Appendix A to Part 391 - Medical Advisory Criteria
49:5.1.1.2.34.7.15.10.16 : Appendix A
Appendix A to Part 391 - Medical Advisory Criteria I. Introduction
This appendix contains the Agency's guidelines in the form of
Medical Advisory Criteria 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, and, in some areas, after
consideration of recommendations from the Federal Motor Carrier
Safety Administration's Medical Review Board and Medical Expert
Panels.
II. Interpretation of Medical Standards
Since the issuance of the regulations for physical
qualifications of commercial motor vehicle drivers, the Federal
Motor Carrier Safety Administration has published recommendations
called Advisory Criteria to help medical examiners in determining
whether a driver meets the physical qualifications for commercial
driving. These recommendations have been condensed to provide
information to medical examiners that is directly relevant to the
physical examination and is not already included in the Medical
Examination Report Form.
A. Loss of Limb: § 391.41(b)(1)
A person is physically qualified to drive a commercial motor
vehicle if that person: Has no loss of a foot, leg, hand or an arm,
or has been granted a Skills Performance Evaluation certificate
pursuant to § 391.49.
B. Limb Impairment: § 391.41(b)(2)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no impairment of:
(i) A hand or finger which interferes with prehension or power
grasping; or
(ii) An arm, foot, or leg which interferes with the ability to
perform normal tasks associated with operating a commercial motor
vehicle; or
(iii) Any other significant limb defect or limitation which
interferes with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or
(iv) Has been granted a Skills Performance Evaluation
certificate pursuant to § 391.49.
2. A person who suffers loss of a foot, leg, hand or arm or
whose limb impairment in any way interferes with the safe
performance of normal tasks associated with operating a commercial
motor vehicle is subject to the Skills Performance Evaluation
Certificate Program pursuant to § 391.49, assuming the person is
otherwise qualified.
3. With the advancement of technology, medical aids and
equipment modifications have been developed to compensate for
certain disabilities. The Skills Performance Evaluation Certificate
Program (formerly the Limb Waiver Program) was designed to allow
persons with the loss of a foot or limb or with functional
impairment to qualify under the Federal Motor Carrier Safety
Regulations by use of prosthetic devices or equipment modifications
which enable them to safely operate a commercial motor vehicle.
Since there are no medical aids equivalent to the original body or
limb, certain risks are still present, and thus restrictions may be
included on individual Skills Performance Evaluation certificates
when a State Director for the Federal Motor Carrier Safety
Administration determines they are necessary to be consistent with
safety and public interest.
4. If the driver is found otherwise medically qualified (§
391.41(b)(3) through (13)), the medical examiner must check on the
Medical Examiner's Certificate that the driver is qualified only if
accompanied by a Skills Performance Evaluation certificate. The
driver and the employing motor carrier are subject to appropriate
penalty if the driver operates a motor vehicle in interstate or
foreign commerce without a current Skill Performance Evaluation
certificate for his/her physical disability.
C. [Reserved] D. Cardiovascular Condition: § 391.41(b)(4)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of
myocardial infarction, angina pectoris, coronary insufficiency,
thrombosis or any other cardiovascular disease of a variety known
to be accompanied by syncope, dyspnea, collapse or congestive
cardiac failure.
2. The term “has no current clinical diagnosis of” is
specifically designed to encompass: “a clinical diagnosis of” a
current cardiovascular condition, or a cardiovascular condition
which has not fully stabilized regardless of the time limit. The
term “known to be accompanied by” is designed to include a clinical
diagnosis of a cardiovascular disease which is accompanied by
symptoms of syncope, dyspnea, collapse or congestive cardiac
failure; and/or which is s likely to cause syncope, dyspnea,
collapse or congestive cardiac failure.
