Physical Qualifications and Examinations: Medical Examination Report and Medical Examiner's Certificate Forms, 74700-74711 [2016-25976]
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74700
§ 1329.23
Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
Compliance reviews.
(a) Centers receiving Part C funding
shall be subject to periodic reviews,
including on-site reviews, in accordance
with sections 706(c), 722(g), and 723(g)
of the Act and guidance set forth by the
Administrator, to verify compliance
with the standards and assurances in
section 725(b) and (c) of the Act and the
grant terms and conditions. The
Administrator shall annually conduct
reviews of at least 15 percent of the
Centers.
(b) A copy of each review under this
section shall be provided, in the case of
section 723(g), by the director of the
DSE to the Administrator and to the
SILC, and in the case of section 722(g),
by the Administrator to the SILC and
the DSE.
§ 1329.24 Training and technical
assistance to Centers for Independent
Living.
The Administrator shall reserve
between 1.8% and 2% of appropriated
funds to provide training and technical
assistance to Centers through grants,
contracts or cooperative agreements,
consistent with section 721(b) of the
Act. The training and technical
assistance funds shall be administered
in accordance with section 721(b) of the
Act.
[FR Doc. 2016–25918 Filed 10–26–16; 8:45 am]
BILLING CODE 4150–04–P
DEPARTMENT OF TRANSPORTATION
Federal Motor Carrier Safety
Administration
[Docket No. FMCSA–2012–0178]
Physical Qualifications and
Examinations: Medical Examination
Report and Medical Examiner’s
Certificate Forms
Federal Motor Carrier Safety
Administration (FMCSA), DOT.
ACTION: Notice of decision on use of
Medical Examination Report and
Medical Examiner’s Certificate Forms.
AGENCY:
FMCSA announces its
decision to allow certified Medical
Examiners (MEs) to use the Medical
Examination Report (MER) Form,
MCSA–5875, and Medical Examiner’s
Certificate (MEC), Form MCSA–5876,
with October, November, and December,
2015 revision dates that are located in
the top left corner of the forms until
existing stocks are depleted. For MEs in
an office where these forms have been
programmed into an electronic system
jstallworth on DSK7TPTVN1PROD with RULES
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This decision is in effect on
October 27, 2016.
DATES:
You may search background
documents or comments to the docket
for this rule, identified by docket
number FMCSA–2012–0178, by visiting
the:
• Federal eRulemaking Portal: https://
www.regulations.gov. Follow the online
instructions for reviewing documents
and comments. Regulations.gov is
available electronically 24 hours each
day, 365 days a year; or
• DOT Docket Management Facility
(M–30): U.S. Department of
Transportation (DOT), 1200 New Jersey
Avenue SE., West Building, Ground
Floor, Room 12–140, Washington, DC
20590–0001.
Privacy Act: In accordance with 5
U.S.C. 553(c), DOT solicits comments
from the public to better inform its
rulemaking process. DOT posts these
comments, without edit, including any
personal information the commenter
provides, to www.regulations.gov, as
described in the system of records
notice (DOT/ALL–14 FDMS), which can
be reviewed at www.dot.gov/privacy.
ADDRESSES:
49 CFR Part 391
SUMMARY:
that will require IT programming, the
current approved versions of the forms
should be programmed as soon as
practicable. FMCSA published sample
versions of the forms in October and
November 2015 prior to posting fillable
Portable Document Format (PDF)
versions in December 2015. Based on
the fact that the October and November
2015 forms contain minor differences
yet collect the same information as the
fillable PDF version, FMCSA
determined the October and November
versions are acceptable. In addition,
MEs are also allowed to continue to use
the versions of the MER Form, MCSA–
5875, that include the Privacy Act
Statement on page one until stocks are
depleted. For MEs in an office where
these forms have been programmed into
an electronic system that will require IT
programming, the current approved
versions of the forms should be
programmed as soon as practicable. The
versions of the forms currently posted
by FMCSA include nonsubstantive
changes that were approved by the
Office of Management and Budget
(OMB) on April 7, 2016 and September
6, 2016, and no longer include the
Privacy Act Statement or a revision date
in the top left corner. State Driver’s
Licensing Agencies (SDLAs) should not
accept versions of the MEC that have
not been approved by OMB, and do not
display both the FMCSA form number
(MCSA–5876) and the OMB expiration
date of August 31, 2018.
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Ms.
Christine A. Hydock, Chief, Medical
Programs Division, Office of Policy,
Federal Motor Carrier Safety
Administration, 1200 New Jersey
Avenue SE., Washington, DC 20590;
telephone (202) 366–4001;
fmcsamedical@dot.gov. If you have
questions about viewing or submitting
material to the docket, contact Docket
Services, telephone (202) 366–9826.
SUPPLEMENTARY INFORMATION:
FOR FURTHER INFORMATION CONTACT:
I. Background
On April 23, 2015, FMCSA published
a final rule adopting regulations to
facilitate the electronic transmission of
MEC information from FMCSA’s
National Registry system to SDLAs for
holders of Commercial Driver’s Licenses
(CDL) and Commercial Learner’s
Permits (CLP). The final rule also
requires the use of the prescribed MER
Form, MCSA–5875, in place of the MER
and the prescribed MEC, Form MCSA–
5876, in place of the MEC. Medical
Examiner’s Certification Integration (80
FR 22790, April 23, 2015). On August 5,
2015, FMCSA received approval from
OMB, for use of the MER Form, MCSA–
5875, and MEC, Form MCSA–5876, in a
fillable Adobe AcrobatTM format.
