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###### Department of Transportation

###### Federal Motor Carrier Safety Administration 

          - 49 CFR Part 391 
          - [FMCSA Docket No. 98-3542 (formerly FHWA Docket No. 98-3542)] 
          - RIN 2126-AA06 (formerly 2125-AC63) 

# AGENCY:

Federal Motor Carrier Safety Administration (FMCSA), DOT. 

# ACTION:

Final rule. 

# SUMMARY:

This document updates and simplifies the medical examination form that is currently used to determine the physical qualification of commercial motor vehicle (CMV) drivers operating in interstate commerce. The FMCSA takes this action in response to numerous requests from medical examiners to update and simplify the medical examination form that is currently used. This action is intended to reduce the incidence of errors on such forms and to provide more uniform medical examinations of CMV drivers engaged in interstate commerce. The current Federal physical qualification standards tested by medical examiners and recorded on the form will not be revised in this rulemaking. 

# DATES:

November 6, 2000. 

# FOR FURTHER INFORMATION CONTACT:

For information about the rulemaking, Ms. Sandra Zywokarte, Office of Bus and Truck Standards and Operations, (202) 366-2987; for information about legal issues related to this notice, Ms. Judith Rutledge, Office of the Chief Counsel, (202) 366-2519, FMCSA, Department of Transportation, 400 Seventh Street, SW., Washington, DC 20590. Office hours are from 7:45 a.m. to 4:15 p.m., e.t., Monday through Friday, except Federal holidays. 

# SUPPLEMENTARY INFORMATION:

## Electronic Access 

                    An electronic copy of this document may be downloaded using a computer, modem and suitable communications software from the Government Printing Office's Electronic Bulletin Board Service at (202) 512-1661. Internet users may reach the Office of the                     **Federal Register's**                     home page at:                     *http://www.nara.gov/​fedreg*                     and the Government Printing Office's web page at                     *http://www.access.gpo.gov/​nara.*

## Background 

The authority to require medical certification of CMV driver qualification was originally granted to the Interstate Commerce Commission (ICC) in the Motor Carrier Act of 1935. The authority was transferred to the DOT in 1966 and is currently codified at 49 U.S.C. 31502(b). On October 9, 1999, the Secretary of Transportation transferred the motor carrier safety functions performed by the Federal Highway Administration (FHWA) to the Office of Motor Carrier Safety, a new office created in the DOT. This transfer was performed pursuant to section 338 of the DOT and Related Agencies Appropriations Act, 2000, Public Law 106-69, 113 Stat. 986, as amended by Public Law 106-73, 113 Stat. 1046. The Motor Carrier Safety Improvement Act of 1999, Public Law 106-159, 113 Stat. 1748, transferred the functions to the Federal Motor Carrier Safety Administration (FMCSA). As a result of the transfer of functions, the FMCSA now administers the driver physical qualification standards and examinations in 49 CFR Part 391. 

The first physical qualification standard for CMV drivers was published by the ICC in 1939. It required a driver to have the following minimum qualifications: 

Good physical and mental health; good eyesight; adequate hearing; no addiction to narcotic drugs; and no excessive use of alcoholic beverages or liquors. 

Over the next three decades, other physical qualification regulations were promulgated by the ICC, but most were not clearly defined until 1970, after the creation of the DOT. On April 22, 1970 (35 FR 6458), the existing physical qualification requirements were substantially tightened, based upon discussions with our agency's medical advisors. This rule required a driver to have a physical examination every 2 years, included guidelines for evaluation of persons in high-risk medical categories, and provided that the examining physician be given full information about the responsibilities of and the exacting demands made on CMV drivers. There have been no major changes since then. 

## Current Medical Examination Form 

The current form, at 49 CFR 391.43(f), has remained unchanged since it was adopted by the DOT in 1970. As a result, our agency has received numerous requests to make changes to the current medical examination form. Physicians and other medical providers have indicated that the format, layout and content of the current form are outdated, difficult to use, or irrelevant. 

Additionally, substantial changes in medical technology and the technology, operating practices, and economics of the motor carrier industry have affected the lifestyles of and, therefore, the physical and mental demands placed on CMV drivers. Having agreed that the current medical form is outdated and its continued use problematic, we decided to initiate rulemaking to revise the form. 

## Medical Examination Form Revision Process 

We contracted with the Association for the Advancement of Automotive Medicine (AAAM) to review and evaluate the current form and develop a revised form. The process was defined and limited by several norms. The underlying physical qualification standards tested by medical providers and recorded on the form would not be revised in this rulemaking. In addition, the instructions for performing and recording physical examinations found in 49 CFR 391.43 would be revised only to the extent necessary to ensure that instructions to medical examiners are understandable and consistent with the information provided on the proposed medical examination form and guidance materials established by us for medical examiners. 

To ensure that the revised form reflected the most current medical concepts and was responsive to the needs of the groups using the forms, the AAAM convened a working group to serve as reviewers of the draft form. The review panel members included two occupational health physicians, a motor carrier, two State motor vehicle administration officials and our agency representatives. A second draft of the form was then submitted to a correspondence advisory group, providing a more comprehensive review process. This larger group of reviewers was made up of medical providers, motor carriers, State motor vehicle agency representatives, Canadian motor transport officials, our agency field staff, and other interested groups. 

## Revised Medical Examination Form 

The revised form, modeled after physical examination forms in use today, has been organized to (1) gain simplicity and efficiency, (2) reflect current medical terminology and examination components and (3) be a self-contained document (i.e., the form will, to the extent possible, include all relevant information necessary to conduct the physical examination and certification). 

