Missouri Skill Performance Evaluation Certificates

(1)

Missouri Skill Performance Evaluation Certificates

For Intrastate Drivers

Missouri

allows

individuals

who

are

not

physically

qualified

to

drive

commercial

motor

vehicles

intrastate

because

of

one

or

more

of

the

following

conditions,

to

apply

for

a

Skill

Performance

Evaluation

certificate:



Limb

amputation



Limb

impairment



Vision

impairment



Insulin

‐

treated

diabetes

mellitus

If

the

application

is

approved,

the

driver

is

authorized

to

haul

in

intrastate

commerce

–

that

is,

the

vehicle

and

its

load

must

originate

and

end

within

Missouri’s

borders

only.

Is

the

Missouri

SPE

certificate

the

same

as

the

federal

SPE

certificate?

No.

The

Missouri

certificate

qualifies

drivers

to

operate

only

within

Missouri

borders.

The

federal

SPE

certificate

program

is

for

interstate

drivers

and

applies

only

to

limb

‐

impaired

and

amputee

drivers.

Drivers

with

vision

impairments

or

diabetes

can

apply

for

a

federal

medical

exemption

to

operate

interstate.

Can

I

apply

for

an

SPE

certificate

on

my

own

or

do

I

need

a

sponsor?

Applications

can

be

filed

by

an

individual

driver

or

jointly

by

the

driver

and

a

sponsoring

employer.

What

is

involved

in

the

SPE

process?

Applicants

must

complete

an

application

and

provide

required

documents.

In

limb

impaired/amputation

cases,

a

skill

evaluation

must

be

performed.

Vision

and

diabetes

exemptions

are

submitted

for

public

comment

before

a

decision

is

made.

I

already

have

a

federal

SPE

certificate

or

medical

exemption.

Now

I

want

to

drive

in

Missouri

only.

Can

I?

You

must

apply

for

a

Missouri

SPE

certificate,

but

some

application

requirements

can

be

waived

if

your

federal

certificate

or

exemption

is

still

valid.

How

long

does

the

Missouri

SPE

certificate

application

process

take?

Once

your

completed

application

is

received,

the

process

normally

is

completed

within

six

months.

However,

the

process

could

take

longer

if

any

application

details

or

documents

are

missing

or

there

are

scheduling

issues

with

a

skill

evaluation

(if

applicable).

What

supporting

documents

are

required

with

the

application?

The

documents

needed

vary

with

each

disabling

condition.

If

you

are

not

physically

qualified

because

of

two

or

more

of

these

disabling

physical

conditions,

then

submit

the

required

documentation

relating

to

each

of

those

conditions.

Most

forms

are

available

for

download

at

www.modot.org/mcs/MedicalProgram.htm

.

Exceptions

include

forms

provided

by

other

agencies,

such

as

a

motor

vehicle

driving

record

or

a

federal

SPE

certificate.

NOTE

:

MoDOT

is

neither

responsible

for

selecting

the

medical

specialist(s)

needed

to

complete

the

application,

providing

the

vehicle

for

a

skill

evaluation,

nor

for

any

expenses

incurred.

These

are

the

applicant’s

responsibility.

(2)

Page

1

of

4

ADDITIONAL INSTRUCTIONS FOR APPLICANTS WITH

INSULIN-TREATED DIABETES MELLITUS (ITDM)

1

Overview

. MoDOT’s Director of Motor Carrier Services may grant an exemption from the physical qualification

for drivers of commercial motor vehicles (

CMVs

) required by 49 CFR § 391.41(b)(3), which requires that a driver

“has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control”.

The Director may grant an exemption by issuing a Skill Performance Evaluation (

SPE

) Certificate for a period up to

two years, if MoDOT finds that: “such exemption would likely achieve a level of safety that is equivalent to, or

greater than, the level that would be achieved absent such exemption.''

2

Publication of Notice of Application.

MoDOT Motor Carrier Services Division must publish a notice of each

completed application received, in the

Missouri Register

, explaining that the application has been filed, and inviting

the public to inspect the safety analysis and any other relevant information known to MoDOT Motor Carrier

Services Division, and to comment on the application. Prior to granting an application for an exemption, MoDOT

Motor Carrier Services Division must publish a second notice in the

Missouri Register,

identifying the person or

class of persons who will receive the exemption, the provisions from which the person will be exempt, the effective

period, and all terms and conditions of the exemption. The terms and conditions established by MoDOT Motor

Carrier Services Division must ensure that the exemption will likely achieve a level of safety that is equivalent to, or

greater than, the level that would be achieved by complying with the regulation. In addition, MoDOT is required to

monitor the implementation of each exemption to ensure compliance with its terms and conditions. If the Director

denies an application for an exemption, MoDOT Motor Carrier Services Division must publish a notice in the

Missouri Register

identifying the person whose application is denied, and the reasons for the denial.

Renewal and Revocation of Exemption.

Generally, the duration of an exemption is limited to not more than two

years from the date of approval, but may be renewable upon application to the Director. MoDOT Motor Carrier

Services Division is required immediately to revoke an exemption if: (1) The person fails to comply with the terms

and conditions of the exemption; (2) The exemption has resulted in a lower level of safety than was maintained

before the exemption was granted; or (3) Continuation of the exemption would not be consistent with the goals and

objectives of the exemption regulations.

Obtaining an Application Packet.

