Federal Register - July 7, 2021
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Source: Federal Register
Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
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LastName, ___________
DOil: _ _ _ _ _ _ _. Examllate: _ _ _ _ _ _ _ ,
MEDICAL EXAMINER DETERMINATION Federal
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0 Does nrne!itstanl:!aids ts iecifyfeqsM - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 0:Meets standardii n 4!rCFRSl.41:.quaUftesfor 2-year certlficate
0
Me!!tsstandards, burperibdic monltoringri,:quirei:! spedfy;reason: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Driver qualified for. 0 3months 06 months O 1 year Oother specio/:c _ _ _ _ _ _ _ _ __
D Wearing cottecthlE! len DWearlng lei;ring aid DAccompanli!d by a waivetex,;mption specifytype1: - - - - - - - - -
D Accornnied.by a. !iill i>elfo.rmance EvaJuatlott SPE Certificate D Qualified byopefirtion of49 CFR91.64 WederaI;
OiMng within an exempt inttatity::tQnatee 49:CFltl!IJ,6,.li 1/ederaD
O:Determinatipnpendin9 spec/fyreasonJ; - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
0Retutntomeditalexarnofficeforfollow-uponmustbM5daysoriess;: _ _ _ _ _ _ _ __
0
ME!dlcal ExarnlnationRportamended/speci/yrWson: - - - - - - - - - - - - - - - - - - - - - - - - - , ifamenifed Medl<;alExamlnersS9nature: _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ __
Q:Jncomp.leteexamlnatfon sp,u:/fyreasonj; - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
! lftJ!.tft-,mtets ttt.stanlilr&outllno bt40RltM1rncol!lplefoaMe!llcaJExallllr C.rllilcaSl;it111I In49€11l:391.43!11,ll$approprrate.
I ha perforrnedthisevafuationtortettilication. I have personali reviewedaffailablerord,rand recorded inf0t1ttatlon pertaining toths evaluation, an.d attest that; to the best .ofmy knqwfE!dge,.1 believe it to be true and .correct.
MedtcLExamlriersSignature: ____________________
MedlcafExaminers Namej,teaseprinrortlpe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Medical ExarnirH!rs.Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City: _ _ _ _ _ _ _ _ .State: _ _ _. lii:rCoder _ _ __
M.E icalExamin.ersTefephoneNumber:.
DateCertifi.aSi911ed:. - - - - - - - - - - - - - -
Medlcaf l:xamlnersStalinse,Ctificate,or Registra,ron lllurnber: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Issuing State:._ _ _..
D MP j D!2l
DPhyskian Ai,sittartt Dthlroprattilr
D Advan,:E!d PractjceNur
Dothet Pr.iititlrWJspecilj,J; - - - - - - - - - - - - - - - - llationaReglstryNumber:: _ _ _ _ _ _ _ _ _ _ __
./v!edlcaf Examlners Certlficate Expiration Date:
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