FMCSA published sample versions of
the MER Form, MCSA–5875, and MEC,
Form MCSA–5876, with October and
November, 2015 revision dates on the
National Registry Web site with the
intent and purpose of educating MEs
regarding the use of new categories on
the forms and assisting MEs in
programming electronic medical records
prior to the Agency’s posting of the
fillable Adobe AcrobatTM versions. At
that time, at least one company that
produces regulatory compliance
publications and forms began printing
and selling the MER Form, MCSA–5875,
and MEC, Form MCSA–5876, with
October and November, 2015 revision
dates. On December 14, 2015, FMCSA
posted the fillable Adobe AcrobatTM
versions of the MER Form, MCSA–5875,
and MEC, Form MCSA–5876, with
December 2015 revision dates on the
FMCSA and National Registry Web
sites. Based on the fact that the October
and November, 2015 forms contain
minor differences yet collect the same
information as the fillable Adobe
AcrobatTM versions posted by FMCSA
on December 14, 2015, FMCSA made
the decision to allow MEs to use any
previously purchased existing stock of
the MER Form, MCSA–5875, and MEC,
Form MCSA–5876, with October or
November, 2015 revision dates until
stocks are depleted. For MEs in an office
where these forms have been
E:\FR\FM\27OCR1.SGM
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Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
jstallworth on DSK7TPTVN1PROD with RULES
programmed into an electronic system
that will require IT programming, the
current approved versions of the forms
should be programmed as soon as
practicable.
On December 21, 2015, FMCSA
published guidance providing a 120-day
grace period during which MEs were
allowed to use either the old MER and
MEC or the newly prescribed MER
Form, MCSA–5875, and MEC, Form
MCSA–5876, until April 20, 2016 (80
FR 79273).
Subsequently, after receiving OMB
approval for nonsubstantive changes to
the forms, FMCSA posted the current
versions of the MER Form, MCSA–5875,
and MEC, Form MCSA–5876, on the
FMCSA and National Registry Web sites
on April 13, 2016. The current versions
include several OMB approved
nonsubstantive and functional changes
but no longer include a revision date in
the top left corner. The specific OMB
approved non-substantive and
functional changes can be found on the
Office of Information and Regulatory
Affairs Web site by selecting the
following link, https://www.reginfo.gov/
public/do/PRAViewDocument?ref_
nbr=201604-2126-006, and then
selecting the link for ‘‘Justification of
Nonmaterial/Non-substantive Change.’’
On June 7, 2016, the Department of
Transportation’s Chief Privacy Officer
and Office of General Counsel reviewed
the requirements of the rulemaking and
determined that the collection of
information maintained and held by
MEs does not constitute information
protected by the Privacy Act. Therefore,
FMCSA submitted to OMB for approval
a request for additional nonsubstantive
changes including removal of the
Privacy Act statement on page one of
the MER Form, MCSA–5875, and the
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addition of disclaimer language
regarding the protection of sensitive
information that was approved on
September 6, 2016. FMCSA has posted
the current versions of the MER Form,
MCSA–5875 and MEC, Form MCSA–
5876 on the FMCSA and National
Registry Web sites. The additional
OMB-approved non-substantive changes
can be found on the Office of
Information and Regulatory Affairs Web
site by selecting the following link
https://www.reginfo.gov/public/do/
PRAViewDocument?ref_nbr=2016042126-006, and then selecting the link for
‘‘Justification of Nonmaterial/Nonsubstantive Change.’’
II. Acceptable Versions of Forms
All changes to the MER and MEC
forms since the August 5, 2015, date on
which OMB provided approval for use
of the forms were nonsubstantive in
nature. Therefore, MEs are allowed to
use MER Form, MCSA–5875, and MEC,
Form MCSA–5876, with October,
November, and December, 2015 revision
dates until existing stocks are depleted.
This includes forms produced by the
private sector with October or
November, 2015 revision dates that
FMCSA never intended to be published
for use by the public and fillable forms
posted on the FMCSA and National
Registry Web sites on December 14,
2015, as well as the MER Form, MCSA–
5875, that includes the Privacy Act
Statement on page one. For MEs in an
office where these forms have been
programmed into an electronic system
that will require IT programming, the
current approved versions of the forms
should be programmed as soon as
practicable. MEs are also encouraged to
use the current versions of the forms
that no longer include the Privacy Act
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74701
Statement or a revision date in the top
left corner, and can be found on the
FMCSA and National Registry Web
sites.
Under the provisions of 49 CFR
383.71(h), until June 22, 2018,
commercial motor vehicle (CMV)
drivers operating vehicles that require a
CDL or CLP are required to provide
SDLAs with an original or a copy of the
MEC, Form MCSA–5876, for entry of the
medical certification status on the driver
record. FMCSA has learned that some
SDLAs are refusing to accept from CMV
drivers the MEC, Form MCSA–5876,
with an October or November, 2015
revision date. In view of the clarification
in this document of the status of the
MEC, Form MCSA–5876, with various
revision dates, FMCSA is directing
SDLAs to accept the MEC, Form MCSA–
5876, with October, November, and
December, 2015 revision dates until
existing stocks are depleted. SDLAs
should also be accepting the versions
that were posted on April 13, 2016, on
the FMCSA and National Registry Web
sites that no longer include a revision
date in the top left corner and the
current version of the MER Form,
MCSA–5875, that is posted on the
FMCSA and National Registry Web sites
that no longer includes the Privacy Act
Statement on page one. On the other
hand, SDLAs should not accept versions
of the MEC that have not been approved
by OMB and do not display both the
FMCSA form number (MCSA–5876) and
the OMB expiration date of August 31,
2018. The final versions of the forms
published on the FMCSA and National
Registry Web sites are shown below for
your reference.