                    Consistent with accepted practices regarding the order of the examination, the first section of the examination form is completed by the driver. This section requests information on the driver's                           ( print page 59364)                        health history, seeking “yes” or “no” answers to a variety of medical condition questions. Any “yes” response requires further clarification by the driver. Once this section is completed, the driver is required to sign the form, affirming that all the information contained in this section is accurate and complete. An additional statement indicates that inaccurate, false, or missing information may invalidate both the examination and any Medical Examiner's Certificate issued based on it.                 

The second section of the examination form covers the physical examination and tests that are performed by the medical examiner. The medical examiner is provided information on both the relevant Federal physical qualification standards and the tests required to measure compliance with those standards. The Federal standards and guidelines for evaluation of a driver's vision, hearing, and blood pressure are included in this section of the form, thereby reducing the potential for errors by the medical examiner. 

Unlike the current physical examination form, the revised form clearly indicates when numerical readings must be recorded. Space is also provided on the form for recording any optional tests which the medical examiner considers necessary to evaluate a driver's physical qualification. 

A full page of the revised form is devoted to instruction and recordation of the medical examiner's findings. The medical certificate is also provided, and must be completed by the medical examiner if he or she finds that the driver meets all the Federal physical qualification requirements. 

The third section of the revised form not only sets forth the Federal physical qualification standards found at 49 CFR 391.41, but also contains more detailed information for the medical examiner regarding the driver's role and the types of duties he or she may face as a result of his or her employment. This section also contains the agency's guidelines to help medical examiners assess a driver's physical qualification. These guidelines are strictly advisory and were established after consultation with physicians, States, and industry representatives. 

In addition to the revisions to 49 CFR 391.43 in the final rule, we are making technical corrections to paragraphs (d) and (g) of that section, to paragraphs (b)(1) and (b)(2)(ii) under § 391.41 and paragraph (d)(2) under § 391.49. 

The FMCSA's primary concern is to enhance highway safety, rather than to unnecessarily limit employment opportunities for individuals with physical impairments. The intent of the final rule is to facilitate medical providers' efforts to establish and document the physical qualification of a driver to operate a CMV by promoting reliable and understandable determinations of medical qualification. 

## Comments 

On August 5, 1998, we published an NPRM rulemaking (63 FR 41769) seeking comments on our proposed medical examination form. We invited individuals, medical providers, motor carriers, and other interested parties to provide comments on how to improve our proposed examination form and instructions for performing and recording physical examinations. Forty-six public comments addressing the notice were received and have been considered in our final decision to amend Federal regulations governing the examination to determine the physical qualification of CMV drivers engaged in interstate commerce. 

We received comments from 23 physicians, 8 employers of truck drivers, 4 State motor vehicle administrations, 1 State enforcement agency, 1 Canadian motor vehicle agency, 3 trucking associations, 1 motor coach association, 1 trade association, 1 nursing association, 1 medical association and 2 advocacy groups. The majority of the comments supported the proposed medical examination form with suggestions for additions and deletions to the form. One comment completely opposed the proposal. Some comments offered suggestions for additions or deletions without indicating support for the form. Others suggested changes to the Federal physical qualification standards tested by medical examiners and recorded on the form. 

Although most comments were generally supportive, a number of comments strongly opposed providing space on the proposed form for recording the results of such optional tests as an electrocardiogram (ECG) and exercise stress test (EST). Still others expressed concerns that the form has too many pages. These comments and others will be discussed in detail below by section, and in accordance with the order of the examination. 

## Discussion of Comments 

### Driver's Information 

                    Comments directed to this section of the examination form suggested format changes for recording and denoting certain information on the form. The FMCSA has considered these comments and modified the form as follows: The format for recording the date of birth on the form will show month, day and year and the area code will be denoted by parentheses. The agency has also added another category,                     *other*, to the area on the form denoting the class of license held by the driver. This change is provided to accommodate non-CDL licensed drivers.                 

### Health History 

This section of the form received a number of comments suggesting additions or deletions of information and changes to the format. The Alabama Power Company, J.B. Hunt Transport, Inc., the Maryland Motor Vehicle Administration, the Wisconsin Department of Transportation and the Ministry of Transportation and Highways in British Columbia expressed support for the inclusion of a driver certification statement affirming that the information provided by the driver is accurate and complete. The American Association of Occupational Health Nurses (AAOHN) and the Maryland Motor Vehicle Administration indicated that the agency's statement that encourages the medical examiner to discuss health history information with the driver is not strong enough and the discussion should be required. Dr. Ellison Wittels commented that “the medical examiner needs to comment on any “yes” answer and address the severity of the problem.” Comments from Dr. Wittles and the AAOHN indicated that more space should be allotted for the medical examiner's review of the health history. Dr. John A. Hansen agreed that there is inadequate space on the proposed form for the medical examiner's “impression and opinion,” and indicated that too much space is allocated to driver's comments and the listing of their medications. In fact, Dr. Hansen suggests that, in general, the format of the proposed form is “excessive.” 

The American College of Occupational and Environmental Medicine (ACOEM) believes that the “expanded medical history section assists the [medical] examiner in making a thorough evaluation,” but questions whether any of the conditions listed in the health history are likely to interfere with the driver's ability to safely operate a CMV. The ACOEM also expressed concerns over the potential for breaching confidential medical information. 

