FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION

FMCSA Contact: Sandra Zywokarte, MC-PSD, (202) 366-2987

Qualifying Individuals with 

Insulin-Treated Diabetes to Operate

Commercial Motor Vehicles

Introduction

The Transportation Equity Act for the 21st Century directs the U.S. Department of

Transportation (DOT) to determine whether it is feasible to develop a safe and 

practical protocol to allow individuals with insulin-treated diabetes mellitus to operate

commercial motor vehicles in interstate commerce. This Tech Brief summarizes the

resulting report, which was submitted to Congress by the Federal Motor Carrier Safety

Administration (FMCSA), formerly the Office of Motor Carriers in the Federal Highway

Administration (FHWA), in August 2000. The report is available at

http://www.fmcsa.dot.gov/rulesregs/medreports.htm.

Background

Current law prohibits insulin-treated diabetics from driving commercial motor vehicles

(i.e., large trucks and motorcoaches) in interstate commerce. The Agency established

that standard in 1970 in response to several studies that indicated that diabetic drivers

had a higher rate of involvement in accidents than the general driving population. In

1977 the Agency solicited comments on a proposed change to the diabetes standard,

but maintained the prohibition after considering comments and literature citing 

highway safety concerns.

Diabetes Waiver Program

In 1986 the American Diabetes Association and others petitioned the Agency to grant

waivers to qualified insulin-treated diabetics on a case-by-case basis. The Agency 

solicited comments and conducted extensive research on the proposal, including 

convening a conference to review the diabetes standard. Conference participants 

recommended that some drivers with diabetes be certified to drive, depending on their

insulin use and certain conditions, including whether they had safe driving records. 

In 1990 the Agency requested comments on a proposal to allow insulin-treated 

diabetics to drive commercial motor vehicles if they met certain criteria and 

were found to be qualified by an

endocrinologist. The Agency also 

sponsored a risk assessment study and

requested comments on a proposed

waiver program to collect data to be

used in updating the diabetes standard. 

A diabetes waiver program began in

1993. The program originally was 

developed as part of a research study 

Tech Brief

The goal of the Federal Motor

Carrier Safety Administration

(FMCSA) is to reduce the 

number and severity of large

truck- and bus-involved 

crashes through more 

commercial motor vehicle 

and operator inspections and 

compliance reviews, stronger

enforcement measures 

against violators, expedited

completion of rulemaking proceedings, scientifically sound

research, and effective commercial driver’s license testing,

recordkeeping, and sanctions.

The Office of Research and

Technology (R&T) manages

research and technology

development and deployment

programs for the FMCSA.

FMCSA R&T activities 

encompass a range of issues

and disciplines relating to

motor carrier safety, including

problem assessment; policy,

safety management, and 

outreach; drivers; truck 

and bus vehicle safety 

performance; and compliance,

enforcement and operations.

Driver physical qualifications

concentrates on the research

of specific medical conditions

in relation to commercial

motor vehicle driving safety,

with emphasis on medical

standards guidelines. 

Office of Research and Technology

400 Virginia Avenue, SW

MC-RT, Suite 600

Washington, DC 20024
to investigate if insulin-treated diabetic drivers admitted to the program could safely operate commercial

motor vehicles. Under the program, the waivers

would last for 3 years—or until resolution of the 

concurrent rulemaking action—whichever occurred

first. The waiver program required each participating

driver to have at least 3 years of recent commercial

driving experience while using insulin, a safe driving

record, and a certification by an endocrinologist and

an ophthalmologist.

In 1996 the District of Columbia Court of Appeals, in

Advocates for Highway and Auto Safety v. Federal

Highway Administration, ruled that the Agency’s

vision waiver program, which used an approach 

similar to the diabetes program to qualify drivers, 

was contrary to law. As a result the diabetes waiver

program was terminated. Drivers with diabetes

waivers at the end of the program were allowed to

continue to operate commercial motor vehicles in

interstate commerce under “grandfather” provisions. 

Purpose

The report determines whether it is feasible to 

develop a safe and practical protocol to allow insulintreated diabetics to operate commercial motor 

vehicles in interstate commerce. 

Methodology

To evaluate the feasibility of allowing insulin-treated

diabetics to operate commercial motor vehicles, the

Agency:

• reviewed relevant background material and 

literature, 

• studied related policies of other DOT 

administrations and States,

• analyzed recent risk assessments, and 

• convened a panel of medical experts. 