3. It is the intent of the Federal Motor Carrier Safety
Regulations to render unqualified, a driver who has a current
cardiovascular disease which is accompanied by and/or likely to
cause symptoms of syncope, dyspnea, collapse, or congestive cardiac
failure. However, the subjective decision of whether the nature and
severity of an individual's condition will likely cause symptoms of
cardiovascular insufficiency is on an individual basis and
qualification rests with the medical examiner and the motor
carrier. In those cases where there is an occurrence of
cardiovascular insufficiency (myocardial infarction, thrombosis,
etc.), it is suggested before a driver is certified that he or she
have a normal resting and stress electrocardiogram, no residual
complications and no physical limitations, and is taking no
medication likely to interfere with safe driving.
4. Coronary artery bypass surgery and pacemaker implantation are
remedial procedures and thus, not medically disqualifying.
Implantable cardioverter defibrillators are disqualifying due to
risk of syncope. Coumadin is a medical treatment which can improve
the health and safety of the driver and should not, by its use,
medically disqualify the commercial motor vehicle driver. The
emphasis should be on the underlying medical condition(s) which
require treatment and the general health of the driver. The Federal
Motor Carrier Safety Administration should be contacted at (202)
366-4001 for additional recommendations regarding the physical
qualification of drivers on coumadin.
E. Respiratory Dysfunction: § 391.41(b)(5)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or
clinical diagnosis of a respiratory dysfunction likely to interfere
with ability to control and drive a commercial motor vehicle
safely.
2. Since a driver must be alert at all times, any change in his
or her mental state is in direct conflict with highway safety. Even
the slightest impairment in respiratory function under emergency
conditions (when greater oxygen supply is necessary for
performance) may be detrimental to safe driving.
3. There are many conditions that interfere with oxygen exchange
and may result in incapacitation, including emphysema, chronic
asthma, carcinoma, tuberculosis, chronic bronchitis and sleep
apnea. If the medical examiner detects a respiratory dysfunction,
that in any way is likely to interfere with the driver's ability to
safely control and drive a commercial motor vehicle, the driver
must be referred to a specialist for further evaluation and
therapy. Anticoagulation therapy for deep vein thrombosis and/or
pulmonary thromboembolism is not medically disqualifying once
optimum dose is achieved, provided lower extremity venous
examinations remain normal and the treating physician gives a
favorable recommendation.
F. Hypertension: § 391.41(b)(6)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of high
blood pressure likely to interfere with ability to operate a
commercial motor vehicle safely.
2. Hypertension alone is unlikely to cause sudden collapse;
however, the likelihood increases when target organ damage,
particularly cerebral vascular disease, is present. This regulatory
criteria is based on the Federal Motor Carrier Safety
Administration's Cardiovascular Advisory Guidelines for the
Examination of commercial motor vehicle Drivers, which used the
Sixth Report of the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure (1997).
3. Stage 1 hypertension corresponds to a systolic blood pressure
of 140-159 mmHg and/or a diastolic blood pressure of 90-99 mmHg.
The driver with a blood pressure in this range is at low risk for
hypertension-related acute incapacitation and may be medically
certified to drive for a one-year period. Certification
examinations should be done annually thereafter and should be at or
less than 140/90. If less than 160/100, certification may be
extended one time for 3 months.
4. A blood pressure of 160-179 systolic and/or 100-109 diastolic
is considered Stage 2 hypertension, and the driver is not
necessarily unqualified during evaluation and institution of
treatment. The driver is given a one-time certification of three
months to reduce his or her blood pressure to less than or equal to
140/90. A blood pressure in this range is an absolute indication
for anti-hypertensive drug therapy. Provided treatment is well
tolerated and the driver demonstrates a blood pressure value of
140/90 or less, he or she may be certified for one year from date
of the initial exam. The driver is certified annually
thereafter.
5. A blood pressure at or greater than 180 (systolic) and 110
(diastolic) is considered Stage 3, high risk for an acute blood
pressure-related event. The driver may not be qualified, even
temporarily, until reduced to 140/90 or less and treatment is well
tolerated. The driver may be certified for 6 months and biannually
(every 6 months) thereafter if at recheck blood pressure is 140/90
or less.