                    The Owner Operator Independent Drivers Association, Inc., (OOIDA) an international trade association representing the interests of independent owner-operators and                           ( print page 59365)                        professional truck drivers, supports the overall goals of the proposal. However, the OOIDA raised concerns regarding the amount and relevancy of information solicited under the health history section and the confidentiality of medical information of drivers. The OOIDA believes that vague terminology and a lack of understanding of medical terms and conditions on the part of drivers will unjustly result in a driver being determined medically unqualified. Therefore, the OOIDA suggests that the medical examiner complete the health history section. The OOIDA also expressed concern that information in this section which it views as “unnecessary and irrelevant” would be used by employers for purposes other than the intended medical certification. Finally, the OOIDA opposes the requirement for a driver certification statement suggesting that such a requirement will not prevent drivers from falsifying or omitting information if a “yes” response would result in the driver being found medically unqualified.                 

The AHAS commented that the “FHWA could significantly improve highway safety by promoting increased definitive diagnoses and treatment of apnea” and noted that “many preliminary diagnoses of apnea are made on the basis of selfreport.” The FMCSA believes the information on sleep disorders in this section will help elicit information from the driver regarding any history of sleep disorders and thereby, facilitate the identification and treatment of such disorders. 

The FMCSA has considered the comments to this section and modified the form as follows: The two questions regarding hospitalization and serious illness in the last 5 years have been combined into one question that reads: “any illness or injury in the last 5 years.” A box has been added to indicate when medications are taken for nervous or psychiatric disorders. The section on sleep disorders was modified to include “pauses in breathing while asleep” and to substitute “loud snoring” for severe snoring. The term “severe” has been dropped from the health history because it is too subjective. Under the section on diabetes, the term “pills” was substituted for “medication.” The condition “pleurisy” has been deleted from the form because it is non-specific and non-discriminating. 

The format for this section has been modified to increase the space allotted for the medical examiner's comments. As a result, the space allocated for the driver's comments has been reduced. The statement encouraging the medical examiner to discuss the health history with the driver has been modified and expanded to address the use of prescription and over-the-counter medications. The statement now reads: the medical examiner must review and discuss with the driver any “yes” answers and potential hazards of medications, including over-the-counter medications, while driving. 

The FMCSA's modification of the information in the health history is limited because this information has previously been subject to several levels of review and subsequent changes by the medical community and other interested groups. 

Although the health history section has been expanded, the FMCSA believes that this information is necessary and relevant. Having this information will assist the medical examiner in conducting a thorough evaluation and facilitate the determination as to the likelihood that an individual has a condition that would interfere with the safe operation of a CMV. 

The FMCSA agrees with the comments that the confidentiality of medical information is an important issue and takes the position that medical information is best maintained by the medical examiner. In fact, the Medical Examiner's Certificate at 49 CFR 391.43(h) carries a statement indicating that the completed medical examination is on file in the office of the medical examiner. Although the FMCSRs do not require that the completed medical examination form be provided to the employer, the FMCSA does not prohibit employers from obtaining copies of the form. The FMCSA does not believe this is a problem since employers must comply with applicable State and Federal laws regarding the privacy and maintenance of employee medical information. 

The agency maintains that the driver certification statement requirement would discourage an individual from omitting or falsifying information as someone is likely to pause and consider his/her action before signing such a statement. This is especially so since the deliberate omission or falsification of information may invalidate the examination and any Medical Examiner's Certificate issued based on it. 

The agency did not adopt the suggestion of one comment to allow medical examiners to complete the health history since this is not the usual process for completion of a health history. However, to ensure involvement by the medical examiner, the FMCSA has made the review and discussion of any “yes” responses with the driver mandatory. 

### Testing: Vision and Hearing 

The majority of comments to this section were suggestions for amending the actual vision and hearing standards which is beyond the scope of this rulemaking. The FMCSA will consider these comments in its ongoing review of physical qualification requirements and in any future rulemakings to amend the standards under § 391.41. The agency is considering, under a separate notice, a rule change regarding field of vision, an area of concern raised in several of the comments. This proposed change is based on a recent review and the recommendations from an expert panel of ophthalmologists. (See Frank C. Berson, M.D., Mark C. Kuperwaser, M.D., Lloyd Paul Aiello, M.D., and James W. Rosenberg, M.D., “Visual Requirements and Commercial Drivers,” October 16, 1998, filed in the docket.) 

The FMCSA has considered the comments to these sections and modified the form as follows: A single box designating “corrective lens” has been added to the form. The four boxes designating “glasses”, “contact lenses”, “right lens” and “left lens” on the proposed form have been deleted. Several comments indicated confusion over which box to check if an individual wore both glasses and contact lenses. The word “individual” has been substituted for the word “patient” under the section for recording numerical readings for hearing testing. 

### Testing: Blood Pressure/Pulse Rate 

There were relatively few comments on this section and the majority of them focused on the need for additional space on the form. Several comments suggested the need for additional space on the form to record both the pulse rate and the quality of the pulse. Other comments suggested space for recording the second reading of the blood pressure since the instructions indicate that the medical examiner should take at least two readings to confirm an individual's blood pressure. Finally, two comments suggested changes to the recommended thresholds for acceptable blood pressures. 

