3892 Federal Register / Vol. 89, No. 14 / Monday, January 22, 2024 / Rules and Regulations 

1Section 14(f) of DOT 2100.6A (Rulemaking and 

Guidance Procedures) states that it is DOT policy 

to encourage providing an opportunity for public 

comment on guidance documents, as public input 

can be very helpful in formulating and improving 

the guidance that DOT offers. 

PART 180—TOLERANCES AND 

EXEMPTIONS FOR PESTICIDE 

CHEMICAL RESIDUES IN FOOD 

■ 1. The authority citation for part 180 

continues to read as follows: 

Authority: 21 U.S.C. 321(q), 346a and 371. 

■ 2. In § 180.544, amend table 1 to 

paragraph (a)(1) by adding, in 

alphabetical order, an entry for the 

commodity ‘‘bean, mung, dry seed’’ to 

read as follows: 

§ 180.544 Methoxyfenozide; tolerances for 

residues. 

(a) * * * 

(1) * * * 

TABLE 1 TO PARAGRAPH (a)(1) 

Commodity Parts per 

million 

* * * * * 

Bean, mung, dry seed .......... 0.5 

* * * * * 

* * * * * 

[FR Doc. 2024–01015 Filed 1–19–24; 8:45 am] 

BILLING CODE 6560–50–P 

DEPARTMENT OF TRANSPORTATION 

Federal Motor Carrier Safety 

Administration 

49 CFR Part 391 

[Docket No. FMCSA–2022–0111] 

Qualifications of Drivers: Medical 

Examiner’s Handbook Regulatory 

Guidance 

AGENCY: Federal Motor Carrier Safety 

Administration (FMCSA), Department 

of Transportation (DOT). 

ACTION: Notification of regulatory 

guidance. 

SUMMARY: FMCSA announces the 

availability of the Medical Examiner’s 

Handbook (MEH), which includes 

updates to the Medical Advisory 

Criteria published in the Code of 

Federal Regulations (CFR). The MEH 

provides information about regulatory 

requirements and guidance to medical 

examiners (ME) listed on FMCSA’s 

National Registry of Certified Medical 

Examiners (National Registry) who 

perform physical qualification 

examinations of interstate commercial 

motor vehicle (CMV) drivers. The 

January 2024 edition of the MEH 

replaces all previous handbook editions. 

DATES: This guidance is applicable on 

January 22, 2024. 

FOR FURTHER INFORMATION CONTACT: Ms. 

Christine A. Hydock, Chief, Medical 

Programs Division, FMCSA, 1200 New 

Jersey Avenue SE, Washington, DC 

20590, (202) 366–4001, 

FMCSAMedical@dot.gov. If you have 

questions on viewing material in the 

docket, call Dockets Operations at (202) 

366–9826. 

SUPPLEMENTARY INFORMATION: 

I. Availability of Documents 

To view comments or any documents 

mentioned as being available in the 

docket, go to https://

www.regulations.gov/docket/FMCSA2022-0111/document and choose the 

document to review. To view 

comments, click ‘‘Browse All 

Comments.’’ If you do not have access 

to the internet, you may view the docket 

online by visiting Dockets Operations 

on the ground floor of the DOT West 

Building, 1200 New Jersey Avenue SE, 

Washington, DC 20590–0001, between 9 

a.m. and 5 p.m., Monday through 

Friday, except Federal holidays. To be 

sure someone is there to help you, 

please call (202) 366–9317 or (202) 366– 

9826 before visiting Dockets Operations. 

II. Legal Basis 

FMCSA has statutory authority under 

49 U.S.C. 31136(a)(3) and 

31149(c)(1)(A)(i)—delegated to the 

Agency by 49 CFR 1.87(f)—to establish 

regulations to ensure the physical 

condition of CMV operators is adequate 

to enable them to operate the vehicles 

safely. The guidance in the MEH and 

Medical Advisory Criteria is related to 

the physical qualification regulations 

required by those sections. 