Persons who desire to apply for an exemption may mail requests for an

application packet to: MoDOT Motor Carrier Services Division, Medical Exemption Program, P.O. Box 270,

Jefferson City, MO 65102-0270, or may telephone Kathy J. Hatfield, Motor Carrier Investigations Specialist, at

573-526-9926, or (toll free) 866-831-6277 ext. #6. MoDOT will mail the required forms and instructions.

Procedures for Applying for an Exemption.

Procedures for the review of exemption applications require MoDOT

Motor Carrier Services Division to review a completed application for an exemption, and to prepare, for the

Director’s signature, a

Missouri Register

notice requesting public comment. After a review of the comments

received, MoDOT Motor Carrier Services Division will make a recommendation to the Director. MoDOT will

publish a notice of the Director's final decision in the

Missouri Register

. The Director will issue a final decision

within 180 days of the date MoDOT Motor Carrier Services Division receives an individual's completed application

packet. However, if the applicant should omit important details or other information necessary for MoDOT Motor

Carrier Services Division to conduct a comprehensive evaluation, the Director will issue a final decision within 180

days of the date that it receives sufficient information. MoDOT recognizes that this potential six-month waiting

period may seem burdensome. However, MoDOT must carefully evaluate each and every application for regulatory

relief from the diabetes standard, to assess the potential safety performance of each applicant. In addition, MoDOT

must prepare and publish notice of each application in the

Missouri Register,

and then must evaluate comments

received before the Director makes a final decision. MoDOT's overriding concern is to ensure the safety of

intrastate CMV operations. MoDOT will notify all applicants in writing once the Director makes a final decision.

Application Requirements.

Every applicant for an exemption must submit an application using MoDOT’s

completed

SPEC-3 FORM

, and must include all supporting documentation. In considering exemptions by

1

Adapted from: Authority--Insulin-Treated Diabetes Exemptions Under 49 U.S.C. 31315 and 31136(e), Federal Register,

September 3, 2003 (Volume 68, Number 170) (Notice of Final Disposition);

exemption will not be contrary to the public interest, and that the exemption achieves an acceptable level of safety.

MoDOT Motor Carrier Services Division will only grant exemptions; therefore, to ITDM applicants who meet the

following requirements:

(1)

Valid CDL or Drivers License.

Possesses a valid intrastate CDL or a license (non-CDL) to operate a

CMV;

(2)

Minimum Period of Insulin Use.

Has demonstrated stable control of his/her diabetes through a minimum

period of insulin use. The minimum period for Type 1 diabetics is 2 months and for Type 2 diabetics is 1

month; however, a longer period may be required if directed by the treating physician;

(3)

Safe Driving Record.

Has a driving record for the preceding three-year period that: Contains no

suspensions or revocations of the applicant's driver's license for the operation of any motor vehicle

(including their personal vehicle), Contains no involvement in an accident for which the applicant received

a citation for a moving traffic violation while operating a CMV, Contains no involvement in an accident for

which the applicant contributed to the cause of the accident, and Contains no convictions for a

disqualifying offense or more than one serious traffic violation, as defined in 49 CFR 383.5, while

operating a CMV;

(4)

No Other Disqualifying Conditions.

Has no other disqualifying physical conditions, including

diabetes-related complications, which would make the applicant unable to safely operate a CMV;

(5)

No Recurrent Hypoglycemic Loss of Consciousness or Seizures.

Has had no recurrent (two or more)

hypoglycemic reactions resulting in a loss of consciousness or seizure within the past five years. A period

of one year of demonstrated stability is required following the first episode of hypoglycemia;

(6)

No Recurrent Hypoglycemic Reactions Requiring Assistance.

Has had no recurrent hypoglycemic

reactions requiring the assistance of another person within the past five years. A period of one year of

demonstrated stability is required following the first episode of hypoglycemia;

(7)

No Recurrent Hypoglycemic Impairment of Cognitive Function.

Has had no recurrent hypoglycemic

reactions resulting in impaired cognitive function that occurred without warning symptoms within the past

five years. A period of one year of demonstrated stability is required following the first episode of

hypoglycemia,

(8)

Endocrinologist Examination.

Has been examined by a board-certified or board-eligible endocrinologist

(who is knowledgeable about diabetes) who has conducted a complete medical examination. The complete

medical examination must consist of a comprehensive evaluation of the applicant's medical history and

current status with a report including the following information:

(A)

The date insulin use began,

(B)

Diabetes diagnosis and disease history,

(C)

Hospitalization records,

(D)

Consultation notes for diagnostic examinations,

(E)

Special studies pertaining to the diabetes,

(F)

Follow-up reports,

(G)

Reports of any hypoglycemic insulin reactions within the last five years,

(H)

A current measure of glycosylated hemoglobin (HgA1C), taken during the 30 days

immediately before filing the application,

(I)

Insulin dosages and types, diet utilized for control and any significant factors such as smoking,

alcohol use, and other medications or drugs taken, and

(J)

Examinations to detect any peripheral neuropathy or circulatory insufficiency of the

extremities;

(9)

Endocrinologist Certification.