Background Research and Literature Review

The Agency conducted background research on the

risk of driving with diabetes. The evidence collected

in earlier studies on the relationship between 

diabetes and automobile crashes had produced 

conflicting results, in many cases due to flawed

methodology. Further, none of the studies addressed

the operation of commercial motor vehicles. Upon

the termination of the waiver program and its

research component, the Agency lacked clear risk

assessment information.

A literature review on the treatment and 

management of insulin-treated diabetes focused on

six reported studies and revealed positive findings.

The two largest and most reported studies—The

Diabetes Control and Complications Trial, and the

United Kingdom Prospective Diabetes Study 

Group—represented the most extensive 

investigations of insulin therapy. Both studies found

that patients experienced reductions in blood 

glucose levels and significantly fewer microvascular

complications (i.e., related to small blood vessels) 

with intensive treatment. However, the two studies

also showed significant adverse effects from 

insulin use, notably a significantly higher rate of

hypoglycemia (i.e., an abnormal decrease of sugar 

in the blood). 

Policies of Other Federal Agencies

Of the other DOT agencies, only the Federal Aviation

Administration (FAA) has a well-developed program

regarding insulin-treated diabetes. In 1994 the FAA

determined that selected insulin-treated diabetics can

be considered for special issuance of a third-class

Airman Medical Certificate under a screening, 

glucose management, and monitoring protocol. The

program developed through a series of steps in 

which the FAA capitalized on its experience, reviewed

relevant research, consulted medical experts, and 

considered comments from the public and interested

organizations.

States and Insulin-Treated Diabetic Drivers

The Agency examined how States regulate insulintreated diabetic drivers. States are permitted to

choose whether to apply Federal regulations to the

medical qualifications for intrastate commercial 

drivers. Some States have chosen to adopt the Federal

standards and not allow insulin-treated diabetics to

operate commercial motor vehicles. Some States have

given “grandfather” rights to insulin-treated diabetic

drivers who were already driving intrastate, while

allowing no new drivers after a certain date. Other

States have programs to allow drivers to apply to

operate in intrastate commerce. Among the States

that allow some insulin-treated diabetics to drive

commercial motor vehicles, the monitoring of the 

drivers varies widely.
Risk Assessments

The report presents four recent risk assessment 

studies that address diabetes and the operation of

commercial motor vehicles:

• two Canadian studies analyzing insurance data for

a group of truck drivers, 

• an FHWA study analyzing data from the diabetes

waiver program, and

• an FMCSA study analyzing insulin-treated diabetic

drivers of large trucks and a comparison group of

drivers with commercial licenses. 

The first study, in which insulin use was not 

considered, analyzed insurance data for 1,307 truck

drivers and found that diabetic drivers of large 

combination trucks did not have higher accident 

rates than their non-diabetic counterparts. However,

that study found a significantly higher accident rate

for diabetic drivers of smaller trucks than for their 

non-diabetic counterparts. The second Canadian 

study used the same database and concluded that

diabetic drivers did not have accidents that were 

significantly more severe (measured in injuries and

fatalities) than non-diabetic drivers. The third study

re-analyzed data from the FHWA waiver program to

address earlier criticism about possible bias when the

drivers in the program were compared to national

data. The analysis showed that the accident rate of

the waiver program drivers was the same as the

national rate. The last study examined 723 insulintreated diabetic drivers of large trucks and a 

comparison group of 1,297 drivers with commercial

driver’s licenses. The results, after adjustment for 

confounding effect (i.e., variation related to the 

independent and dependent variables), showed no

significant differences between the two groups in 

the rate or severity of accidents. 

Expert Medical Panel

In 1999 the Agency convened a panel of experts in

the treatment of diabetes. The panel addressed the

screening and monitoring issues associated with a

program allowing insulin-treated diabetics to operate

commercial motor vehicles. In its written reports and

discussion at a meeting in Washington, DC, the 

panel suggested that advances in the treatment of

diabetes make it possible to control the disease and

identify individuals who are capable of doing so. 

The panel identified methods to avoid acute 

complications, including hypoglycemia, and endorsed

a protocol for monitoring glucose before and 

during the operation of a commercial motor vehicle.

The panel concluded that from a medical standpoint it is feasible to permit some individuals with

insulin-treated diabetes to operate commercial 

motor vehicles. 

Findings and Recommendations

The report concludes that it is feasible to develop 

a safe and practicable protocol to allow some 

insulin-treated diabetics to operate commercial 

motor vehicles. Research on the treatment and 

management of insulin-treated diabetes, combined

with the determination of the medical panel, 

indicate that the disease and its adverse effects 

can be successfully controlled and monitored.