6. Annual recertification is recommended if the medical examiner
does not know the severity of hypertension prior to treatment. An
elevated blood pressure finding should be confirmed by at least two
subsequent measurements on different days.
7. Treatment includes nonpharmacologic and pharmacologic
modalities as well as counseling to reduce other risk factors. Most
antihypertensive medications also have side effects, the importance
of which must be judged on an individual basis. Individuals must be
alerted to the hazards of these medications while driving. Side
effects of somnolence or syncope are particularly undesirable in
commercial motor vehicle drivers.
8. Secondary hypertension is based on the above stages.
Evaluation is warranted if patient is persistently hypertensive on
maximal or near-maximal doses of 2-3 pharmacologic agents. Some
causes of secondary hypertension may be amenable to surgical
intervention or specific pharmacologic disease.
G. Rheumatic, Arthritic, Orthopedic, Muscular, Neuromuscular or
Vascular Disease: § 391.41(b)(7)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or
clinical diagnosis of rheumatic, arthritic, orthopedic, muscular,
neuromuscular or vascular disease which interferes with the ability
to control and operate a commercial motor vehicle safely.
2. Certain diseases are known to have acute episodes of
transient muscle weakness, poor muscular coordination (ataxia),
abnormal sensations (paresthesia), decreased muscular tone
(hypotonia), visual disturbances and pain which may be suddenly
incapacitating. With each recurring episode, these symptoms may
become more pronounced and remain for longer periods of time. Other
diseases have more insidious onsets and display symptoms of muscle
wasting (atrophy), swelling and paresthesia which may not suddenly
incapacitate a person but may restrict his/her movements and
eventually interfere with the ability to safely operate a motor
vehicle. In many instances these diseases are degenerative in
nature or may result in deterioration of the involved area.
3. Once the individual has been diagnosed as having a rheumatic,
arthritic, orthopedic, muscular, neuromuscular or vascular disease,
then he/she has an established history of that disease. The
physician, when examining an individual, should consider the
following: The nature and severity of the individual's condition
(such as sensory loss or loss of strength); the degree of
limitation present (such as range of motion); the likelihood of
progressive limitation (not always present initially but may
manifest itself over time); and the likelihood of sudden
incapacitation. If severe functional impairment exists, the driver
does not qualify. In cases where more frequent monitoring is
required, a certificate for a shorter period of time may be
issued.
H. Epilepsy: § 391.41(b)(8)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no established medical history or
clinical diagnosis of epilepsy or any other condition which is
likely to cause loss of consciousness or any loss of ability to
control a motor vehicle.
2. Epilepsy is a chronic functional disease characterized by
seizures or episodes that occur without warning, resulting in loss
of voluntary control which may lead to loss of consciousness and/or
seizures. Therefore, the following drivers cannot be qualified:
(i) A driver who has a medical history of epilepsy;
(ii) A driver who has a current clinical diagnosis of epilepsy;
or
(ii) A driver who is taking antiseizure medication.
3. If an individual has had a sudden episode of a nonepileptic
seizure or loss of consciousness of unknown cause which did not
require antiseizure medication, the decision as to whether that
person's condition will likely cause loss of consciousness or loss
of ability to control a motor vehicle is made on an individual
basis by the medical examiner in consultation with the treating
physician. Before certification is considered, it is suggested that
a 6 month waiting period elapse from the time of the episode.
Following the waiting period, it is suggested that the individual
have a complete neurological examination. If the results of the
examination are negative and antiseizure medication is not
required, then the driver may be qualified.
4. In those individual cases where a driver has a seizure or an
episode of loss of consciousness that resulted from a known medical
condition (e.g., drug reaction, high temperature, acute
infectious disease, dehydration or acute metabolic disturbance),
certification should be deferred until the driver has fully
recovered from that condition and has no existing residual
complications, and not taking antiseizure medication.