Submits a signed statement from an examining endocrinologist (which

must be submitted using MoDOT’s completed

SPEC-F Form

) indicating the following medical

determinations: The endocrinologist is familiar with the applicant's medical history for the past five years,

either through actual treatment over that time or through consultation with a physician who has treated the

applicant during that time; the applicant has been using insulin to control his/her diabetes before the date of

the application for the minimum period of insulin use described above; the applicant has been educated in

diabetes and its management, thoroughly informed of and understands the procedures which must be

followed to monitor and manage his/her diabetes and what procedures should be followed if complications

arise; and the applicant has the ability and has demonstrated willingness to properly monitor and manage

his/her diabetes; and

(4)

Page

3

of

4

(10)

Ophthalmologist or Optometrist Examination and Certification.

Submits a separate signed statement

from an ophthalmologist or optometrist (which must be submitted using MoDOT’s completed

SPEC-D

Form

) that the applicant has been examined and that the applicant does not have diabetic retinopathy and

meets the vision standard at 49 CFR 391.41(b)(10), or has been issued a valid medical exemption. If the

applicant has any evidence of diabetic retinopathy, he or she must be examined by an ophthalmologist and

submit a separate signed statement from the ophthalmologist that he or she does not have unstable

proliferative diabetic retinopathy (i.e., unstable advancing disease of blood vessels in the retina).

Special Driving Conditions Required After Issuance of an Exemption to ITDM Individuals.

There are special

conditions attached to the issuance of any exemption for ITDM. The Director will impose the following

requirements:

(1)

Medical Supplies for Glucose Management.

Individuals with ITDM shall maintain appropriate medical

supplies for glucose management while preparing for the operation of a CMV and during its operation. The

supplies shall include the following:

(A)

An acceptable glucose monitor with memory,

(B)

Supplies needed to obtain adequate blood samples and to measure blood glucose,

(C)

Insulin to be used as necessary, and

(D)

An amount of rapidly absorbable glucose to be used as necessary;

(2)

Driver’s Daily Record.

Individuals with ITDM shall maintain a daily record of actual driving time which

must show the times when the driver performs the daily glucose measurements described in the next

paragraph; and

(3)

Monitoring and Maintaining Blood Glucose Levels.

Individuals with ITDM shall self-monitor their

blood glucose levels prior to driving, and every two to four hours while driving, using a portable glucose

monitoring device equipped with a computerized memory. Prior to and while driving, individuals shall

adhere to the following protocol for monitoring and maintaining appropriate blood glucose levels:

(1)

Check glucose before starting to drive and take corrective action if necessary. If glucose is less than

100 milligrams per deciliter (mg/dl), take glucose or food and recheck in 30 minutes. Do not drive if

glucose is less than 100 mg/dl. Repeat the process until glucose is greater than 100 mg/dl;

(2)

While driving check glucose every two to four hours and take appropriate action to maintain it in the

range of 100 to 400 mg/dl;

(3)

Carry a source of rapidly absorbable glucose, and have food available, at all times when driving. If

glucose is less than 100 mg/dl, stop driving and eat. Recheck in 30 minutes and repeat procedure until

glucose is greater than 100 mg/dl; and

(4)

If glucose is greater than 400 mg/dl, stop driving until glucose returns to the 100 to 400 mg/dl range.

If more than two hours after last insulin injection and eating, take additional insulin. Recheck blood

glucose in 30 minutes. Do not resume driving until glucose is less than 400 mg/dl.

Follow-up Documentation to Be Provided to MoDOT.

In addition to the requirements for controlling ITDM,

MoDOT Motor Carrier Services Division will monitor exemption recipients during the period that the exemption is

valid. MoDOT Motor Carrier Services Division will conduct monitoring by requiring the exemption recipients to

submit the following information to the Medical Exemption Program, MoDOT Motor Carrier Services Division,

P.O. Box 270, Jefferson City, MO 65102.

(1)

Quarterly - Written Confirmation from Endocrinologist.

Provide written confirmation from the

endocrinologist on a quarterly basis:

(A)

The make and model of the glucose monitoring device with memory;

(B)

The individual's blood glucose measurements and glycosylated hemoglobin are generally in an

adequate range based on:

a.

All daily glucose measurements taken with the glucose monitoring device and correlated with

the daily records of driving time; and

b.

A current measurement of glycosylated hemoglobin.

(2)

Annually - Comprehensive Medical Evaluation by Endocrinologist.

Submit on an annual basis, a

comprehensive medical evaluation by an endocrinologist. The evaluation will include a general physical

examination and a report of glycosylated hemoglobin concentration. The evaluation will also involve an

assessment of the individual's willingness and ability to monitor and manage the diabetic condition;

(3)

Annually - Confirmation of No Diabetic Retinopathy.

Provide on an annual basis confirmation by an

ophthalmologist or optometrist that there is no diabetic retinopathy and the individual meets the current

vision standards at 49 CFR 391.41(b)(10). If there is any evidence of diabetic retinopathy, provide annual

(5)

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4

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4

documentation by an ophthalmologist that the individual does not have unstable proliferative diabetic

retinopathy;

(4)

Annually - Documentation of Ongoing Education.

Submit annual documentation by an endocrinologist

of ongoing education in management of diabetes and hypoglycemia awareness;

(5)

Report All Episodes Relating to Diabetes.

Report all episodes of severe hypoglycemia, significant

complications, or inability to manage diabetes; and

(6)

Report Any Accident Involvement.

Report any involvement in an accident or any other adverse event

whether or not they are related to an episode of hypoglycemia.

Medical Examination-Certificate of Physical Examination.