Moreover, recent risk assessments provide evidence

that diabetic commercial drivers can perform in an

acceptably safe manner. Finally, the FAA program 

and the re-analysis of the FHWA’s diabetes waiver

program demonstrate that it is possible to screen 

and monitor insulin-treated diabetics so that safe 

performance is feasible.

Based largely on the experience of the FAA and

FHWA, a viable program for allowing individuals with

insulin-treated diabetes to drive commercial motor

vehicles must have three components: 

1. a screening component to identify qualified 

applicants that would examine the applicants’

experience and safety in operating commercial

motor vehicles with insulin-treated diabetes, their

history of hypoglycemia, and the results of 

examinations by endocrinologists and 

ophthalmologists; 

FMCSA’s proposed exemption process would evaluate insulintreated diabetic truck drivers on a case-by-case basis.
Researcher

The report was prepared by

Conwal, Inc.

6858 Old Dominion Drive, 

Suite 200

McLean, VA 22101

Contract No: DTFH61-92-Z-00158

Distribution

This Tech Brief is distributed

according to a standard 

distribution. Direct distribution 

is made to the Service Centers 

and Divisions.

Availability

The report is available on the

FMCSA Web site at

http://www.fmcsa.dot.gov/rules

regs/medreports.htm.

Key Words

diabetes, commercial motor 

vehicle, driver, insulin, waiver

Notice

This Tech Brief is disseminated

under the sponsorship of the U.S.

Department of Transportation

(DOT) in the interest of 

information exchange. The Tech

Brief provides a synopsis of the

report: it does not establish 

policies or regulations, nor does 

it imply DOT endorsement of the

conclusions or recommendations.

The U.S. Government assumes 

no liability for its contents or 

their use.

Web Site

All FMCSA Tech and Analysis

Briefs are available on the 

FMCSA Web site at

http://www.fmcsa.dot.gov/

safetyprogs/research/research

pubs.htm. 

Technical Writer

Wendy Grzywacz, Avalon

Integrated Services.

2. guidelines for drivers for the management of insulin-treated diabetes, including

maintaining appropriate supplies and monitoring safe blood glucose levels; and 

3. a specific process to be used for monitoring insulin-treated diabetic drivers, 

including the required medical examinations and their submission requirements, 

how to take and review glucose measurements, and how to report episodes of

severe hypoglycemia and accidents.

Assessment of Legal Issues

The report addresses the legal consequences of permitting insulin-treated diabetics to

drive commercial motor vehicles in interstate commerce. Such a rule would be subject

to a challenge of its validity, and tort liability for damages sustained in an accident

involving an insulin-treated diabetic driver. However, these consequences are similar 

to those associated with any other rule involving driver standards and qualifications.

For employers who hire insulin-treated diabetic individuals, the rule might expose 

them to new standards of responsibility for monitoring the health of drivers meeting

Federal guidelines.

New Developments

On July 31, 2001, the FMCSA published a Federal Register notice seeking comments on

an exemption process to allow certain insulin-treated diabetic drivers to operate 

commercial motor vehicles in interstate commerce. Federal law (49 U.S.C. 31315 and

31136(e)) permits the Agency to grant an exemption from the diabetes standard if it is

likely to achieve an equivalent or greater level of safety than without the exemption. 

Under the proposal, the Agency would implement an exemption process using 

case-by-case evaluations, similar to the vision exemption process. Federal diabetes 

requirements would not be amended. The process would consist of three parts. First, 

a screening component would identify qualified applicants after examining their 

experience and safety operating commercial motor vehicles with insulin-treated 

diabetes, any history of hypoglycemia, and medical exam results. Second, the Agency

would provide guidelines to drivers for managing their diabetes, including appropriate

supplies and protocol. Finally, the Agency would specify the process for monitoring

insulin-treated commercial drivers, including required medical exams and submission

requirements, how to take and review glucose measures, and how to report episodes

of severe hypoglycemia and accidents.

Reference

A Report to Congress on the Feasibility of a Program to Qualify Individuals with Insulin

Treated Diabetes Mellitus to Operate Commercial Motor Vehicles in Interstate

Commerce as Directed by the Transportation Equity Act for the 21st Century. FMCSA,

Washington, DC, July 2000.

November 2001

Publication No. FMCSA-MCRT-02-001