5. Drivers with a history of epilepsy/seizures off antiseizure
medication and seizure-free for 10 years may be qualified to drive
a commercial motor vehicle in interstate commerce. Interstate
drivers with a history of a single unprovoked seizure may be
qualified to drive a commercial motor vehicle in interstate
commerce if seizure-free and off antiseizure medication for a
5-year period or more.
I. Mental Disorders: § 391.41(b)(9)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no mental, nervous, organic or
functional disease or psychiatric disorder likely to interfere with
ability to drive a motor vehicle safely.
2. Emotional or adjustment problems contribute directly to an
individual's level of memory, reasoning, attention, and judgment.
These problems often underlie physical disorders. A variety of
functional disorders can cause drowsiness, dizziness, confusion,
weakness or paralysis that may lead to incoordination, inattention,
loss of functional control and susceptibility to accidents while
driving. Physical fatigue, headache, impaired coordination,
recurring physical ailments and chronic “nagging” pain may be
present to such a degree that certification for commercial driving
is inadvisable. Somatic and psychosomatic complaints should be
thoroughly examined when determining an individual's overall
fitness to drive. Disorders of a periodically incapacitating
nature, even in the early stages of development, may warrant
disqualification.
3. Many bus and truck drivers have documented that “nervous
trouble” related to neurotic, personality, or emotional or
adjustment problems is responsible for a significant fraction of
their preventable accidents. The degree to which an individual is
able to appreciate, evaluate and adequately respond to
environmental strain and emotional stress is critical when
assessing an individual's mental alertness and flexibility to cope
with the stresses of commercial motor vehicle driving.
4. When examining the driver, it should be kept in mind that
individuals who live under chronic emotional upsets may have deeply
ingrained maladaptive or erratic behavior patterns. Excessively
antagonistic, instinctive, impulsive, openly aggressive, paranoid
or severely depressed behavior greatly interfere with the driver's
ability to drive safely. Those individuals who are highly
susceptible to frequent states of emotional instability
(schizophrenia, affective psychoses, paranoia, anxiety or
depressive neuroses) may warrant disqualification. Careful
consideration should be given to the side effects and interactions
of medications in the overall qualification determination.
J. Vision: § 391.41(b)(10)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has distant visual acuity of at least 20/40
(Snellen) in each eye with or without corrective lenses or visual
acuity separately corrected to 20/40 (Snellen) or better with
corrective lenses, distant binocular acuity of at least 20/40
(Snellen) in both eyes with or without corrective lenses, field of
vision of at least 70 degrees in the horizontal meridian in each
eye, and the ability to recognize the colors of traffic signals and
devices showing standard red, green, and amber.
2. The term “ability to recognize the colors of” is interpreted
to mean if a person can recognize and distinguish among traffic
control signals and devices showing standard red, green and amber,
he or she meets the minimum standard, even though he or she may
have some type of color perception deficiency. If certain color
perception tests are administered, (such as Ishihara,
Pseudoisochromatic, Yarn) and doubtful findings are discovered, a
controlled test using signal red, green and amber may be employed
to determine the driver's ability to recognize these colors.
3. Contact lenses are permissible if there is sufficient
evidence to indicate that the driver has good tolerance and is well
adapted to their use. Use of a contact lens in one eye for distance
visual acuity and another lens in the other eye for near vision is
not acceptable, nor telescopic lenses acceptable for the driving of
commercial motor vehicles.
4. If an individual meets the criteria by the use of glasses or
contact lenses, the following statement shall appear on the Medical
Examiner's Certificate: “Qualified only if wearing corrective
lenses.” commercial motor vehicle drivers who do not meet the
Federal vision standard may call (202) 366-4001 for an application
for a vision exemption.
K. Hearing: § 391.41(b)(11)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: First perceives a forced whispered voice in
the better ear at not less than 5 feet with or without the use of a
hearing aid, or, if tested by use of an audiometric device, does
not have an average hearing loss in the better ear greater than 40
decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a
hearing aid when the audiometric device is calibrated to American
National Standard (formerly ADA Standard) Z24.5-1951.