                    The FMCSA has considered the comments to this section and modified the form as follows: The space allocated for the pulse rate has been enlarged to accommodate the recording of both the pulse rate and the quality of the pulse. The recommendation for space for recording a second blood pressure reading was not adopted because the medical examiner is not limited to just two readings and the possibility exists                           ( print page 59366)                        that several readings may be necessary to establish a fixed blood pressure. Only the fixed blood pressure should be recorded on the form. Any change to the threshold value for an acceptable blood pressure is outside the scope of this rulemaking. The FMCSA is considering a review and update of its recommendations regarding blood pressure.                 

### Testing: Laboratory and Other Test Findings 

This was clearly one of the most commented on sections in the proposal. The majority of the comments were opposed to including space on the form for recording the optional tests, ECG and EST. Those opposing or having serious concerns over this issue include: the ATA, the OOIDA, the National Automobile Dealers Association, the Georgia Motor Trucking Association, DSI Transport, Inc., Houston Industries, Inc., the Illinois State Police, Dr. Russell J. Green, Medical Director for Hillcrest Health Works, and Dr. Ellison H. Wittels. The OOIDA, Houston Industries, Inc., and Dr. Wittels also recommended that the Echocardiogram and chest x-ray be deleted from the form. Their opposition was based on the following concerns: (1) The efficacy of these tests to detect coronary artery disease (CAD) and predict future coronary events in asymptomatic individuals is unsupported, (2) optional tests would increase the costs for all parties, and (3) the appearance of the optional tests on the form will be misinterpreted as mandatory requirements. 

The FMCSA believes that the concerns of the ATA, the OOIDA and others regarding the recommendations for and recordation of the optional tests, ECG and EST, on the examination form have merit. According to the information (See part A.l. on “Screening for Asymptomatic Coronary Artery Disease,” by the U.S. Preventive Services Task Force’s “Guide to Clinical Preventive Services,” 2nd ed., Baltimore: Williams & Wilkins, December 1995, in the docket as appendix 1 to the ATA's comment) submitted by Dr. Donald Whorton (on behalf of the ATA) and Dr. Richard Moore, it seems that the benefits of screening to identify asymptomatic CAD are unproven. The evidence summarized in the Guide indicated that the use of a resting ECG for screening for asymptomatic CAD showed limited sensitivity and specificity. Relative to the first quality, it was reported that 29 percent of patients with clinically proven CAD had a normal resting ECG (a sensitivity of 71 percent). The evidence presented also indicated that one-third to one-half of patients with normal coronary arteries had positive findings (poor specificity in the 50 to 67 percent range). Moreover, the Guide gave evidence that the predictive value of the resting ECG was low. Prospective studies found that symptomatic CAD develops in 3 to 15 percent of persons with abnormal ECG findings and that most coronary events occur in persons without resting ECG abnormalities. Based on these findings, routine ECG testing is not an efficient approach for detecting CAD or predicting future events. 

While exercise ECG is more accurate than resting ECG in detecting CAD and predicting future coronary events, the Guide reported that its sensitivity and predictive values do not promote comprehensive endorsement as a screening test. For example, most patients with asymptomatic CAD do not have positive exercise results (poor sensitivity). Relative to prediction, although asymptomatic persons with a positive result on an exercise ECG are more likely to experience an event than those with a negative result, long-term studies have shown that only one to eleven percent will suffer an acute myocardial infarction or sudden death. The majority of events will occur with a negative test result. Thus, the less than desirable qualities of exercise ECG do not allow it to enjoy a broad endorsement as a screening tool and, in addition, it is more expensive than the resting ECG. 

Notwithstanding this lack of evidence to support screening for asymptomatic CAD, the FMCSA believes that screening individuals in certain occupations, such as truck and bus drivers, may be justified because of possible benefits to public safety. However, since the FMCSA is not aware of any studies which have addressed the efficacy of screening these individuals to detect asymptomatic CAD, it proposes to establish a panel of medical experts to review and make recommendations for amending the agency's standards and guidelines for qualifying commercial drivers with cardiac conditions, and for screening drivers for cardiac risk factors. 

The FMCSA has considered the comments to this section and modified the form as follows: Space will be provided for describing and recording any optional tests which the medical examiner considers necessary to assess a driver's physical qualification. However, references to specific tests (ECG, EST, echocardiogram, and chest x-ray) in this section have been removed. This will eliminate the potential for such optional tests to be misinterpreted as mandatory requirements and allow more space for the medical examiner to describe, record and comment on any optional test conducted as part of the examination. 

                    Although the FMCSA has not adopted the recommendations of the Parents Against Tired Truckers (P.A.T.T.) to require the eight question Epworth Sleep Disorder Test as part of the physical examination, the agency recognizes and shares P.A.T.T.'s concerns that excessive day-time sleepiness as a result of untreated sleep apnea can affect a driver's ability to perform safely. The FMCSA has ongoing research to evaluate the prevalence and performance of a population of CMV drivers with sleep apnea. An extension of this research involves the development and evaluation of a screening tool for identifying drivers with sleep apnea. Moreover, the FMCSA's 1991 report, “Pulmonary/Respiratory Conditions and Commercial Drivers,” provides specific recommendations for qualifying CMV drivers with sleep apnea. This report may be obtained from the National Technical Information Service, by calling 1-800-553-6847 and identifying the report by title and “PB” number (PB91-236455), or by going to:                     *http://www.fmcsa.dot.gov/​rulesregs/​medreports.htm.*

### Physical Examination 

                    This section of the form received a number of comments suggesting additions or deletions of information and changes to the format. There was unanimous agreement among those commenting that the recording of height and weight in centimeters and kilograms may be problematic and a source of errors and, therefore, should be recorded in inches and pounds. Other comments indicated that the “yes” and “no” columns which answer the question, “Is driver's ability to safely operate a commercial motor vehicle affected?” may be confusing as the usual procedure is to check “yes” if there are underlying abnormalities and then comment on whether they present a safety risk. A number of comments indicated that routine rectal and pelvic examinations are not appropriate or relevant to driver safety and should be eliminated. The AAOHN indicated that more space should be allotted for the medical examiners comments to “yes” answers under this section and recommended expanding the section on certification status to include the status of individuals who meet the standard and qualify for a 2-year medical                           ( print page 59367)                        certificate. The proposed form indicated that this section should be completed only if the driver does not qualify for a 2-year certificate.                 