BILLING CODE 4910–EX–P
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74702
Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
Medical Examination Report Form, MCSA-5875 Posted September 20, 2016
-------------~
City: _ _ _ _ _ _ _ _ Stmtl'l'l'ovlnce:_._._ _ ZlpCodee _ _ _ _ 1
CLP/CDLApplicanti'Holdar":
0
~
0
No
Cr1ver IDVertfitd Bt"": _____________ l
I HlrsycMJrlJSOOT/FMi::SAmedical certifimeell!!fbeen denied or issued for less than 2year.51 0 Ys 0 No 0 Not SuN
L'RIVER HEALTH HIS TOR\
Ovw ONo 0
Haw you -had sulgGI')I? If "yes." plaase listanci4111Cp!ain b"'-.
ARt you curnmtlytakilg medications (presc~over-lhe,cwnter, herbalremedies.,dietwppkme:nts}l
pleasedemibe below.
If·~
Not Sure
QV.QNoQNotSure
'"'This doc1.1111erot «itttiolnssensltlvol inforiMllon and is forolllclalme only. lmpropo~t handling ofthis lnforiMllon could negativ<ilylffe.:t lndllllduals. Handle and secure this
Wonnation appn>Pflahlyto PfE'Wnt inadwm.ntdi<clo<""' b)II<M>plng till! documents under the control ofautmriad PI!""M. Properlydlspooeofthlsdocumontwhl!n
no lo"'!l"r requlrndto b•>~naOIVIoinnd bJ1 regulotoll' requirementS...
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008:
First Name:
DRIVER
~IEALTH
HISTORY
74703
,
Not
Doyw have- haveyw- .....
I. Hudibrain injuriftorillnesses (eg.cooaJSSioti)
2. Seizure, epilepsy
3. Eye problams (~g~D=sorconttxts)
4. Ear and/or hearing pRlblem5
s. Hean disease; heart attack. bvpass.orotherheart
problarns
6. Pacemaker, stents, Implantable devices, or other hurt
procedUiti
7. High blood prusun~
s. High cholesterol
9. Chronic: llong"'lilm'i! cough, shortnfiS ofb-11. or other
breathing problams
I G. lung disease {e:g. asthma!
11. Kicbey pRlblems, kidney stone, or palnlpd>lems with
urination
I z. Stomach.llwr, or digestive problans
I !1. Diabetes or blood sugar problems
lmullnused
14. Anxitty, depression. MrVOUsness,other mental health
problems
IS. Ftintlng or pa,sslng out
Not
Ys No Sul'e
Ys No Sul'e
000
00 0
00 0
00 0
00 0
00 0
00 0
000
00 0
00 0
00 0
00
00
00
00
0
0
0
0
00 0
16. Diulnes$, hudach..., numbnau, tingling. or mamory
loss
I 7. U,_p!ained weight loss
!8; Strolal.minktrok» (TIA). paralysis, or weakness
19. Missing or limited use of a1111, hand, finger, leg. foot, toe
20. Neck or back problems
21. Bone. muscle. Joint or nerve problems
22. Blood clots or bi<Ndf1g pRlblams
23.Cancer
24. Chronic (long-term)lnfection or other chronic: dls8ses
25. Slap dis:ordGH, pauses in b-hingwhile asleep,
daytlmesleepinau,loud snoring
26. Have you ever had a !IMp test (eg.,s/eepapt~e/1)1
27. HII\'IOyou- spent a night In the hospital!'
28. Have you ever had a broken bone?
29.Hawyou-usedordoyounowUHtobacc:o7
3tl. Do ycu CUINMiy drink alcchol7
31. Have ycu used an IUegal submnc• wllhln the past two
yors?
32. H-you ever ailed a drug test or been dependent on
lin lftegal substance?
00 0
00 0
000
00 0
00 0
00 0
00 0
000
00 0
00 0
00 0
000
00 0
00 0
00 0
00 0
00 0
ORo ONotSUH
Olharholth condltlan(s) not dascribecl above:
OM
Did you answ«"Yes"toany of questiOns 1-32? If so. please comment further on those health conditions belcw.
Ov- 0No ONotSUH
Icertiljr that the aboveillfonnation is accul'lltaand complata.l understand that inamnta. false or missing infonnatiOn may invalidate the l!lfllmination
and my Medical Examillel's Cettific:ata, tllllt submlsslon affrauclulllnt or intentionally false information in 'iiolation of§ CFR 3!!!l35, and tllllt submission
offraudulent or intentionaUyalse: informlitiOn may subject me to civil or criminal penalties under42CFB39!!.37 and~ Appendices Aand a.
Drivar's Signatu111:
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Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
I
Exam Date:
First Name:
last Name:
TESTING
Pulseratil< · - - - Pulserhythmregular:OYes 0No
Systolic
Urin¥s
Diastolic
Sitting
Se<cnd reading
(optional)
Sp, Gr.
Protl!in
Sugar
Blood
Urinalysis lnequlred.
Num!!lkal readingS
must be recorda<!.
Plme/Jl llloc4 orwgarin the: urinemaybeanindicatior> forfilrthe:rtesting to
Oth• tasting lflndlcatad
lilleoutanyood.~medicaiPfO!;IIem.
Htlring
Vklon
Stondard i$ «least 20140acuity(Sneffen) in each eye with orwilhwtcorreaia!.At Stat>dcrd:Must lil:st petee/vewhisperedvoice<ltoot less than 5feet0Ravetage
least 70"fieldafvision in horizontal meridian meawredin each eye. The: use ofa:JF· hemingmofless thanorl!!qlalto4/ld8, in better.ear(with or without hearing ail$.
red:ive /ensesshouldbenotedon theMedital&ominefs Cettifil::ate.
