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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1637 lnslrU<:tions for Completing the Medital EJ Personal lnforrnatic,n: Please complete this section using your name as written on your drivers license, your current address and phone number, your date of birth, age,.drivers license number and issuing state. 0 0. Driver ID Verified By; The Medical Examiner/staff completes. this item and notes the type of photo 10 Driver Health History: 0 0 0 CLP/COL Applicant/Holder. Check uyes"if you are a commerdal learners permtCLP or commercial drivers ticenseCDL holder,or are applying for a CLP or CDL CDL means a license issuedby a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicl.e CIIIV. A CMVthat requires a DL is one that: 1 has a gross combination weight rating or gross comblnationweight of26,00l pounds or more inclusive of a towed unit with a gross vehicle weight rating GVWR or gross vehicle weight GVW.of more than 10,000 pounds;or 2has a GVWR Have you ever had surgery: Pleaseheck.0 yes0 ifyou have ever: ha CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section 1 is accurate and complete. VerDate Sep<11>2014 15:58 Jul 06, 2021 Jkt 253001 PO 00000 Frm 00055 Fmt 4700 Sfmt 4725 E:FRFM07JYR1.SGM 07JYR1 ER07JY21.082 khammond on DSKJM1Z7X2PROD with RULES Page6
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Section 1: Driver Information
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used to verify the drivers identity such as, commercial drivers license, drivers license, or passport, etc.
Has your tJSDOT/FIVICSA medical certificate ever been denied or Issued for less than two ,-rs?
Please check the correct box "yes" or "no" and if you arent sure check the not sureirbox;
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c:,r .VW of 26,001 pounds or more; or 3 is designed to transport 16 or more passengers, including the driver; or 4J is used to transport either hazardous materials requiring hazardous materials.
placards on the vehicle or any quantity ofa selectagent or toxin.
1-32: Please .complete this section by checking the "yes" box to indicate that you have, or have ever had, the health condition listed or the "No box if you have not. Check the "not sure" box ifyou are unsure.
Other Health Conditions not described above: If you have,.or havehad,ahy other health conditions not listed in the section above, check"Yes"and in the box provided and listthoseconditions.
Any yes answers to questions 1-32 above: If you have answered "yes" to any of the questions fn the Driver Health History !iection above, please explain your answers further in the box below the question, For example, if you answered yes" to question 5 regarding heart disease, heart attack;
bypass, or other heart problem, indicate which type ofheartcond!tion. Ifyou checked yes" to .question 23. regarding cancer, indicate the typ.e of cancer. Please add any Information that will be helpful to the Medical Examiner.