The FMCSA has considered the comments to this section and modified the form as follows: The directions for completing this section appear in one location on the form and now read: Check “yes” if there are any abnormalities. Check “no” if the body system is normal. Discuss any “yes” answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. Height and weight will be recorded on the form in inches and pounds as the medical community has indicated that it is more comfortable with these units of measurement. References to both the pelvic or rectal examination have been dropped from the form, and as a result, the reference to hemorrhoids was dropped too. The term “abnormal” has been dropped because it is too subjective and the term “weakness” has been substituted for semi-paralysis. Several comments were not adopted as they addressed areas extensively discussed by medical providers and other interested parties during the development of this rule. 

                    The instructions for completing the section on the certification status has been modified and reads: Note Certification Status Here. Additional boxes have been added to indicate (1) when a driver meets the standards in 49 CFR 391.41 and qualifies for a 2-year medical certificate, and (2) when the certification is conditionally met under the FMCSRs (                    *e.g.,*                     when wearing corrective lenses, a hearing aid or when accompanied by a waiver/exemption/skill performance evaluation (SPE) certificate). The handicapped driver waiver form has been replaced by a skill performance evaluation certificate. See 65 FR 25285 (May 1, 2000) for more detailed information.                 

### Medical Examiner's Certificate 

The replica of the Medical Examiner's Certificate that appeared on the proposed form under item number 7 “Physical Examination” has been removed to allow more space on the form. This will accommodate the information added to the section on Certification Status and provide significantly more space for the medical examiner's comments under this section. 

The box on the Medical Examiner's Certificate titled, “Name (Print)” has been changed and reads: Medical Examiner's Name (Print). This was done to clarify whose name is to be entered in the box. Another box on the Certificate which indicates that a driver is qualified only when accompanied by a waiver has been modified and reads: accompanied by a ________ waiver/exemption. The term “exemption” has been added to be consistent with the terminology in 49 U.S.C. 31315 and 31136(e) regarding the granting of waivers and exemptions. A box has been added to indicate that a driver is qualified only when carrying an SPE certificate. 

### Instructions to the Medical Examiner 

The majority of the comments directed to this section of the form were favorable and support the concept of a self-contained form which ensures the medical examiner access to the applicable medical standards, guidelines and other useful information including the role and duties of both the medical examiner and driver. For example, not all medical examiners, as suggested in one comment, are aware of existing guidance which allows medical examiners to issue medical certificates for periods less than 2 years in cases where drivers are qualified, but may have conditions which require more frequent monitoring. 

A number of comments opposed the inclusion in this section of the recommendations to conduct optional ECG and EST tests. They cited the lack of evidence to support such screening, costs versus benefits, and the potential for the optional tests to be misinterpreted as mandatory. 

                    The FMCSA has considered the comments to this section of the form and made the following modifications. The recommendations for evaluating cardiac risk factors and conducting the optional baseline ECG and EST tests have been removed from the Instructions to the Medical Examiner (Advisory Criteria) on the form and from the Instructions for Performing and Recording Physical Examinations,                     *Heart*, at 49 CFR 391.43 (f). However, these recommendations have been and are currently available to assist medical examiners in making physical qualification determinations, and are found in the FMCSA's conference report, “Cardiac Conditions and Commercial Drivers.” This report may be obtained from the National Technical Information Service, by calling 1-800-553-6847, and identifying the report by title and “PB” number (PB88-233960), or by going to:                     *http://www.fmcsa.dot.gov/​rulesregs/​medreports.htm.*                     Moreover, as previously indicated, the FMCSA plans to establish a medical panel to review its cardiac standards and guidelines for qualifying commercial drivers. As part of the review, the panel will be asked to address the issue of screening CMV drivers for CAD. Other modifications to this section were either editorial in nature or changes to update information to be consistent with current FMCSA guidelines.                 

Several comments recommended designating or certifying medical examiners to ensure more uniform evaluations for fitness to operate CMVs. This issue is being addressed under a separate rulemaking which proposes to link the driver physical qualification determinations with the CDL process. 

### Format of the Examination Form 

In general, comments on the format were favorable. J.B. Hunt Transport, Inc. stated, “placing applicable FHWA guidance directly on the proposed form * * * is an effective way to insure the medical examiner is aware of the specific regulation.” The ATA stated, “FHWA's revised medical examination form, coupled with the above discussed ATA recommendations, will help serve as an adequate means to provide consistency and completeness.” The ATA recommended that the FHWA permit motor carriers the flexibility to reformat the form to fewer pages, provided that the content of the form remains the same, and allow the form to be maintained electronically. The AHAS commented, “Advocates believes that, taken as a whole, both the form itself and the supplementary guidance that the agency wants to provide in order to guide health care providers will be substantial improvements over the present form. We agree with FHWA that the use of this form with its added guidance to practitioners could have a positive economic impact by resulting in more careful screening of commercial drivers to detect health conditions that could prove to be a safety risk both for drivers and for the occupants of other vehicles sharing the road with large trucks and buses.” 