The notice and comment rulemaking 

procedures of the Administrative 

Procedure Act (APA) do not apply to 

interpretative rules and general 

statements of policy (commonly called 

‘‘guidance’’) (5 U.S.C. 553(b)(A)). The 

MEH is a guidance document that does 

not amend any Agency regulation or 

establish any requirements for MEs or 

drivers not found in existing 

regulations. Accordingly, FMCSA was 

not required under the APA to solicit 

public comment on the MEH. 

Nevertheless, to ensure that the MEH 

provides clear, useful, and relevant 

information for stakeholders and as 

encouraged by DOT policy,1 FMCSA 

opted to make a draft of the MEH 

available for public review and 

comment (87 FR 50282 (Aug. 16, 2022)). 

Although FMCSA voluntarily provided 

an opportunity for public comment on 

the MEH, its decision to do so does not 

make applicable any of the other 

procedural requirements in the APA or 

most of the other statutes or Executive 

orders that would apply if the 

opportunity for prior notice and public 

comment were required. 

III. Background 

FMCSA’s mission is to reduce 

crashes, injuries, and fatalities involving 

large trucks and buses. A critical 

element of FMCSA’s safety program is 

ensuring CMV drivers are in adequate 

physical condition to operate the 

vehicles safely. MEs on the National 

Registry make the determination 

regarding a driver’s physical 

qualification. 

The Federal Motor Carrier Safety 

Regulations (FMCSRs), in 49 CFR 

391.41 through 391.49, provide the 

basic driver physical qualification 

standards for interstate CMV operators. 

MEs make physical qualification 

determinations on a case-by-case basis 

and may consider guidance to assist 

with making those determinations. 

FMCSA first posted the MEH to its 

website in 2008 to provide guidance to 

MEs on the physical qualification 

standards in the FMCSRs and the 

conducting of the physical qualification 

examination. FMCSA has also issued 

guidance for MEs in the form of Medical 

Advisory Criteria, now published at 49 

CFR part 391, Appendix A. However, 

FMCSA withdrew the MEH in 2015 

because some of the information was 

obsolete or was prescriptive in nature, 

and informed MEs and training 

organizations that the MEH was no 

longer in use and should not be 

considered as Agency guidance. 

FMCSA’s Medical Review Board 

(MRB) was established to provide 

FMCSA with medical advice and 

recommendations on medical standards 

and guidelines for the physical 

qualifications of CMV operators, ME 

education, and medical research (49 

U.S.C. 31149(a)(1)). The MRB, in view 

of its statutory creation and advisory 

function, is chartered by DOT as an 

advisory committee under the Federal 

Advisory Committee Act (5 U.S.C. Ch. 

10). See also Announcement of 

Establishment of the Federal Motor 

Carrier Safety Administration Medical 

Review Board (70 FR 57642 (Oct. 3, 

2005)). The Secretary appoints MRB’s 

members to reflect expertise in a variety 

of medical specialties relevant to the 

driver fitness requirements of FMCSA 

(49 U.S.C. 31149(a)(2)). 

To assist in the development of the 

MEH, FMCSA, in collaboration with its 


ddrumheller on DSK120RN23PROD with RULES1
Federal Register / Vol. 89, No. 14 / Monday, January 22, 2024 / Rules and Regulations 3893 

Chief Medical Officer, requested advice 

from the MRB for the Agency to 

consider via MRB Task Statement 17–1. 

Specifically, FMCSA asked the MRB to 

review and provide recommendations 

for streamlining the MEH. This included 

removing non-regulatory directive 

language and updating and removing 

obsolete information. At public 

meetings, the MRB discussed the 

development of the new MEH and 

Medical Advisory Criteria and reviewed 

drafts of the MEH. Details of the 

meetings, including MRB Task 

Statement 17–1, are posted on the 

Agency’s public website at https://

www.fmcsa.dot.gov/medical-reviewboard-mrb-meeting-topics. 