AcUity
Uncorrected
201_
201_
201_
Corrected
201_
20/_
201_
Horizontal Field ofVIslofl
Checkifht~~~ringaidUSI!dfor-:
ORightE'ar OlaftE'ar OHeither
Right E'ar Laft EaT
Record dis!ance (in ~from dl'lwratwhlch a foKI!d
Whisper Test lleaults
Aight Eye: _dagrMS
LeftEye: _degrees
whispe!'Uvoicecanflrstbeheard
Yti1 No OH
Applicant can recognizund distinguish among traffic control
signals and devla!s shQwlng red, gra1n, and amber colors
0 0
A!ldl•etricTestllwula
Mcnocularvision
Referred to ophthalmologist or optometrist7
flecl!IV«< documentation frorn cphthalmologis! or optomMrlst?
0 0
flight Ear
SOOHz
2000Hz
500Hz
1000Hz
2000Hz
00
Normal Abnormal
llodyS,St.m
Left Ear
1000Hz
1.General
2 Skin
0
0
0
Hyes
4. E'ars
s. MoutMhroat
Normal Abnormal
Bod,S,St.m
0
0
10. Back/Spine
0
0
0
0
0
0
0
7. Lungs/chest
0
0
0
6. Cardiovascular
0
0
&Abdomen
9. Genfto.ur!Nl')l $)'Starn Including hemlas
0
0
0
11. Extremities/joints
12. Neurological system including~
13. Gait
14. Vascular system
0
0
0
0
0
0
0
0
DlscJssanyabnarmal ~In derollin tht sprxebelow!llldindla!rrwtltthe:r itwoold affect.flledrlvers ablliry rooperarro CMv.
Etlterappl/albklfein nurnberbe(Qr!teodlcomment
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last Name:
First Name;
MEDICAl EXAMINER DETERMINATION
74705
0011:
F"d"'"l'
USe tha~·mmm~mtilwperfonnedln!l«l1td!itlcewltltthl!f!<deml ,«owrCoiritrSakf¥Regulation$ t49CFRW.4!:39J.421:
0
0
0
~:leG$ not mtilt standards (specify 111!1!00):
MlllltSstandaldsin49CFR 3!11 Al:qualiflts for 2-yurc~
Meets standardr, but periodic monitoring required (specify reasoo):
Dr(wr qualified for: 0 3months 0 6months 0 1yaar
Qothar(spt!<:lzyr.
0 W.rlng c:orrec~lve lenses
0 Wearing hearing aid 0 Accompanied by a waiver/exemption (spe.a1ji(JIPe):
0 A«ompanied by a Skill ParformancA> Evalilatioo (SPE) Cartificata 0 Qualified by oparatfl:m of49 CfB 3!U 64 l&:dggO
0 Driving within an exempt intracity zone (see49CFR39L@~
0 Determination pending (spedfy111!1!00):
0 Return to medical acam officteforfolfow.upon (rOOSt be45 days orkss}:
0 Medical Examination Reporumended (spec:i/ytWS011}!
llfamendet:JJ Medical Examlnet"sSignatune:
0
Data:
Incomplete examfnatlon {sped(yreaSOil}!
!lftl!ell'lvlrmHIIII!e~•llnlllln~mtmo!],lhencomplateaMeclkalbM!Ina's(lrtlftateassfilltdln~IJRDJ.dhl.asappreprlin.[
t haw performed this evaluation for certification. I have personally reviewed all.availablerecords and recorded Information pertaining to this evaluation,
and attest that to the best of my lcnowle.clge, I believe It to be true and correct.
Medical Examiner's Slgnatura:
Medical Examlnal's Nama (please print or~
State _ _ ZipCodR:.
Medical &aminal's Address:
City:
Medical ExaminenTelephone Number:
DateO!I'tiflc:ate Signed:
Issuing State: _ _
Medical EXaminer's State License. catiflcate. or Reglstratfl:m Number:
0MD Doo 0 l'tiysiclan AssiStant
0 OtherPmctitione.r (speclzyr.
0
Chiropractor
0
Advanced Praetlc:e Nu!'H
1Medical Examinel's Certificate: Expiration Date:
National RegistiY Number:
I
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Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
I
First Name:
last Name:
DOB:
MEDICAl EXAM!NtR PEHRMINATION '$tot¢'
/Jtethlsteaiol'lfMV~Jmfntltlons~ill~wltlt!MFedem!MotorCarrier&!fely~fftCFR3?l.4!-39U91wltltiHiy~State
.vaflanas (which wi/JOnlybevalldfMiiltnJsttJteopetiJI»ns}:
0
0
0
0
0
Does not meet standards in 49 CFR391A1 with any appllcableStatevarianc:es (specify reasoni:
Memstandardsln49 CFU!!1.41 with any applcableStatnarlances:
Meets standards, but periodic monitcring required {spedfyMason}:
err-qualll!ed for: Q3months Q6months Q!yur Q other (spocify):
0 waring h1111ring aid 0 Accompanied by a wai-/exA~tnption C;pedl'ytype;:
Waaring ccrra:ti~lenAccompani.t by a Skill Performance Evaluation (SPE) Certificata 0 GrandfatMred from State requiram~~nts c;totl!)
llfthdilnrllillllslhellaMar&tdlne41n~aB~I~,wfthapplaiMtStatt:'llllllal-, lhiR-JIIIttaMiilk:ll ~IRI'll Ce111caR.•Iplll'lllllaa.l
I haU. parfonned this evaluation for Cllrtifrc:ation.l ha~ piiiSOnally re'llii!Wid all availableNCOrds and l'8alrded Information pertaining to this evaluation,
and attest that to the best of my linowledge, I believe it to be true and correct.
Medicall?xaminm Signature:
Medio::tll?xamlnen Name (J>feaseptirot« type~
Medical !x~tmiMI's Address:
City:
Medicall?xaminmTalephona Number:
Dlte~ificateSigMd:
State--· Zfp Code:
Issuing State _ _
Medlcall?xaminen State ll~ c.rtlficate, cr Registration Number:
ODD
0 Physician Assistant 0 Chllopractor 0 Advanced Practice Num~
0MD
0 Other Practitioner (specify):
r,,-..
