DOCTOR’S CERTIFICATE U.S. Department of Labor Wage and Hour Division OMB No. 1235-0016 Expires: 08/31/2015 _____________________________________________________________________________________________ This is to certify that I have this day examined: ___________________________________________________________ (Name of Driver of Migrant Workers) in accordance with Section 398.3(b) of the Federal Motor Carrier Safety Regulations of the Federal Highway Administration and that I find him: _________________________ Qualified under said rules. _________________________ Qualified only when wearing glasses. I have kept on file in my office a completed examination. ___________________ (Date) ______________________________________________________ (Place) _____________________________________________________________________________________________ (Signature of examining doctor) _____________________________________________________________________________________________ (Address of doctor) _____________________________________________________________________________________________ (Signature of driver) _____________________________________________________________________________________________ (Address of driver) Form WH-515 (Rev. 05/08) American LegalNet, Inc. www.FormsWorkFlow.com __________________________________________________________________________________________________ GENERAL INSTRUCTIONS Take this form to your doctor. Ask the doctor to read the following section, examine you, and fill in the certificate (located on the front of this form). After making a copy for your employer and yourself, submit the original with your Farm Labor Contractor or Farm Labor Contractor Employee application (Form WH-530). You must carry your copy with you whenever you are driving workers subject to the Migrant and Seasonal Agricultural Worker Protection Act (MSPA). __________________________________________________________________________________________________ TO THE DOCTOR Regulations 29 C.F.R. § 500.104(b)(1)(ii)(I) and 49 C.F.R. § 398.3(b) provide for the following minimum qualifications for persons who drive any motor vehicle carrying migrant workers subject to the regulations: (A) No loss of foot, leg, hand or arm. (B) No mental, nervous, organic, or functional disease, likely to interfere with safe driving. (C) No loss of fingers, impairment of use of foot, leg, fingers, hand or arm, or other structural defect or limitation, likely to interfere with safe driving. (D) Eyesight. Visual acuity of at least 20/40 (Snellen) in each eye either without glasses or by correction with glasses; form field of vision in the horizontal meridian shall not be less than a total of 140 degrees; ability to distinguish colors red, green and yellow; drivers requiring correction by glasses shall wear properly prescribed glasses at all times when driving. (E) Hearing. Hearing shall not be less than 10/20 in the better ear, for conversational tones, without a hearing aid. (F) Liquor, narcotics and drugs. Shall not be addicted to the use of narcotics or habit-forming drugs, or the excessive use of alcoholic beverages or liquors. __________________________________________________________________________________________________ INFORMATION AND USE The MSPA and Federal Regulations require farm labor contractors and farm labor contractor employees to submit a doctor’s certificate when they seek authorization to drive migrant/seasonal agricultural workers. Failure to submit this statement may result in driving authorization not to be authorized. The Wage and Hour Division of the U.S. Department of Labor uses this statement to verify that those who drive migrant/seasonal agricultural workers are physically fit to do so. The MSPA and regulations require–subject to certain limited exemptions–any farm labor contractor, agricultural employer, or agricultural association (or their employees) providing transportation to migrant and seasonal agricultural workers to have a legible doctor’s certificate (or copy thereof) on file at the principal place of business for every driver employed or used. In addition, the regulations provide for each driver to have the certificate (or copy thereof) in his or her possession while driving migrant or seasonal farm workers subject to the Act. Failure to carry the certificate, or a legible copy thereof, results in the driver not being authorized to transport migrant and seasonal agricultural workers at that time and may result in the assessment of a civil money penalty. __________________________________________________________________________________________________ PUBLIC BURDEN STATEMENT Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. We estimate that it will take an average of 20 minutes to complete this collection of information, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE; RETURN IT TO THE PATIENT. __________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com