                    Other comments indicated that the form has too many pages and questioned whether medical examiners would read them. The ACOEM commented, “It is unlikely that expanding explanations from one side of a page to four sides will drastically increase the quality.” The Federal Express Corporation believes “the proposed three page form unnecessarily adds to the paperwork burden of medical examiners and motor carriers.” Schneider National did not comment specifically on the proposed form, but                           ( print page 59368)                        included a copy of its physical exam form which Schneider considers both “comprehensive” and “helpful” in determining driver fitness. The Schneider form includes a 3-page physical exam form, 1-page driver's job description and 2 pages of instructional/informational materials, for a total of 6 pages.                

The FMCSA believes the format of its examination form achieves the agency's overall objectives of accuracy and efficiency, and to be a self-contained document. Although the FMCSA has concluded that the new form would not increase cost and time burdens, it has adopted the ATA's recommendation to allow motor carriers and others to reformat the form, including an electronic version, so long as it remains a self-contained form and incorporates all of the information in 49 CFR 391.43(f), as amended in this rulemaking. 

In addition to the revisions to 49 CFR 391.43 in this final rule, the FMCSA has made technical corrections to paragraphs (c)(1), (d) and (g) of that section. We are also making technical corrections to 49 CFR 391.41, paragraphs (b)(1) and (b)(2)(ii) and finally, to 49 CFR 391.49, paragraph (d)(2). 

The FMCSA's primary concern is to enhance highway safety, not to unnecessarily limit employment opportunities for individuals with physical impairments. Consistent with its safety mandate and regulations, the FMCSA is interested in promoting individual determinations of medical qualification to operate a CMV. The revised medical examination form is intended to facilitate medical examiners' efforts to establish and document the physical qualifications of a driver to operate a CMV by promoting reliable and understandable determinations of physical qualification. 

## Executive Order 12866 (Regulatory Planning and Review) and DOT Regulatory Policies and Procedures 

The FMCSA has determined that this action is not a significant regulatory action under Executive Order 12866 or significant under the regulatory policies and procedures of the DOT. It is anticipated that the economic impact of this final rule will be minimal because the use of existing printed supplies of the forms addressed in this action will be allowed until the forms are depleted, or until 12 months after the effective date of this rulemaking, whichever occurs first. Allowing the use of existing forms will avert substantial monetary loss by motor carriers, medical providers, and vendors of forms that might otherwise result from this rulemaking. Moreover, users of the examination form have the flexibility to reformat the form to fewer pages, including an electronic version so long as it remains a self-contained form and incorporates all of the information in 49 CFR 391.43(f), as amended in this rulemaking. According such flexibility will have the potential to reduce costs. This action will facilitate regulatory uniformity and result in easier compliance with and enforcement of the driver qualification requirements of the FMCSRs. This form will, to the extent possible, include all relevant information necessary to establish and record the physical qualification of a driver to operate a CMV. As a result, the FMCSA believes that this rulemaking will have a positive economic impact. Therefore, a full regulatory evaluation is not required. 

## Regulatory Flexibility Act 

In compliance with the Regulatory Flexibility Act, 5 U.S.C. 601-612, the FMCSA has evaluated the effects of this final rule on small entities. The FMCSA believes that this action will not have a significant economic impact on a substantial number of small entities or the nation's economy because it would allow individual small carriers, medical examiners and vendors of the form to use the forms they now have on hand until those supplies have been depleted, or until 12 months after the effective date of this rulemaking. Additionally, users of the forms will have the flexibility to reformat the forms to less pages, including an electronic version, so long as it remains a self-contained form and incorporates all of the information in 49 CFR 391.43(f), as amended in this rulemaking. To the extent that this final rule will facilitate compliance with driver qualification requirements, the projected positive economic impact is not expected to be sufficiently significant to warrant a full regulatory evaluation. Accordingly, the FMCSA certifies that this action will not have a significant economic impact on a substantial number of small entities. 

## Unfunded Mandates Reform Act of 1995 

The FMCSA has determined that this rulemaking will not result in the expenditure by State, local and tribal governments, or by the private sector, in the aggregate of $100 million or more in any one year, as required by the Unfunded Mandates Reform Act of 1995 (2 U.S.C. 15e32). 

## Executive Order 13132 (Federalism) 

This action has been analyzed in accordance with the principles and criteria contained in Executive Order 13132 dated August 4, 1999, and it has been determined this action does not have a substantial direct effect or sufficient federalism implications on States that would limit the policymaking discretion of the States. Nothing in this document directly prempts any State law or regulation. 

## Executive Order 12372 (Intergovernmental Review) 

Catalog of Federal Domestic Assistance Program Number 20.217, Motor Carrier Safety. The regulations implementing Executive Order 12372 regarding intergovernmental consultation on Federal programs and activities do not apply to this program. 

## National Environmental Policy Act 

                    The agency has analyzed this action for the purposes of the National Environmental Policy Act of 1969, as amended (42 U.S.C. 4321*et seq.*), and has determined that this action will not have any effect on the quality of the environment.                 