,~",·~~"'
Na!lional Registry Number. L ... ~.
~ •'~-~-~"-'
-~
'"- -~- ---~
~--
I
'
Medical Examiner's Certificala Expiration Date
l
I
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74707
Instru.ctions for Completing the Medical Examination Report Form (MCSA-5875)
L Step-By-Step .lnstm.etiom
Ddver:
Semon 1: Driver information
PenonaliJd'o:rmation: Please complete 1his section using your name as written on your driver's license. your
outterJt address and phone number, your date ofbirlh. age, gender> driver's license number and issuing state.
o
CLPICDL Applicant/Holder: Check ''yes" if you are a commercial teamer's pennit (CLP) or com~
mercial driver's license (CDL) hOlder, or are applying for aCLP or CDL. CDLttteans a license
issued by a State orlhe District of Cohmbia which authorizes the individual to operate a class of a
commercial motor vehicle (CMV). A CMV that requires a CDL is one that: (l) has a gross combination weight rating or gross combination weight of 26.001 pounds or more inclusive of a towed unit
with a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000
pounds; or (2) bas a GVWR or GVW of26,001 pounds or more; or (3) is designed to transport 16 or
more passengers, including the driver;. or (4) is used to transport either hazardous materials requiring
hazardous materials placards on the vehicle or any quantity of a select agent or toxin.
o Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID
used to verifY the driver's identity sud~ as, commercial driver's license, driver's license, or pas!IJI'Od. etc.
o Question: Has your USDOTIFMCSA medical certlfleate ever been denlecl or Issued for less than
two years? Please check the correct box "yes" or "no" and ifyou aren't sure Check the ''not sure" box.
Driver Health mstory:
o Have yoo ever had ftll'lleJ'Y! Please check ''yes" ifyou have ever had surgery and provide a written
explanation of the details (type of surgery, date of S\lrgel'y, etc.)
o
Are you c:u.rrently taking medleatiODS (pD!SCI'Iptlon., over-the-counter, herbal remedies, dJet
supplements): Please check "yes" if you are taking any diet supplements, herbal remedies. or
prescription or over the counter medications. In the box below the question, indicate the name of the
medication and the dosage.
o #l-32: .Please complete this sectioo by cbecldngthe "yes" box to indicate that you have, or have ever bad,
the health oondit:ion listed or the "No" box if you have not. Check the "not sure" box if you are unsure.
o other Health CondltiODS not tlescriiJed allove; Ifyou have. or have had, any other health conditions not listed in the section above. dleck:''Yes" and in the box provided and list those condition(s).
o Any yes IIIISWers to qaestions #1-32 above: lfyou have answered "yes" to any ofthe questions in
the Driver Health History section above, please explain your answers further in the box. below the
question. For example, if you answered "yes" to question #5 regarding heart disease, heart attack.
bypass, or other heart problem, indicate which type of heart condition. If you checked "yes" toquestion #23 regarding cancer, indicate the type of cancer. Please add any infonnation that win be heJpful
to the Medical Examiner,
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CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating
that the information you provided in Section 1 is accurate and complete.
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Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
Me4ieal Examiner:
Section 2: Examination Report
Driver Health History Review: .Review answers provided by the driver in the driver health history
section and discuss any «yes" and "not sure" responses. In addition. be sure to oompare the medication
list to the health history responses ensuring that the medication list matches the medical conditions
noted. Explore with the driver any answers that seem unclear. Record any information that the driver
omitted. As the Medical Examiner conducting the driver's physical examination you are required to
complete the entire medical examination even if you detect a medical condition that you consider
disqualifYing. such as deafuess. Medical Examiners are expected to determine the driver's physical
qualification for operating a commercial vehicle safely. Thus, if you find a disqualifYing condition for
which a driver may receive a Federal Motor Carrier Safety Administration medical exemption, please
record that on the driver's Medical Examiner's Certificate, Form MCSA-5876. as well as on the Medical
Examination Report Form. MCSA-5875.
Testing:
o Pulse rate and rhythm, JaeiPt, and wdght: record these as indicated on the form.
o
Blood Pressure: record the blood pressure (systolic and diastolic) ofthe driver being examined. A
second reading is optional and should be recorded if found to be necessary.
o
Urinalysis: record the numerical readings for the speeific gravity. prolein. blood and sugar.
o Vlsioa: The current vision standard is provided on the form. When other than the Snellen chart is
used, give test results in SneHen•oomparable values. When recording distance vision, use 20 feet as
normal. Record the vision acuity results and indicate if the driver can recognize and distinguish
among traffic control signals and devices showing red, green. and amber colors; has monocular
vision; has been referred to an ophthalmologist or optometrist; and if documentation has been
received from an ophthalmologist or optometrist.
o
Bearing: The current hearing standard is provided on the form. Hearing can be tested using either a
whisper lest or audiometric test. Record the test results in the corresponding section for the lest used.
PhyUeal Examination: Check the body systems for abnormalities and indicate normal or abnormal for
each body system listed. Discuss any abnormal answers in detail in the space provided and indicate
whether it would affect the driver's ability to safely operate a commercial motor vehicle.
ln. litis nut Bdtm, you will be contpleting either the FedJmll or Stllttl ~not IJotlt.
Medieal Examiner Determination (Federal): Use this section for examinations performed in
accordance with the FMCSRs (49 CFR 391.41-39:1.49). Complete the medical examiner determination
sectionoompletely. When determining a driver's physical qualification. please note that English language
proficiency (49 CFR part 391.11: General qualifications of drivers) is not factored into that
determination.
o Does not meet standards: Select this option when a driver is determined to be not qualified and
provide an explanation of why the driver does not meet the standards in 49 CFR391.41.
o Mods standa:nls in 49 CFR 391.41; qualities for l-year t:erliliadioa: Select this option when a
driver is determined to be qualified and will be issned a 2-year Medical Examiner's Certificate.