After consideration of the public 

comments and further internal review, 

FMCSA is now issuing a revised MEH, 

which includes updated Medical 

Advisory Criteria, with the goal of 

providing information about regulatory 

requirements and guidance for MEs to 

consider when making physical 

qualification determinations in 

conjunction with established best 

medical practices. In addition to being 

included in the MEH, the revised 

Medical Advisory Criteria are being 

published in Appendix A to 49 CFR part 

391 concurrent with this notification. 

The final version of the criteria is 

identical in both publications. 

The Agency notes that the updated 

MEH reflects the fact that medical 

certification under 49 CFR 391.64 for 

certain drivers who participated in 

FMCSA’s Vision Waiver Study Program 

is no longer available. On January 21, 

2022, FMCSA published a new 

alternative vision standard and 

eliminated physical qualification under 

§ 391.64 (87 FR 3390). As of March 22, 

2023, all Medical Examiner’s 

Certificates, Form MCSA–5876, issued 

under § 391.64 became void. FMCSA is 

aware that references to medical 

certification under § 391.64 exist in 

FMCSA’s current regulations and forms. 

The Agency plans to remove obsolete 

provisions in an upcoming technical 

amendment rule. 

IV. Comments Received 

FMCSA received 67 comments in 

response to the draft MEH from a wide 

range of commenters, including 

individuals; medical providers (such as 

MEs listed on the National Registry and 

Concentra); drivers; motor carriers 

(including owner-operators and 

Schneider National, Inc.); a patient 

advocacy group (the Alliance of Sleep 

Apnea Partners (ASAP)); safety 

advocacy groups (a joint comment was 

filed by the Truck Safety Coalition 

(TSC), Citizens for Reliable and Safe 

Highways (CRASH), and Parents 

Against Tired Truckers (PATT)); the 

National Transportation Safety Board 

(NTSB); five members of Congress who 

filed a joint comment; and additional 

associations. Specifically, the medical 

associations were the American 

Academy of Sleep Medicine (AASM), 

the American College of Occupational 

and Environmental Medicine (ACOEM), 

and the American Physical Therapy 

Association. The trade associations were 

the American Trucking Associations 

(ATA), the National Association of 

Small Trucking Companies, the 

National Beer Wholesalers Association, 

the Owner-Operator Independent 

Drivers Association (OOIDA), and the 

Truckload Carriers Association. 

The comments covered a variety of 

topics. Although the APA notice and 

comment requirements do not apply to 

guidance documents, FMCSA provides 

its responses to some of the comments 

in the interest of transparency. 

General Comments 

Some commenters wanted FMCSA to 

provide more specificity regarding 

certain types of evaluations and stated 

the draft MEH is less useful than the 

previous MEH due to its lack of 

specificity. Most of the physical 

qualification standards are broadly 

stated, and establishing specific testing 

requirements, such as methodology and 

acceptable laboratory values, would 

have to occur through rulemaking. 

Thus, FMCSA believes the level of 

specificity in the current version of the 

MEH is appropriate for a regulatory 

guidance document. 

However, FMCSA made numerous 

changes to improve the overall clarity, 

quality, and substance of the MEH based 

on suggestions from commenters. For 

example, based on comments from 

ACOEM and an individual, FMCSA 

edited several sections to emphasize 

privacy protections for the individuals 

being examined, particularly that the 

right to receive a copy of the Medical 

Examination Report Form, MCSA–5875, 

is personal to the individual and does 

not depend on who paid for or 

requested the physical qualification 

examination. In response to a comment 

from OOIDA, FMCSA also clarified 

when the individual’s consent is 

required for the ME and the employer to 

request and receive protected health 

information about the individual being 

examined. 

FMCSA incorporated a suggestion 

from OOIDA to add that individuals 

may request a second opinion and 

physical qualification examination from 

another ME if they choose but are 

expected to provide the same medical 

information to both MEs. In response to 

comments from an individual and 

ACOEM, FMCSA also stated that MEs 

should visualize the body while 

examining an individual and conduct 

an inguinal hernia examination for all 

males. 