Because diabetes is a chronic disease requiring

constant control and monitoring, MoDOT Motor Carrier Services Division will impose conditions on ITDM

individuals who have been issued an exemption. The required conditions include the following:

(1)

Yearly Physical Examination.

Each individual must have a physical examination every year:

(a)

The physical examination must first be conducted by an endocrinologist indicating the driver is:

1.

Free of insulin reactions. ``Free of insulin reactions'' in this context means that the

individual has had:

(A)

No recurrent (two or more) hypoglycemic reactions resulting in a loss of

consciousness or seizure within the past five years. A period of one year of

demonstrated stability is required following the first episode of hypoglycemia,

(B)

No recurrent hypoglycemic reactions requiring the assistance of another person

within the past five years. A period of one year of demonstrated stability is required

following the first episode of hypoglycemia, and

(C)

No recurrent hypoglycemic reactions resulting in impaired cognitive function that

occurred without warning symptoms within the past five years. A period of one year

of demonstrated stability is required following the first episode of hypoglycemia,

2.

Able to and has demonstrated willingness to properly monitor and manage his/her

diabetes, and

3.

Will not likely suffer any diminution in driving ability due to his/her diabetic condition;

and

(b)

Secondly, the physical examination must be conducted by a medical examiner who attests that the

individual is physically qualified under 49 CFR 391.41, or holds a valid exemption or SPE

Certificate.

(2)

Compliance Conditions.

Each individual must agree to and must comply with the following conditions:

(a)

Submit blood glucose records to both the endocrinologist and medical examiner at the annual

examinations or when otherwise directed by an authorized agent of MoDOT Motor Carrier

Services Division; and

(b)

Provide a copy of the endocrinologist's report to the medical examiner at the time of the annual

medical examination; and

(3)

Provide Report Indicating No Diabetic Retinopathy.

Each individual must provide a copy of the

optometrist's or ophthalmologist's report indicating that there is no diabetic retinopathy and the individual

meets the current vision standards at 49 CFR 391.41(b)(10). If there is any evidence of diabetic retinopathy,

the individual must provide to the medical examiner at the time of the annual medical examination a copy

of the ophthalmologist's report indicating that the individual does not have unstable proliferative diabetic

retinopathy; and

(4)

Provide Annual Medical Certification To Employer.

Each individual must provide a copy of the annual

medical certification to the employer for retention in the driver's

qualification

file, or must keep a copy in

his/her driver's

qualification

file if he/she is self-employed. The driver must also have a copy of the

certification when driving for presentation to a duly authorized Federal, State, or local enforcement official.

(6)

ALL

APPLICATIONS

The

following

documents

must

be

completed

and

submitted

with

every

application

for

a

SPE

Certificate:



Statement

of

Treating

Physician

(

SPEC

‐

B

FORM

)



Waiver

or

Privacy

Regarding

Personal

Health

Information

(

SPEC

‐

C

FORM

)



HIPAA

Compliant

Authorization

for

Release

of

Information



Physical

Examination

Form

and

Medical

Examiner's

Certificate

Form



Road

Test

and

Road

Test

Certification

Form.

A

motor

carrier

or

a

person

who

is

competent

to

administer

the

test

and

evaluate

its

results

must

administer

the

road

test.



Driver

Employment

Application

Form.

This

form

is

provided

for

your

use

if

you

do

not

have

a

copy

of

the

last

one

you

completed

for

your

last

employer.



Copy

of

State

motor

vehicle

driving

record

(MVR)

for

the

past

3

years

from

each

State

in

which

you

held

a

driver's

license

or

permit.

*

Available

through

the

Missouri

Department

of

Revenue



Copy

of

your

interstate

SPE

certificate,

exemption

or

waiver

of

certain

physical

defects

issued

by

FMCSA

or

the

individual

State(s),

if

applicable.

*Available

from

the

FMCSA

and/or

other

states

LIMB

IMPAIRMENT

OR

AMPUTATION

FORMS

A

board

‐

certified

or

board

‐

eligible

orthopedic

surgeon,

doctor

of

physical

medicine

or

physiatrist

must

complete

the

Medical

Evaluation

Summary.

Although

you

may

choose

any

qualified

medical

specialist,

we

recommend

that

you

go

to

a

physical

rehabilitation

facility

for

this

examination.

These

facilities

and

their

personnel

generally

have

more

experience

in

evaluating

the

amputee

or

a

limb

‐

impaired

individual.



Application

for

Skill

Performance

Evaluation

Certificate

to

Operate

Intrastate

Commercial

Motor

Vehicles

(Applicant

with

Limb

Impairment

or

Amputation)

(

SPEC

‐

1

FORM

)



Medical

Evaluation

Summary

(

SPEC

‐

A

FORM

)

(Limb

Impairment

or

Amputation

Only)

VISION

IMPAIRMENT



Application

for

Skill

Performance

Evaluation

(SPE)

Certificate

to

Operate

Intrastate

Commercial

Motor

Vehicles

(Applicant

with

Impaired

Vision)

(

SPEC

‐

2

FORM

)



Optometrist/Ophthalmologist

Certification

(

SPEC

‐

D

FORM

)



Affidavit

of

Driving

Experience

(

SPEC

‐

E

FORM

)

INSULIN

‐

TREATED

DIABETES

MELLITUS.



