Bus Application Unit STATE OF NEW JERSEY > The Motor Vehicle Commissions requires that a complete, legible Medical Examination Report be submitted every two years for commercial drivers maintaining a passenger endorsement. To avoid processing delays of your passenger endorsement application or suspension of your passenger endorsement, all fields on the Medical Examination Report must be fully completed. Incomplete Medical Examination Reports may be rejected and could result in the suspension of your passenger endorsement. CHECKLIST SECTIONS 1-7 COMPLETE DRIVER'S SIGNATURE MEDICAL EXAMINER SIGNATURE, ADDRESS & PHONE NO. DATE OF PHYSICAL MAIL TO: NJ Motor Vehicle Commission Driver Review Bus Application Unit PO Box 127 Trenton, NJ 08666 For further assistance, contact the MVC Bus Application Unit by phone at (609) 292-7500 ext. 5039. REV 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION 649-F (6045) 1. DRIVER'S INFORMATION Driver completes this section Driver's Name (Last, First, Middle) Social Security No. Birthdate M/D/Y Age New Certification Sex M Recertification F Follow-up A B Other C D Date of Exam Address City, State, Zip Code Work Tel: ( ) Home Tel: ( ) Driver License No. License Class State of Issue 2. HEALTH HISTORY Yes No Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Yes No Any illness or injury in the last 5 years? Head/Brain injuries, disorders or illnesses Seizures, epilepsy medication_______________________________ Eye disorders or impaired vision (except corrective lenses) Ear disorders, loss of hearing or balance Heart disease or heart attack; other cardiovascular condition medication_______________________________ Heart surgery (valve replacement/bypass, angioplasty, pacemaker) High blood pressure medication___________________ Muscular disease Shortness of breath Lung disease, emphysema, asthma, chronic bronchitis Kidney disease, dialysis Liver disease Digestive problems Diabetes or elevated blood sugar controlled by: diet pills insulin Nervous or psychiatric disorders, e.g., severe depression medication____________________ Loss of, or altered consciousness Fainting, dizziness Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Stroke or paralysis Missing or impaired hand, arm, foot, leg, finger, toe Spinal injury or disease Chronic low back pain Regular, frequent alcohol use Narcotic or habit forming drug use 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. ) American LegalNet, Inc. www.FormsWorkFlow.com TESTING (Medical Examiner completes Section 3 through 7) Name: 3. Last, First, Middle, 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. ACUITY Right Eye Left Eye Both Eyes UNCORRECTED 20/ 20/ 20/ CORRECTED 20/ 20/ 20/ HORIZONTAL FIELD OF VISION Applicant can recognize and distinguish among traffic control sign als and devices showing standard red, green, and amber colors ? Yes No Right Eye Left Eye 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 4. HEARING Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature 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. INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3. Numerical readings must be recorded. a) Record distance from individual at which forced whispered voice can first be heard. 5. BLOOD PRESSURE/ PULSE RATE Blood Pressure Systolic Diastolic Right Ear Left Ear 1000 Hz 2000 Hz 500 Hz Average: 1000 Hz 2000 Hz Right ear Left Ear \ Feet \ Feet b) If audiometer is used, record hearing loss in decibels. (acc. to ANSI Z24.5-1951) 500 Hz Average: Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP. Reading 140-159/90-99 Category Stage 1 Expiration Date 1 year Recertification 1 year if