## Paperwork Reduction Act of 1995 

                    Under the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3501,                     *et seq.*), Federal agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct, sponsor, or require through regulations. The FMCSA has determined that this final rule will affect collection of information requirements for the purposes of the PRA because it revises a form associated with a currently-approved information collection covered by OMB Approval No. 2126-0006, entitled Medical Qualification Requirements. Interested parties were invited to provide comments regarding the form revision in an NPRM which was issued on August 5, 1998. Comments which were received are discussed above in Discussion of Comments. Because the current information collection is due to expire on September 30, 2000, it has been submitted to OMB for a three-year renewal. The renewal request, which includes a revised estimate of 20 minutes to complete and document the medical examination, is more accurate. The FMCSA is not making any additional revisions to the information collection as a result of this final rule.                 

## Regulation Identification Number 

                    A regulation identification number (RIN) is assigned to each regulatory action listed in the Unified Agenda of                           ( print page 59369)                        Federal Regulations. The Regulatory Information Service Center publishes the Unified Agenda in April and October of each year. The RIN contained in the heading of this document can be used to cross reference this action with the Unified Agenda.                 

# List of Subjects in 49 CFR Part 391

      - Driver qualifications-physical examinations
      - Highway safety
      - Motor carriers
      - Reporting and recordkeeping requirements
      - Safety
      - Transportation

Issued on: September 19, 2000. 

Clyde J. Hart, Jr., 

Acting Deputy Administrator, Federal Motor Carrier Safety Administration.

In consideration of the foregoing, the FMCSA amends title 49, CFR, chapter III, part 391 as set forth below: 

# PART 391—QUALIFICATIONS OF DRIVERS [AMENDED] 

1. The authority citation for part 391 continues to read as follows: 

Authority:49 U.S.C. 322, 504, 31133, 31136, and 31502; and 49 CFR 1.73. 

2. Section 391.41 is amended by revising paragraphs (b)(1) and (b)(2)(ii) to read as follows: 

§ 391.41 

* * * * *

(b) * * *

(1) Has no loss of a foot, a leg, a hand, or an arm, or has been granted a skill performance evaluation certificate pursuant to § 391.49; 

(2) * * * 

(ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or has been granted a skill performance evaluation certificate pursuant to § 391.49. 

* * * * *

3. Section 391.43 is amended by revising paragraphs (c)(1), (d), (f), (g) and (h) to read as follows: 

§ 391.43 

* * * * *

(c) * * * 

(1) Be knowledgeable of the specific physical and mental demands associated with operating a commercial motor vehicle and the requirements of this subpart, including the medical advisory criteria prepared by the FHWA as guidelines to aid the medical examiner in making the qualification determination; and 

* * * * *

(d) Any driver authorized to operate a commercial motor vehicle within an exempt intracity zone pursuant to § 391.62 of this part shall furnish the examining medical examiner with a copy of the medical findings that led to the issuance of the first certificate of medical examination which allowed the driver to operate a commercial motor vehicle wholly within an exempt intracity zone. 

* * * * *

(f) The medical examination shall be performed, and its results shall be recorded, substantially in accordance with the following instructions and examination form. Existing forms may be used until current printed supplies are depleted or until November 6, 2001, whichever occurs first. 

## Instructions for Performing and Recording Physical Examinations 

The medical examiner must be familiar with 49 CFR 391.41, Physical qualifications for drivers, and should review these instructions before performing the physical examination. Answer each question “yes” or “no” and record numerical readings where indicated on the physical examination form. 

The medical examiner must be aware of the rigorous physical, mental, and emotional demands placed on the driver of a commercial motor vehicle. In the interest of public safety, the medical examiner is required to certify that the driver does not have any physical, mental, or organic condition that might affect the driver's ability to operate a commercial motor vehicle safely.

*General information.*                                The purpose of this history and physical examination is to detect the presence of physical, mental, or organic conditions of such a character and extent as to affect the driver's ability to operate a commercial motor vehicle safely. The examination should be conducted carefully and should at least include all of the information requested in the following form. History of certain conditions may be cause for rejection. Indicate the need for further testing and/or require evaluation by a specialist. Conditions may be recorded which do not, because of their character or degree, indicate that certification of physical fitness should be denied. However, these conditions should be discussed with the driver and he/she should be advised to take the necessary steps to insure correction, particularly of those conditions which, if neglected, might affect the driver's ability to drive safely.                             

*General appearance and development.*                                Note marked overweight. Note any postural defect, perceptible limp, tremor, or other conditions that might be caused by alcoholism, thyroid intoxication or other illnesses.                             

*Head-eyes.*                                When other than the Snellen chart is used, the results of such test must be expressed in values comparable to the standard Snellen test. If the driver wears corrective lenses for driving, these should be worn while driver's visual acuity is being tested. If contact lenses are worn, there should be sufficient evidence of good tolerance of and adaptation to their use. Indicate the driver's need to wear corrective lenses to meet the vision standard on the Medical Examiner's Certificate by checking the box, “Qualified only when wearing corrective lenses.” In recording distance vision use 20 feet as normal. Report all vision as a fraction with 20 as the numerator and the smallest type read at 20 feet as the denominator. Monocular drivers are not qualified to operate commercial motor vehicles in interstate commerce.                             