Application

for

Skill

Performance

Evaluation

(SPE)

Certificate

to

Operate

Intrastate

Commercial

Motor

Vehicles

(Applicant

with

Insulin

‐

Treated

Diabetes

Mellitus

(ITDM))

(

SPEC

‐

3

FORM

)



Optometrist/Ophthalmologist

Certification

(

SPEC

‐

D

FORM

)



Affidavit

of

Driving

Experience

(

SPEC

‐

E

FORM

)



Endocrinologist

Certification

(

SPEC

‐

F

FORM

)

Questions?

Contact the MoDOT Motor Carrier Services Safety and Compliance team.

Call toll-free, 1- 866-831-6277.

Return

completed

application

and

supporting

documents

to:

ATTN:

MEDICAL

EXEMPTION

PROGRAM

MoDOT

Motor

Carrier

Services

P.O.

Box

270

(7)

(version 12-18-03)

Page

1 of 4

DRIVER'S ROAD TEST EXAMINATION

Driver's Name: ___________________________________________________

Address: ________________________________________________________

City: __________________________ State: __________ Zip: ___________

Phone: ________________________ Cell: ___________________________

The motor carrier shall give the road test or a person designated by it. However, another person

must give a driver who is a motor carrier the test. A person who is competent to evaluate and

determine whether the person who takes the test has demonstrated that he or she is capable of

operating the vehicle and associated equipment that the motor carrier intends to assign shall give

the test.

Rating of

Performance

______

The pretrip inspection (As required by Sec. 392.7)

______

Coupling and uncoupling of combination units, if the equipment he or she may drive

includes combination units.

______

Placing the equipment in operation.

______

Use of vehicle's controls and emergency equipment.

______

Operating the vehicle in traffic and while passing other vehicles.

______

Turning the vehicle.

______

Braking, and slowing the vehicle by means other than braking.

______

Backing and parking the vehicle.

______

Other, Explain: ______________________________________________

______________________________________________________________________

Type of equipment used in giving test: ______________________________________

______________________________________________________________________

Examiner's Signature: ___________________________________________________

Date: _______________________

(8)

(version 12-18-03)

Page

2 of 4

RECORD OF ROAD TEST

Instructions to Evaluator: Check ( ) items which the driver performs satisfactorily, use "X" where

performance is unsatisfactory. Any item not evaluated, leave blank.

Driver's Name _________ Home Address _

Social Security No. __________________ License No. __________________ State ________ Class _______

Equipment Driven: Truck Tractor ____________________________ Trailer(s) ____________________________

(Make & Model)

(Body Type & Length of Each)

Length of Test ____________________ Mi. From/In _______________ To ______________________________

Start Time ___________________ Finish Time __________________ Weather Conditions _________________

PART 1 PRETRIP INSPECTION AND

EMERGENCY EQUIPMENT

Chec

ks

general

condition

approaching

unit

______

Chec

ks

fuel,

oil.

Water

a

nd

for

excessiv

e

oil

o

n

engin

e

_____

_

Chec

ks aro

und

unit - Tires,

lights,

trailer

hook-up,

brak

e

and

light

line,

door

s

a

nd

inspect

s

for

bo

dy

damag

e

_____

_

Test

s st

eering,

brak

e

action,

tractor

protectio

n

valve,

an

d

parking

br

ake

_____

_

Chec

ks ho

rn,

windshield

wipers,

mirror

s, e

mergenc

y

equipment

;

reflectors,

flares,

fuses,

tir

e

chain

s (i

f

necessary),

fire

equipment

_____

_

Chec

ks ins

truments

for

normal

reading

s

_____

_

Chec

ks das

hboard

warning

lights

for

proper

functioni

ng

_____

_

Cleans

windshield,

windows,

mirror

s,

light

s and

reflector

s

_____

_

Reviews

and

signs

previo

us repo

rt

______

PART 2 COUPLING AND UNCOUPLING

Connect

s

gla

d

hand

s to

trailer

to

apply

trailer

brakes

before

coupli

ng

_____

_

Connect

s

gla

d

hand

s and

light

line

properl

y

_____

_

Couples

without

difficult

y

_____

_

Raises

landing

gear

fully

after

coupli

ng

_____

_

Visually

chec

ks

king

assembly

to

be

certai

n

of

proper

coupli

ng

_____

_

Chec

ks

coupling

by

applying

hand

valv

e

or

tractor-pr

o

tectio

n

valv

e

(trailer

air

supply

valve)

and

gentl

y

applying

pressure

by

trying

to

pull

away

from

trailer

_____

_

Assures

himself

that

surfac

e

will

support

trailer

befor

e

uncoupli

ng

______

PART 3 PLACING VEHICLE IN MOTION

AND USE OF CONTROLS

A.

MOTOR

Places

transmissio

n

i

n

neutral

befor

e

starting

engi

ne

_____

_

Start

s eng

ine

without

difficult

y

_____

_

Chec

ks ins

truments

at

regular

interval

s

_____

_

Maintains

proper

engine

rpm

while

drivi

ng

_____

_

B.

BRAKES

Know

s

proper

use

of

and

chec

ks tr

actor-protec-

tio

n

valve

(trailer

air

supply

valve)

_____

_

Test

s se

rvic

e

brakes

_____

_

Builds

full

air

pressure

befor

e

movi

ng

_____

_

C.