ACOEM also asked FMCSA to clarify 

issues regarding incomplete 

examinations, and the MEH now states 

that once an ME begins an examination, 

the results must be reported to the 

National Registry even if the 

examination is not completed. At the 

request of ACOEM and two MEs, 

FMCSA clarified issues relating to the 

use of the determination pending status, 

including that it does not extend the 

expiration date of an individual’s 

current Medical Examiner’s Certificate, 

Form MCSA–5876. One commenter, 

who is both an ME and a commercial 

driver’s license holder, noted that some 

MEs do not use the most current 

versions of forms, so FMCSA clarified 

that using the current form is 

mandatory. 

FMCSA made several other revisions 

to the MEH in response to comments 

and suggestions from ACOEM. For 

example, FMCSA clarified that the 

alternative vision standard is applicable 

only if the worse eye cannot be 

corrected to meet the distant visual 

acuity standard with corrective lenses. 

FMCSA added that if the individual 

meets the vision standard while wearing 

corrective lenses, it is not necessary to 

document the distant visual acuity 

without corrective lenses. FMCSA also 

added that when it is indicated that a 

medical exemption is required, the 

Medical Examiner’s Certificate, Form 

MCSA–5876, is not valid unless the 

individual applies for and is issued the 

medical exemption from FMCSA. It was 

emphasized that MEs may certify an 

individual for less than the maximum 

period whenever they determine they 

need to monitor the individual more 

frequently. FMCSA moved the 

discussion of renal dialysis from the 

section on cardiovascular diseases to the 

section on diabetes because diabetes 

leads to a greater incidence of kidney 

disease than cardiovascular disease 

does. 

In addition, ACOEM requested that 

FMCSA establish a regular cadence for 

updating the MEH. FMCSA intends to 

update the MEH periodically. 

Concentra and ACOEM questioned 

why certain medical expert panel 

reports and other guidance were 

included in the draft MEH, while others 

were not. After reviewing the 

comments, FMCSA agrees that 

including some reports but not others 

has the potential to create confusion. 


ddrumheller on DSK120RN23PROD with RULES1
3894 Federal Register / Vol. 89, No. 14 / Monday, January 22, 2024 / Rules and Regulations 

The more recent evidence reports and 

medical expert panel reports are readily 

available on FMCSA’s website at 

https://www.fmcsa.dot.gov/regulations/ 

medical/reports-how-medicalconditions-impact-driving. Thus, 

FMCSA decided to remove references to 

these additional sources of information 

from the MEH. FMCSA notes that 

evidence reports and medical expert 

panel reports are disseminated by 

FMCSA in the interest of information 

exchange and are not official Agency 

guidance. 

FMCSA revised the sections on 

narcolepsy and idiopathic hypersomnia 

based on comments by AASM and an 

individual. FMCSA deleted the 

references to obstructive sleep apnea 

(OSA) and added that the conditions 

should be diagnosed with an overnight 

lab-based sleep study followed by a 

Multiple Sleep Latency Test the next 

morning. 

FMCSA made several changes in the 

section relating to the scheduled drug 

and alcohol standards in light of 

comments by SAPList.com. For 

example, FMCSA clarified that DOTregulated drug and alcohol testing is not 

part of the physical qualification 

examination but may be conducted 

concurrently with the examination for 

pre-employment or other authorized 

purposes. FMCSA also clarified that 

substance abuse professionals are not 

certified and not part of non-DOT drug 

testing. FMCSA also provided a more 

in-depth discussion of the intent of 

Questions 31 and 32 on the Medical 

Examination Report Form, MCSA–5875. 

Obstructive Sleep Apnea (OSA) 

Of the 67 comments received, 36 

referenced OSA. Of these, 27 

commented only on OSA. 