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o Meets standards, hut periodi~ monitoring is n:quired~ Select this option when a driver is determined to be qualified but needs periodic monitoring and provide an explanation ofwhy periodic
monitoring is required. Select the corresponding time frame that the driver is qualified and if selecting other, specifY the time frame.
Dderminatioa that driver meets standards: Select all categories that apply to the driver's
certification (e.g., wearing coiTeCtive lenses, accompanied by a waiver/exemption, driving
within an exempt intracity zone, etc.).
o Ddemdnatlon pending: Select this option when more infonnation is needed to make a qualification
decision snd specifY a date, on or before the 45 day expiration date, for the driver to return to the
medical exam office for follow-up. This will allow for a delay of the qualification decision for as
msny as 45 days. If1he disposition of the pending examination is not updated via 1he Nab.Onal Regis·
tty on or before the 45 day expiration date, FMCSA will notifY the examining medical examiner snd
1he driver in writing that the examination is no longer valid snd that the driver is required to be reexamined.
MER amended: .A Medical Examination Report Fonn (MER). MCSA-5875, may only be
amended white in determination pending status for situations where new infonnation (e.g., test
results. etc.) has been received or there has been a change in the driver's medical status since the
initial examination. but prior to a fmal qualification determination. Select this option wherta Medical Examination Report Forttt, MCSA-5875, is being amended; provide the reason for the amendment, sign snd date. In addition_ initial and date any chsnges made on the Medical Examination
Report Form, MCSA-5875. A Medical Examinatioo Report Forttt, MCSA-5875, cannot be
amended after sn examination has been in determination pending stalus for more than 45 days or
after a final qualification detetmination has been made. The driver is required to obtain a new physical examination snd auew Medical Examination Report Form. MCSA-5875, should be oompleted.
o
Ineomplete examinatlou: Select this when the physical examination is not completed for sny
reason (e.g., driver decides they do not want to continue with the examinatloo snd leaves) other
thsn situations outlined under determination pending.
o Metlical Examiner illfonnation, signature and date: Provide your name. address. phone number.
occupation. license, certificate. or registration number snd issuing state. national registty number.
sigoature snd date.
o Metlieal Examiner's CertUicate .Expiration Date: Enter the date the driver's Medical Examiner's
Certificate (MEC) expires.
Medieal Examiner Detennination (State)~ Use this section for examinations perfonned in accordance
with the FMCSRs (49 CFR 391.41-391.49) with any applicable State varisnoes (which will ooly be valid
for intrastate operations). Complete the medical examiner determination section completely.
o Does not meet standanls in 49 CFR 391.41 with llftY applicable State variances: Select this
option when a driver is determined to be not qualified and provide sn explanation of why the driver
does not meet the standards in 49 CFR 391.41 with any applicable State variances.
o Meets standards in 49 CFR 391.41 with IIDY .applleable State vadanees: Select this Option when
a driver is determined to be qualified snd will be issued a 2-year Medical Examiner's Certificate.
o
Meets standanls,.llut periodic monitoring is required! Select this optioo when a driver is determined to be qualified but needs periodic mooitoring and provide an explanation of why periodic
monitoring is required. Select the corresponding time frame that the driver is qualifted snd if selecting other, specifY the time frame.
Determinatiou that driver meets stand.arcls: Select aU categories that apply to the driver's
certification (e.g,. wearing corrective lenses, accompanied by a waiver/exemption, etc.).
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o Medkal Examinerinfonnation. signature and date; Provide your name. address. phone number,
occupation, Hcense. certificate, or registration number and issuing state, national registty number,
signature and date.
o Medkal Examiner'sCerttfteate Expiratioo Date: Enterthe date the 41riverts Medical Examiner's
Certificate (MEC) expires.
n.
Ifupdating an esfsting exam, you must l'elllbmit the new exam results, via the Medical Exandnatlou
Results Fonn, MCSA-5850, to tbe National Registry, and the most neent dated exam wDI take
precedence.
m. To obtaill ad.ditlooal infonnation regarding tbis fonn go to the Medkal Program's page on tbe Federal
Motor Carrier Safety Administration's website at http;/lmyw.fmqa.d.ot.&Qv!J:gulaflonslmedkal.
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Federal Register / Vol. 81, No. 208 / Thursday, October 27, 2016 / Rules and Regulations
pursuant to the Marine Mammal
Protection Act (MMPA). This action is
being taken as a result of a status review
conducted by NMFS in response to a
petition to designate a group of beluga
whales in the western Sea of Okhotsk as
a depleted stock. The biological
evidence indicates that the group is a
population stock as defined by the
MMPA, and the stock is depleted as
defined by the MMPA.
[FR Doc. 2016–25976 Filed 10–26–16; 8:45 am]
BILLING CODE 4910–EX–c
DEPARTMENT OF COMMERCE
National Oceanic and Atmospheric
Administration
This final rule is effective
November 28, 2016.
DATES:
50 CFR Part 216
[Docket No. 151113999–6950–02]
Designating the Sakhalin Bay-Nikolaya
Bay-Amur River Stock of Beluga
Whales as a Depleted Stock Under the
Marine Mammal Protection Act (MMPA)
National Marine Fisheries
Service (NMFS), National Oceanic and
Atmospheric Administration (NOAA),
Commerce.
ACTION: Final rule.
jstallworth on DSK7TPTVN1PROD with RULES
AGENCY:
We, NMFS, issue a final
determination to designate the Sakhalin
Bay-Nikolaya Bay-Amur River Stock of
beluga whales (Delphinapterus leucas)
as a depleted stock of marine mammals
SUMMARY:
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Copies of supporting
documents, including the status review,
the proposed rule, and a list of
references cited in the final rule, are
available via the Federal e-rulemaking
Portal, at www.regulations.gov (search
for Docket ID NOAA–NMFS–2015–
0154), or at https://
www.fisheries.noaa.gov/pr/species/
mammals/whales/beluga-whale.html.