CLUTCH

AND

TRANSMISSION

Start

s

unit

moving

smoothl

y

_____

_

Uses

clutc

h

properl

y

_____

_

D.

LIGHTS

(if

tested

at

night)

Adjusts

spee

d

for

range

of

headlight

s

_____

_

Dim

s l

ights

when

approaching

another

vehicle

or

following

other

traffi

c

______

PART 4 BACKING AND PARKING

A.

BACKING

Gets

out

and

checks

area

befor

e

backi

ng

_____

_

Understand

s and

utilizes

mirror

s pro

perl

y

_____

_

Signal

s

when

backing

(if

appropriate)

_____

_

Avoi

ds bac

king

from

blind

si

de

_____

_

B.

PARKING

(CITY)

Park

s

without

hitting

any

other

vehicles

or

station-

ary

object

s

_____

_

Park

s

correct

distance

from

cur

b

_____

_

Secures

unit

properly - set

s pa

rking

brake,

tran

s

missio

n

in

correct

gear,

shuts

off

engine,

bloc

ks

wheel

s (w

he

n

necessary)

_____

_

Carefully

enter

s tr

affic

from

parked

positio

n

_____

_

C.

PARKING

(ROAD)

Park

s

off

pavement

_____

_

Secures

unit

properl

y

_____

_

Uses

emergency

warning

signal

or

devices

wh

en

(9)

(version 12-18-03)

Page

3 of 4

REMARKS:

______________________________________________________________________________________________

GENERAL PERFORMANCE: Satisfactory

Needs Training

Explain: ____________________________

______________________________________________________________________________________________

QUALIFIED FOR: Straight Truck

TractorSemitrailer

Twin Trailers

Other Combination

Special Equipment _______________________________________________________________

(SPECIFY)

__________________________________________

Date __________________

___

SIGNATURE OF EXAMINER

PART 5 SLOWING AND STOPPING

Uses

clutc

h

an

d

gears

properl

y

_____

_

Gear

s

dow

n

properly

befor

e

descending

hill

s

_____

_

Start

s

without

rolling

bac

k

_____

_

Test

s br

ake

s bef

or

e

descending

grades

_____

_

Uses

brake

s pro

perly

o

n

grades

_____

_

Makes

proper

use

of

mirror

s

_____

_

Plan

s st

op

far

enoug

h

i

n

advanc

e

to

avoi

d

hard

braki

ng

_____

_

Sto

ps

clear

of

cf

crosswal

ks

______

PART 6 OPERATING IN TRAFFIC, PASSING

AND TURNING

A.

TURNING

Signal

s in

tention

to

tur

n

well

in

advanc

e

_____

_

Gets

into

proper

lan

e

well

in

advance

of

tur

n

_____

_

Chec

ks tr

affic

conditions

an

d

turns

only

w

hen

inter-

sctio

n

is

clear

_____

_

Restrict

s t

raffic

from

passing

o

n

right

when

perpar-

ing

to

complet

e

right

hand

tur

n

_____

_

Complete

s tu

r

n

promptly

and

safely

and

does

not

imped

e

other

traffi

c

_____

_

B.

TRAFFIC

SIGN

S

AND

SIGNAL

S

Plan

s st

op

in

advanc

e

an

d

adjusts

speed

correctl

y

_____

_

Obey

s

all

traffic

signal

s

_____

_

Comes

to

a

complet

e

sto

p

at

all

sto

p

sig

ns

_____

_

C.

INTERSECTION

S

Yields

right

of

wa

y

_____

_

Chec

ks

for

cross

traffic

regardles

s

of

traffic

control

s

_____

_

Enters

all

intersectio

ns

prepared

to

sto

p

if

necessar

y

_____

_

D.

GRAD

E CR

OSSING

S

Sto

ps at

a

minimum

15

feet

but

not

mor

e

tha

n 50

feet

before

crossing

if

sto

p

is

necessar

y

_____

_

Select

s pro

per

gear

and

does

not

shift

gears

whil

e

crossi

ng

_____

_

Know

s

and

understand

s F

ederal

and

State

rule

s

governing

grade

crossing

s

_____

_

E.

PASSING

Allow

s

sufficient

space

ahead

for

passi

ng

_____

_

Passes

only

i

n

saf

e

locatio

ns

_____

_

Signal

s

changing

lanes

befor

e

an

d

after

passi

ng

_____

_

Warns

driver

ahead

of

hi

s in

tentio

n

to

pas

s

_____

_

Passes

with

sufficient

speed

differential

to

minimiz

e

obstructing

traffi

c

_____

_

Returns

to

right

lan

e

promptly

but

only

when

safe

t

o

do

so

___

F.

SPEED

Observes

spee

d

limit

s

_____

_

Drives

at

spe

ed

consistent

wit

h

abilit

y

_____

_

Adjusts

spee

d

properly

to

road,

weather

a

nd

traf-

fic

conditio

ns

_____

_

Slow

s

dow

n

in

advance

of

curves,

danger

zones

and

intersectio

ns

_____

_

Maintains constant

speed

where

possibl

e

_____

_

G.

COURTESY

AND

SAFETY

Yields

right

of

wa

y

_____

_

Consistently

strives

to

driv

e

i

n

safe

manner

_____

_

Allow

s

faster

traffic

to

pas

s

_____

_

Uses

horn

only

w

hen

necessar

y

______

PART 7 MISCELLANEOUS

A.