Several commenters, including ATA 

and OOIDA, indicated that the guidance 

in the MEH relating to OSA runs afoul 

of Public Law 113–45 (127 Stat. 557 

(Oct. 15, 2013), 49 U.S.C. 31305 note), 

which provides FMCSA may implement 

or enforce a requirement providing for 

the screening, testing, or treatment of 

CMV operators for sleep disorders only 

if the requirement is adopted pursuant 

to a rulemaking proceeding. When 

drafting the MEH, FMCSA was mindful 

of Public Law 113–45. However, Public 

Law 113–45 is not applicable here 

because the MEH offers only guidance 

and FMCSA has not adopted 

requirements regarding OSA screening, 

testing, or treatment. Because this is not 

a rulemaking proceeding, FMCSA 

cannot accommodate the requests by 

commenters that FMCSA require MEs to 

use specific, objective criteria for OSA 

screening, treatment, and treatment 

evaluation. 

FMCSA has gone to great efforts 

throughout the MEH to distinguish 

between regulatory requirements and 

non-binding guidance. The MEH states 

that MEs are free to choose whether to 

utilize guidance and recommendations 

as a basis for decision-making and that 

when the terms ‘‘recommend,’’ 

‘‘consider,’’ ‘‘may,’’ ‘‘should,’’ or 

‘‘could’’ are used in the MEH, they are 

used in a recommendatory or 

permissive sense and relate to guidance. 

In particular, the MEH states that the 

FMCSRs do not include requirements 

for MEs to screen individuals for OSA 

or to recommend that an individual be 

referred for OSA testing and do not 

include preferred diagnostic testing 

methods, treatment methods, or 

requirements by which to assess 

compliance with treatment. Instead, the 

MEH presents various considerations for 

ME when making a physical 

qualification determination. 

Several commenters, including ASAP, 

ATA, CRASH, PATT, and TSC, 

indicated FMCSA should initiate a 

rulemaking to develop specific OSA 

screening, testing, and treatment 

requirements for CMV drivers rather 

than to issue more guidance. The notice 

issued in 2017 withdrawing an advance 

notice of proposed rulemaking explains 

FMCSA’s reasons for not proceeding 

with a rulemaking on OSA (see 

Evaluation of Safety Sensitive Personnel 

for Moderate-to-Severe Obstructive 

Sleep Apnea, 82 FR 37038 (Aug. 8, 

2017)). 

Several comments were received 

regarding the link in the MEH to the 

November 21, 2016, joint MRB and 

Motor Carrier Safety Advisory 

Committee recommendations regarding 

OSA. FMCSA continues to include the 

link in the final MEH for ease of access. 

As suggested by NTSB, FMCSA added 

text to state that the joint 

recommendations includes information 

on screening and diagnosing individuals 

with moderate-to-severe OSA, and not 

just certifying such individuals. 

AASM, ASAP, OOIDA, and an 

individual questioned why the draft 

MEH included a window of 3 to 5 years 

for retesting individuals diagnosed with 

moderate-to-severe OSA treated with 

continuous positive airway pressure. 

FMCSA removed the recommendation 

of a time frame for retesting. FMCSA 

added that ‘‘untreated moderate-tosevere OSA is associated with 

cardiovascular and cerebrovascular 

morbidity, metabolic disease, and 

mortality’’ in response to a comment 

from AASM. 

AASM recommended that FMCSA 

remove ‘‘moderate-to-severe’’ from the 

statement that untreated moderate-tosevere OSA may contribute to certain 

adverse conditions because they may be 

experienced at any level of OSA 

severity. FMCSA determined that the 

focus of the guidance is appropriately 

on moderate-to-severe OSA because it is 

likely to interfere with the ability to 

control and drive a CMV safely as 

required by the applicable standard. 