2. Since the prescribed standard under the Federal Motor Carrier
Safety Regulations is from the American National Standards
Institute, formerly the American Standards Association, it may be
necessary to convert the audiometric results from the International
Organization for Standardization standard to the American National
Standards Institute standard. Instructions are included on the
Medical Examination Report Form.
3. If an individual meets the criteria by using a hearing aid,
the driver must wear that hearing aid and have it in operation at
all times while driving. Also, the driver must be in possession of
a spare power source for the hearing aid.
4. For the whispered voice test, the individual should be
stationed at least 5 feet from the medical examiner with the ear
being tested turned toward the medical examiner. The other ear is
covered. Using the breath which remains after a normal expiration,
the medical examiner whispers words or random numbers such as 66,
18, 3, etc. The medical examiner should not use only sibilants (s
sounding materials). The opposite ear should be tested in the same
manner.
5. If the individual fails the whispered voice test, the
audiometric test should be administered. If an individual meets the
criteria by the use of a hearing aid, the following statement must
appear on the Medical Examiner's Certificate “Qualified only when
wearing a hearing aid.”
L. Drug Use: § 391.41(b)(12)
1. A person is physically qualified to drive a commercial motor
vehicle if that person does not use any drug or substance
identified in 21 CFR 1308.11, an amphetamine, a narcotic, or other
habit-forming drug. A driver may use a non-Schedule I drug or
substance that is identified in the other Schedules in 21 CFR part
1308 if the substance or drug is prescribed by a licensed medical
practitioner who:
(i) Is familiar with the driver's medical history, and assigned
duties; and
(ii) Has advised the driver that the prescribed substance or
drug will not adversely affect the driver's ability to safely
operate a commercial motor vehicle.
2. This exception does not apply to methadone. The intent of the
medical certification process is to medically evaluate a driver to
ensure that the driver has no medical condition which interferes
with the safe performance of driving tasks on a public road. If a
driver uses an amphetamine, a narcotic or any other habit-forming
drug, it may be cause for the driver to be found medically
unqualified. If a driver uses a Schedule I drug or substance, it
will be cause for the driver to be found medically unqualified.
Motor carriers are encouraged to obtain a practitioner's written
statement about the effects on transportation safety of the use of
a particular drug.
3. A test for controlled substances is not required as part of
this biennial certification process. The Federal Motor Carrier
Safety Administration or the driver's employer should be contacted
directly for information on controlled substances and alcohol
testing under Part 382 of the FMCSRs.
4. The term “uses” is designed to encompass instances of
prohibited drug use determined by a physician through established
medical means. This may or may not involve body fluid testing. If
body fluid testing takes place, positive test results should be
confirmed by a second test of greater specificity. The term
“habit-forming” is intended to include any drug or medication
generally recognized as capable of becoming habitual, and which may
impair the user's ability to operate a commercial motor vehicle
safely.
5. The driver is medically unqualified for the duration of the
prohibited drug(s) use and until a second examination shows the
driver is free from the prohibited drug(s) use. Recertification may
involve a substance abuse evaluation, the successful completion of
a drug rehabilitation program, and a negative drug test result.
Additionally, given that the certification period is normally two
years, the medical examiner has the option to certify for a period
of less than 2 years if this medical examiner determines more
frequent monitoring is required.
M. Alcoholism: § 391.41(b)(13)
1. A person is physically qualified to drive a commercial motor
vehicle if that person: Has no current clinical diagnosis of
alcoholism.
2. The term “current clinical diagnosis of” is specifically
designed to encompass a current alcoholic illness or those
instances where the individual's physical condition has not fully
stabilized, regardless of the time element. If an individual shows
signs of having an alcohol-use problem, he or she should be
referred to a specialist. After counseling and/or treatment, he or
she may be considered for certification.
[80 FR 22822, Apr. 23, 2015, as amended at 83 FR 47521, Sept. 19,
2018]