GENERAL

DRIVING

ABILITY

AND

HABITS

Consistently

alert

and

attentiv

e

_____

_

Consistently

is

aware

of

changing

traffic

conditio

ns

_____

_

anticipate

s pro

blem

s

_____

_

Perform

s ro

utine

functions

without

taking

eyes

from

ro

ad

_____

_

Chec

ks ins

truments

regularly

while

drivi

ng

_____

_

Personal

appearance

i

s

professional

_____

_

Remain

s

calm

under

pressur

e

_____

_

B.

USE

O

F

SPECIAL

EQUIPMEN

T

(SPECIFY)

_____________________________________

___

_____

_

_____________________________________

___

_____

_

_____________________________________

___

_____

_

_____________________________________

___

_____

_

_____________________________________

___

_____

_

_____________________________________

___

______

(10)

(version 12-18-03)

Page

4 of 4

CERTIFICATION OF ROAD TEST

Driver's Name __________________________________________________________________

______ ______ ______

_________________________________________ ______________

(Social Security Number)

(Operators or Chauffeurs License Number)

(State)

Type of Power Unit _ Type of Trailer(s) ______

If passenger carrier, type of bus ____________________________________________________

This is to certify that the above named driver was given a road test under my supervision on

___________________________, 20_____ consisting of approximately ____________________

miles of driving.

It is my considered opinion that this driver possesses sufficient driving skill to operate safely the

type of commercial motor vehicle listed above.

_________________________________________________________

___________________

(Signature of Examiner)

(Title)

______________________________________________________________________________

(Organization and Address of Examiner)

(11)

(version 121803)

Page 1 of 2

APPLICATION FOR EMPLOYMENT

COMPANY _____________________ STREET ADDRESS ___________________________________

CITY, STATE AND ZIP CODE ____________________________________________________________

NAME _________________________________________________________

(FIRST) (MIDDLE) (Maiden Name, if any) (LAST)

ADDRESS ___________________________________________________________

HOW LONG? ________

(STREET) (CITY) (STATE & ZIP CODE)

DATE OF BIRTH _____________________________ SOCIAL SECURITY NO. _________________________

TELEPHONE NUMBER _______________________________ EMAIL ADDRESS ________________________

______________________________________________________

HOW LONG? ________

______________________________________________________ HOW LONG? ________

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS DRIVER

STATE

LICENSE NO.

TYPE

EXPIRATION DATE

DRIVER

LICENSES

DRIVING EXPERIENCE

CLASS OF EQUIPMENT

TYPE OF EQUIPMENT

(VAN, TANK, FLAT, ETC.)

DATES

FROM TO

APPROX. NO. OF

MILES (TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMITRAILER

TRACTOR TWO TRAILERS

OTHER

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MOR SPACE IS NEEDED)

DATES

NATURE OF ACCIDENT

(HEADON, REAREND, UPSET, ETC.)

FATALITIES

INJURIES

LAST ACCIDENT

NEXT PREVIOUS

ADDRESS

FOR PAST

THREE

YEARS

(12)

(version 121803)

Page 2 of 2

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING

VIOLATIONS)

LOCATION

DATE

CHARGE

PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES _____ NO _____

B. Has any license, permit or privilege ever been suspended or revoked?

YES _____ NO _____

(IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS)

EMPLOYMENT RECORD (Attach Sheet If More Space Is Needed)

NOTE: DOT requires that employment for at least 3 years and/or commercial driving experience for the past 10

years be shown.

LAST EMPLOYER: NAME _____________________________________________________________________

ADDRESS __________________________________________________________________________________

POSITION HELD ______________________ FROM __________ TO ___________SALARY _______________

REASONS FOR LEAVING _____________________________________________________________________

SECOND LAST EMPLOYER: NAME _____________________________________________________________

ADDRESS __________________________________________________________________________________

REASONS FOR LEAVING _____________________________________________________________________

THIRD LAST EMPLOYER: NAME _______________________________________________________________

ADDRESS __________________________________________________________________________________

REASONS FOR LEAVING _____________________________________________________________________

TO BE READ AND SIGNED BY APPLICANT

This certifies that I completed this application, and that all entries on it and information in it are true and complete to

the best of my knowledge.

__________________________________

______________________________________________

DATE

APPLICANT'S SIGNATURE

Note: A motor carrier may require an applicant to provide information in addition to the information required by the

Federal Motor Carrier Safety Regulations.

(13)

X:\wallat\Posted on Web\Medical Forms\HIPAAcompliantReleaseForm.doc

HIPAA-C

OMPLIANT

A

UTHORIZATION FOR

R

ELEASE OF

I

NFORMATION

P

URSUANT TO

45

C.F.R.

164.508

Patient Name:

Date of Birth:

Provider/Covered Entity:

(Organizations, individuals, or classes of persons requested to disclose patient information)

(To be completed by Motor Carrier Services:)

Name:

Address:

Requestors:

(To whom the provider/covered entity is requested to disclose patient information):

Missouri Highways and Transportation Commission, and/or

Missouri Department of Transportation, Motor Carrier Services Division.