Several commenters stated that MEs 

should not consider a single factor as 

being determinative with respect to 

whether an individual needs to be 

screened for OSA. FMCSA agrees and 

reiterates that the MEH provides 

guidance stating that the use of multiple 

risk factors is a reasonable approach to 

identify individuals at risk for 

moderate-to-severe OSA, rather than 

relying only on a single factor. The MEH 

guidance leaves it to the ME to 

determine whether an individual needs 

to be screened based on the individual 

circumstances. 

AASM and ASAP recommended 

adding that moderate-to-severe OSA is 

to be ‘‘adequately treated’’ or ‘‘treated 

effectively.’’ As indicated in the MEH, 

determining whether treatment is 

adequate or effective should be left to 

the ME to determine based on the 

individual circumstances. 

High Blood Pressure 

Several commenters, including 

ACOEM and Concentra, stated that the 

hypertension table from the 2013 expert 

panel recommendations titled ‘‘Medical 

Examiner Physical Qualification 

Standards and Clinical Guidelines for 

Cardiovascular Disease and Commercial 

Motor Vehicle Driver Safety’’ was vague, 

confusing, and difficult to understand. 

FMCSA agrees that the table has the 

potential to create confusion. FMCSA 

therefore decided to remove the 

hypertension table from the MEH and to 

continue the current guidance in the 

Medical Advisory Criteria. FMCSA is 

currently conducting research on this 

topic and will update the MEH based on 

the final report if warranted. 

Non-Insulin-Treated Diabetes Mellitus 

The NTSB and ACOEM stated that the 

information provided for non-insulintreated diabetes is inadequate and that 

there should be some guidance on the 

complications and co-morbidities of 

non-insulin-treated diabetes mellitus. 

FMCSA does not have a medical 

standard specific to non-insulin-treated 

diabetes mellitus, and therefore cannot 

provide the level of specificity sought 

by these commenters. 


ddrumheller on DSK120RN23PROD with RULES1
Federal Register / Vol. 89, No. 14 / Monday, January 22, 2024 / Rules and Regulations 3895 

2See section 5203(a)(2)(A) and (a)(3) of the Fixing 

America’s Surface Transportation Act, Public Law 

114–94, 129 Stat. 1312, 1535 (Dec. 4, 2015). 

However, FMCSA provided some 

additional information, including 

considerations for MEs when making a 

physical qualification determination for 

an individual with non-insulin-treated 

diabetes mellitus. In addition, FMCSA 

is in the process of seeking approval 

from the Office of Management and 

Budget for a new Non-Insulin-Treated 

Diabetes Mellitus Assessment Form. If 

approved, FMCSA will post the form on 

its website for MEs to use as a 

voluntary, optional tool to request 

additional information, with the 

individual’s consent, when making a 

physical qualification determination for 

an individual with non-insulin-treated 

diabetes mellitus. It will also update the 

MEH with this information if approved. 

Out of Scope Comments 

Some commenters requested changes 

to the MEH that are beyond the scope 

of this guidance, including some that 

would require rulemaking and changes 

to existing law. 

V. Publication of the Regulatory

Guidance

Each guidance document issued by 

FMCSA must be published on a 

publicly accessible DOT internet 

website on the date of issuance (49 

U.S.C. 113 note).2 Accordingly, in 

addition to being available in this 

docket, the MEH will be available in 

FMCSA’s Guidance Portal (https://

www.fmcsa.dot.gov/guidance) and on 

FMCSA’s website at https://

www.fmcsa.dot.gov/regulations/ 

medical/medical-regulations-andguidance-resource-links and on the 

National Registry website at https://

nationalregistry.fmcsa.dot.gov/resourcecenter. 

FMCSA expects to review the 

guidance no later than 5 years after it is 

published and will consider at that time 

whether the guidance should be 

withdrawn, reissued, or incorporated 

into FMCSA’s regulations. 

Robin Hutcheson, 

Administrator. 

[FR Doc. 2024–01056 Filed 1–19–24; 8:45 am] 

BILLING CODE 4910–EX–P 


ddrumheller on DSK120RN23PROD with RULES1