Those documents are also available
from NMFS at the following address:
Chief, Marine Mammal and Sea Turtle
Conservation Division, Office of
Protected Resources, National Marine
Fisheries Service, 1315 East-West
Highway, Silver Spring, MD 20910–
3226.
ADDRESSES:
RIN 0648–BF55
PO 00000
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FOR FURTHER INFORMATION CONTACT:
Shannon Bettridge, Shannon.Bettridge@
noaa.gov, Office of Protected Resources,
301–427–8402.
SUPPLEMENTARY INFORMATION:
Background
Section 115(a) of the MMPA (16
U.S.C. 1383b(a)) allows interested
parties to petition NMFS to initiate a
status review to determine whether a
species or stock of marine mammals
should be designated as depleted. On
April 23, 2014, we received a petition
from the Animal Welfare Institute,
Whale and Dolphin Conservation,
Cetacean Society International, and
Earth Island Institute (petitioners) to
‘‘designate the Sakhalin Bay-Amur River
stock of beluga whales as depleted
under the MMPA.’’ We published a
notification that the petition was
available (79 FR 28879; May 20, 2014).
After evaluating the petition, we
determined that the petition contained
substantial information indicating that
the petitioned action may be warranted
(79 FR 44733; August 1, 2014).
Following the determination that the
petitioned action may be warranted, we
convened a status review team and
conducted a status review to evaluate
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Issued on: October 20, 2016.
T.F. Scott Darling, III,
Administrator.
74711
]]>Agencies
[Federal Register Volume 81, Number 208 (Thursday, October 27, 2016)]
[Rules and Regulations]
[Pages 74700-74711]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-25976]
=======================================================================
-----------------------------------------------------------------------
DEPARTMENT OF TRANSPORTATION
Federal Motor Carrier Safety Administration
49 CFR Part 391
[Docket No. FMCSA-2012-0178]
Physical Qualifications and Examinations: Medical Examination
Report and Medical Examiner's Certificate Forms
AGENCY: Federal Motor Carrier Safety Administration (FMCSA), DOT.
ACTION: Notice of decision on use of Medical Examination Report and
Medical Examiner's Certificate Forms.
-----------------------------------------------------------------------
SUMMARY: FMCSA announces its decision to allow certified Medical
Examiners (MEs) to use the Medical Examination Report (MER) Form, MCSA-
5875, and Medical Examiner's Certificate (MEC), Form MCSA-5876, with
October, November, and December, 2015 revision dates that are located
in the top left corner of the forms until existing stocks are depleted.
For MEs in an office where these forms have been programmed into an
electronic system that will require IT programming, the current
approved versions of the forms should be programmed as soon as
practicable. FMCSA published sample versions of the forms in October
and November 2015 prior to posting fillable Portable Document Format
(PDF) versions in December 2015. Based on the fact that the October and
November 2015 forms contain minor differences yet collect the same
information as the fillable PDF version, FMCSA determined the October
and November versions are acceptable. In addition, MEs are also allowed
to continue to use the versions of the MER Form, MCSA-5875, that
include the Privacy Act Statement on page one until stocks are
depleted. For MEs in an office where these forms have been programmed
into an electronic system that will require IT programming, the current
approved versions of the forms should be programmed as soon as
practicable. The versions of the forms currently posted by FMCSA
include nonsubstantive changes that were approved by the Office of
Management and Budget (OMB) on April 7, 2016 and September 6, 2016, and
no longer include the Privacy Act Statement or a revision date in the
top left corner. State Driver's Licensing Agencies (SDLAs) should not
accept versions of the MEC that have not been approved by OMB, and do
not display both the FMCSA form number (MCSA-5876) and the OMB
expiration date of August 31, 2018.
DATES: This decision is in effect on October 27, 2016.
ADDRESSES: You may search background documents or comments to the
docket for this rule, identified by docket number FMCSA-2012-0178, by
visiting the:
Federal eRulemaking Portal: https://www.regulations.gov.
Follow the online instructions for reviewing documents and comments.
Regulations.gov is available electronically 24 hours each day, 365 days
a year; or
DOT Docket Management Facility (M-30): U.S. Department of
Transportation (DOT), 1200 New Jersey Avenue SE., West Building, Ground
Floor, Room 12-140, Washington, DC 20590-0001.
Privacy Act: In accordance with 5 U.S.C. 553(c), DOT solicits
comments from the public to better inform its rulemaking process. DOT
posts these comments, without edit, including any personal information
the commenter provides, to www.regulations.gov, as described in the
system of records notice (DOT/ALL-14 FDMS), which can be reviewed at
www.dot.gov/privacy.
FOR FURTHER INFORMATION CONTACT: Ms. Christine A. Hydock, Chief,
Medical Programs Division, Office of Policy, Federal Motor Carrier
Safety Administration, 1200 New Jersey Avenue SE., Washington, DC
20590; telephone (202) 366-4001; fmcsamedical@dot.gov. If you have
questions about viewing or submitting material to the docket, contact
Docket Services, telephone (202) 366-9826.
SUPPLEMENTARY INFORMATION:
I. Background
On April 23, 2015, FMCSA published a final rule adopting
regulations to facilitate the electronic transmission of MEC
information from FMCSA's National Registry system to SDLAs for holders
of Commercial Driver's Licenses (CDL) and Commercial Learner's Permits
(CLP). The final rule also requires the use of the prescribed MER Form,
MCSA-5875, in place of the MER and the prescribed MEC, Form MCSA-5876,
in place of the MEC. Medical Examiner's Certification Integration (80
FR 22790, April 23, 2015). On August 5, 2015, FMCSA received approval
from OMB, for use of the MER Form, MCSA-5875, and MEC, Form MCSA-5876,
in a fillable Adobe AcrobatTM format.