ATTN: Medical Exemption Program—Motor Carrier Services

P.O. Box

Jefferson City, MO 65102-0

TEL: (573) 522-9001; FAX: (573) 522-4260

Information Requested:

The Patient identified above authorizes the disclosure of all protected medical information in any form

(including oral, written and electronic) to the Requestors listed above, and Requestors’ re-disclosure of the data and information

to its agents, consultants, counsel, and whomever Requestors deems reasonable and necessary to further the administration of

the Skill Performance Evaluation Certification program. Patient expressly requests that all covered entities under HIPAA

identified above shall disclose full and complete protected health information concerning the Patient, relating to the time period

beginning on and ending on

, inclusive. This includes, but is not

limited to, the following:



All medical records, including, but not limited to: inpatient & emergency room treatment; all clinical charts, reports,

documents, correspondence, test results, statements, questionnaires/histories, examination reports, office and doctor’s

handwritten notes, and records received from other physicians or health care providers;



All laboratory, histology, cystology, pathology, radiology, CT scan, MRI, echocardiogram reports;



All radiology films;



All pharmacy prescription records.

Purposes of Release:

Release of this information is requested for the purposes of evaluating, reviewing, and monitoring the

patient’s qualifications to operate commercial motor vehicles safely, in connection with the patient’s application for issuance of a

Skill Performance Evaluation Certificate by the Missouri Department of Transportation, Motor Carrier Services Division.

Signature of Patient:

Date:

In addition to the authorization and other provisions contained above, hereby incorporated by reference, I authorize the release

of mental health records (includes psychological testing) to Requestors and re-disclosure of the data and information to their

agents, counsel or whomever Requestors deems reasonable and necessary to further the administration of my Skill

Performance Evaluation Certificate application. This includes any and all data, notes, records, reports and information protected

by state and federal law.

Signature of Patient:

Date:

This authorization is effective until the later of

, or the date when my application for issuance of a

Skill Performance Evaluation Certificate is finally determined, or (if the application is granted) the date when my SPE

Certificate expires.

I understand that I may revoke this authorization at any time, by giving written notice to the Missouri Department of

Transportation, Motor Carrier Services Division, at the address mentioned above. I understand that revocation is only

effective after the written notice is received by MoDOT Motor Carrier Services Division, and that any use or disclosure of the

information under this authorization, made before the revocation is effective, will not be affected by the revocation.

I understand that I am entitled to receive a copy of this authorization.

I understand that, after information is released under this authorization, it may be disclosed by the recipient, and if

re-disclosed, the information will no longer be protected by federal or state privacy rules.

I understand that the covered entity to which this authorization is directed may not condition treatment, payment, enrollment,

or eligibility benefits on whether or not I sign this authorization.

(14)

Medical Examination Report

FOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

1.

DRIVER'S INFORMATION

_{Driver completes this section}

Date of Exam

M Recertification

M / D / Y

Driver's Name (Last, First, Middle)

Social Security No.

Birthdate

Age

Sex

New Certification

F Follow-up

Address

City, State, Zip Code

Work Tel: ( )

Driver License No.

License Class

State of Issue

A

C

B

D

Home Tel: ( )

Other

HEALTH HISTORY

Driver completes this section, but medical examiner is encouraged to discuss with driver.

2.

Yes No

Lung disease, emphysema, asthma, chronic bronchitis _{Fainting, dizziness}

Any illness or injury in the last 5 years? _{Kidney disease, dialysis} _{Sleep disorders, pauses in breathing} Head/Brain injuries, disorders or illnesses _{Liver disease} while asleep, daytime sleepiness, loud

Seizures, epilepsy _{Digestive problems} snoring

medication_______________________________

Diabetes or elevated blood sugar controlled by:

Stroke or paralysis

Eye disorders or impaired vision (except corrective lenses) diet Missing or impaired hand, arm, foot, leg, Ear disorders, loss of hearing or balance pills _{finger, toe}

Heart disease or heart attack; other cardiovascular condition insulin Spinal injury or disease medication_______________________________ Nervous or psychiatric disorders, e.g., severe depression

medication____________________ Chronic low back pain Heart surgery (valve replacement/bypass, angioplasty,

pacemaker) _{Loss of, or altered consciousness} Regular, frequent alcohol use High blood pressure medication___________________ Narcotic or habit forming drug use Muscular disease

Shortness of breath

For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including

over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my

Medical Examiner's Certificate.

Driver's Signature

Date

Medical Examiner's Comments on Health History

(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. This discussion must be documented below. )

(15)

TESTING (Medical Examiner completes Section 3 through 7)

Name: Last,

First,

Middle,

3.

VISION

Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian

measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.

INSTRUCTIONS:

When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a

ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver

habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious.

Monocular drivers are not qualified.

Numerical readings must be provided.

Applicant can recognize and distinguish among traffic control

Yes

HORIZONTAL FIELD OF VISION

ACUITY

UNCORRECTED

CORRECTED

Right Eye

20/

Left Eye

20/

Left Eye

Both Eyes

20/

sign als and devices showing standard red, green, and amber colors

?

No

Applicant meets visual acuity requirement only when wearing:

Corrective Lenses

Monocular Vision:

Yes

No

Complete next line only if vision testing is done by an opthalmologist or optometrist

Date of Examination

Name of Ophthalmologist or Optometrist (print)

Tel. No.

License No./ State of Issue

Signature

4.

HEARING

Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB

Check if hearing aid used for tests.

Check if hearing aid required to meet standard.<

Missouri Skill Performance Evaluation Certificates