49 CFR 391 41-391.49) and with knowledge
of the driving duties, I find this person is qualified; and , if applicable only when:
(B)
wearing corrective lenses
wearing hearing aid
accompanied by a____
waiver/exemption*
driving with an exempt intracity zone
(49 CFR 391.62)**
accompanied by a Skills Performance
Evaluation Certificate (SPE)*
qualified by operation of 49 CFR
391.64**
The information I have provided regarding this physical examination is true and
complete. A complete examination form with any attachment embodies my findings
completely and correctly, and is on file in my office.
Medical Examiner Signature
(C)
Date
(E)
Medical Examiner Name (Print)
(F)
(G)
MD DO Chiropractor
Physician’s Assistant
Advance Practice Nurse
Medical Examiner License or Certification No./Issuing State
(H)
Phone No.
(D)
Driver Signature
(I)
Driver Address
(L)
Driver License No
(J)
State
(K)
Medical Certification Expiration Date
(M)
All fields must be legible and completed by the appropiate person
(A) - CDL holders name
(E) date of the examination
(B) medical examiners certificate must include all 6 boxes
to be valid
*if checked, submit waiver/exemption or SPE along with the
medical examiner’s certificate
**if checked, medical examiner’s certificate can only be
valid for 1 year from the examination date
(C) - medical examiner who completes the exam must sign
(F) medical examiner’s name must be legible
(G) indicates the type of medical examiner who
performed the examination, one box must be
checked
(H) must be legible and complete
(I), (J), (K) and (L) to be completed by the CDL holder
(M) cannot be valid for more than 2 year from
the examination date
(C) must have medical examiner’s complete telephone
number, including area code
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