FMCSA published sample versions of the MER Form, MCSA-5875, and
MEC, Form MCSA-5876, with October and November, 2015 revision dates on
the National Registry Web site with the intent and purpose of educating
MEs regarding the use of new categories on the forms and assisting MEs
in programming electronic medical records prior to the Agency's posting
of the fillable Adobe AcrobatTM versions. At that time, at
least one company that produces regulatory compliance publications and
forms began printing and selling the MER Form, MCSA-5875, and MEC, Form
MCSA-5876, with October and November, 2015 revision dates. On December
14, 2015, FMCSA posted the fillable Adobe AcrobatTM versions
of the MER Form, MCSA-5875, and MEC, Form MCSA-5876, with December 2015
revision dates on the FMCSA and National Registry Web sites. Based on
the fact that the October and November, 2015 forms contain minor
differences yet collect the same information as the fillable Adobe
AcrobatTM versions posted by FMCSA on December 14, 2015,
FMCSA made the decision to allow MEs to use any previously purchased
existing stock of the MER Form, MCSA-5875, and MEC, Form MCSA-5876,
with October or November, 2015 revision dates until stocks are
depleted. For MEs in an office where these forms have been
[[Page 74701]]
programmed into an electronic system that will require IT programming,
the current approved versions of the forms should be programmed as soon
as practicable.
On December 21, 2015, FMCSA published guidance providing a 120-day
grace period during which MEs were allowed to use either the old MER
and MEC or the newly prescribed MER Form, MCSA-5875, and MEC, Form
MCSA-5876, until April 20, 2016 (80 FR 79273).
Subsequently, after receiving OMB approval for nonsubstantive
changes to the forms, FMCSA posted the current versions of the MER
Form, MCSA-5875, and MEC, Form MCSA-5876, on the FMCSA and National
Registry Web sites on April 13, 2016. The current versions include
several OMB approved nonsubstantive and functional changes but no
longer include a revision date in the top left corner. The specific OMB
approved non-substantive and functional changes can be found on the
Office of Information and Regulatory Affairs Web site by selecting the
following link, https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=201604-2126-006, and then selecting the link
for ``Justification of Nonmaterial/Non-substantive Change.''
On June 7, 2016, the Department of Transportation's Chief Privacy
Officer and Office of General Counsel reviewed the requirements of the
rulemaking and determined that the collection of information maintained
and held by MEs does not constitute information protected by the
Privacy Act. Therefore, FMCSA submitted to OMB for approval a request
for additional nonsubstantive changes including removal of the Privacy
Act statement on page one of the MER Form, MCSA-5875, and the addition
of disclaimer language regarding the protection of sensitive
information that was approved on September 6, 2016. FMCSA has posted
the current versions of the MER Form, MCSA-5875 and MEC, Form MCSA-5876
on the FMCSA and National Registry Web sites. The additional OMB-
approved non-substantive changes can be found on the Office of
Information and Regulatory Affairs Web site by selecting the following
link https://www.reginfo.gov/public/do/PRAViewDocument?ref_nbr=201604-2126-006, and then selecting the link for ``Justification of
Nonmaterial/Non-substantive Change.''
II. Acceptable Versions of Forms
All changes to the MER and MEC forms since the August 5, 2015, date
on which OMB provided approval for use of the forms were nonsubstantive
in nature. Therefore, MEs are allowed to use MER Form, MCSA-5875, and
MEC, Form MCSA-5876, with October, November, and December, 2015
revision dates until existing stocks are depleted. This includes forms
produced by the private sector with October or November, 2015 revision
dates that FMCSA never intended to be published for use by the public
and fillable forms posted on the FMCSA and National Registry Web sites
on December 14, 2015, as well as the MER Form, MCSA-5875, that includes
the Privacy Act Statement on page one. For MEs in an office where these
forms have been programmed into an electronic system that will require
IT programming, the current approved versions of the forms should be
programmed as soon as practicable. MEs are also encouraged to use the
current versions of the forms that no longer include the Privacy Act
Statement or a revision date in the top left corner, and can be found
on the FMCSA and National Registry Web sites.
Under the provisions of 49 CFR 383.71(h), until June 22, 2018,
commercial motor vehicle (CMV) drivers operating vehicles that require
a CDL or CLP are required to provide SDLAs with an original or a copy
of the MEC, Form MCSA-5876, for entry of the medical certification
status on the driver record. FMCSA has learned that some SDLAs are
refusing to accept from CMV drivers the MEC, Form MCSA-5876, with an
October or November, 2015 revision date. In view of the clarification
in this document of the status of the MEC, Form MCSA-5876, with various
revision dates, FMCSA is directing SDLAs to accept the MEC, Form MCSA-
5876, with October, November, and December, 2015 revision dates until
existing stocks are depleted. SDLAs should also be accepting the
versions that were posted on April 13, 2016, on the FMCSA and National
Registry Web sites that no longer include a revision date in the top
left corner and the current version of the MER Form, MCSA-5875, that is
posted on the FMCSA and National Registry Web sites that no longer
includes the Privacy Act Statement on page one. On the other hand,
SDLAs should not accept versions of the MEC that have not been approved
by OMB and do not display both the FMCSA form number (MCSA-5876) and
the OMB expiration date of August 31, 2018. The final versions of the
forms published on the FMCSA and National Registry Web sites are shown
below for your reference.
BILLING CODE 4910-EX-P
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Issued on: October 20, 2016.
T.F. Scott Darling, III,
Administrator.
[FR Doc. 2016-25976 Filed 10-26-16; 8:45 am]
BILLING CODE 4910-EX-c