*Ears.*                                Note evidence of any ear disease, symptoms of aural vertigo, or Meniere's Syndrome. When recording hearing, record distance from patient at which a forced whispered voice can first be heard. For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18, 23, etc. The examiner should not use only sibilants (s-sounding test materials). The opposite ear should be tested in the same manner. If the individual fails the whispered voice test, the audiometric test should be administered. For the audiometric test, record decibel loss at 500 Hz, 1,000 Hz, and 2,000 Hz. Average the decibel loss at 500 Hz, 1,000 Hz and 2,000 Hz and record as described on the form. If the individual fails the audiometric test and the whispered voice test has not been administered, the whispered voice test should be performed to determine if the standard applicable to that test can be met.                             

*Throat.*                                Note any irremediable deformities likely to interfere with breathing or swallowing.                             

*Heart.*                                Note murmurs and arrhythmias, and any history of an enlarged heart, congestive heart failure, or cardiovascular disease that is accompanied by syncope, dyspnea, or collapse. Indicate onset date, diagnosis, medication, and any current limitation. An electrocardiogram is required when findings so indicate.                             

*Blood pressure (BP).*                                If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosed with mild hypertension (initial BP is greater than 160/90 but below 181/105) should be certified for one 3-month period and should be recertified on an annual basis thereafter if his or her BP is reduced. An individual diagnosed with moderate to severe hypertension (initial BP is greater than 180/104) should not be certified until the BP has been reduced to the mild range (below 181/105). At that time, a 3-month certification can be issued. Once the driver has reduced his or her BP to below 161/91, he or she should be recertified every 6 months thereafter.                             

*Lungs.*                                Note abnormal chest wall expansion, respiratory rate, breath sounds including wheezes or alveolar rales, impaired respiratory function, dyspnea, or cyanosis. Abnormal finds on physical exam may require further testing such as pulmonary tests and/or x-ray of chest.                                       ( print page 59370)    

*Abdomen and Viscera.*                                Note enlarged liver, enlarged spleen, abnormal masses, bruits, hernia, and significant abdominal wall muscle weakness and tenderness. If the diagnosis suggests that the condition might interfere with the control and safe operation of a commercial motor vehicle, further testing and evaluation is required.                             

*Genital-urinary and rectal examination.*                                A urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problems. Note hernias. A condition causing discomfort should be evaluated to determine the extent to which the condition might interfere with the control and safe operation of a commercial motor vehicle.                             

*Neurological.*                                Note impaired equilibrium, coordination, or speech pattern; paresthesia; asymmetric deep tendon reflexes; sensory or positional abnormalities; abnormal patellar and Babinski's reflexes; ataxia. Abnormal neurological responses may be an indication for further testing to rule out an underlying medical condition. Any neurological condition should be evaluated for the nature and severity of the condition, the degree of limitation present, the likelihood of progressive limitation, and the potential for sudden incapacitation. In instances where the medical examiner has determined that more frequent monitoring of a condition is appropriate, a certificate for a shorter period should be issued.                             

*Spine, musculoskeletal.*                                Previous surgery, deformities, limitation of motion, and tenderness should be noted. Findings may indicate additional testing and evaluation should be conducted.                             

*Extremities.*                                Carefully examine upper and lower extremities and note any loss or impairment of leg, foot, toe, arm, hand, or finger. Note any deformities, atrophy, paralysis, partial paralysis, clubbing, edema, or hypotonia. If a hand or finger deformity exists, determine whether prehension and power grasp are sufficient to enable the driver to maintain steering wheel grip and to control other vehicle equipment during routine and emergency driving operations. If a foot or leg deformity exists, determine whether sufficient mobility and strength exist to enable the driver to operate pedals properly. In the case of any loss or impairment to an extremity which may interfere with the driver's ability to operate a commercial motor vehicle safely, the medical examiner should state on the medical certificate “medically unqualified unless accompanied by a Skill Performance Evaluation Certificate.” The driver must then apply to the Field Service Center of the FMCSA, for the State in which the driver has legal residence, for a Skill Performance Evaluation Certificate under § 391.49.                             

*Laboratory and Other Testing.*                                Other test(s) may be indicated based upon the medical history or findings of the physical examination.                             

*Diabetes.*                                If insulin is necessary to control a diabetic driver's condition, the driver is not qualified to operate a commercial motor vehicle in interstate commerce. If mild diabetes is present and it is controlled by use of an oral hypoglycemic drug and/or diet and exercise, it should not be considered disqualifying. However, the driver must remain under adequate medical supervision.                             

Upon completion of the examination, the medical examiner must date and sign the form, provide his/her full name, office address and telephone number. The completed medical examination form shall be retained on file at the office of the medical examiner. 
      ( print page 59371)          ( print page 59372)          ( print page 59373)          ( print page 59374)          ( print page 59375)          ( print page 59376)          ( print page 59377)          ( print page 59378)          ( print page 59379)    
(g) If the medical examiner finds that the person he/she examined is physically qualified to drive a commercial motor vehicle in accordance with § 391.41(b), the medical examiner shall complete a certificate in the form prescribed in paragraph (h) of this section and furnish one copy to the person who was examined and one copy to the motor carrier that employs him/her. 

(h) The medical examiner's certificate shall be substantially in accordance with the following form. Existing forms may be used until current printed supplies are depleted or until November 6, 2001, whichever occurs first. 

      ( print page 59380)    
§ 391.49

4. Section 391.49 is amended in paragraph (d)(2) by revising the erroneous reference “§ 391.43(e)” to read “§ 391.43(h)”. 

BILLING CODE 4910-22-P

[FR Doc. 00-25337 Filed 10-4-00; 8:45 am] 

BILLING CODE 4910-22-C