HomeMy WebLinkAbout99-00337
LINDA J, SALINGER,
Appellant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v,
COMMONWEAL TH OF
PENNSYLVANIA, DEPARTMENT OF
TRANSPORTATION,
Appellee
'N099 )"'/e' '7'"
. . .. _>.J . ((/.,:{1 {i...._,
: CIVIL ACTION
PETlTlON FOR APPEAL FROM
LICENSE SUSPENSIO~
AND NOW, comes Appellant, Linda J, Salinger, by and through her attorney,
Robert J. Mulderig, Esquire, and files the following Petition:
1, Appellant Is Linda J, Salinger, an adult individual currently residing at 504
Shed Road, Newville, Cumberland County, Pennsylvania,
2, Appellant is a school bus driver employed by Deitch Bus Company, 2212
Newville Road, Carlisle, Cumberland County, Pennsylvania,
3, In 1990, Appellant underwent surgery for repair of her ruptured intracranial
aneurysm.
4. She had some brief seizure activity associated with bleeding from this
aneurysm prior to surgery.
5, She has had no subsequent seizure activity and is not prone to having
seizures,
6, As a precautionary measure to avoid possible future seizures Appellant
has been taking Dllantin,
7, On December 14, 1998, Suzanne McCombie, a physician's assistant with
Graham Medical Clinic, P,C" 100 South High Street, Newville, Pennsylvania, submitted
a physical examination form stating that the Appellant was qualified to operate a school
bus, A copy of said form is attached hereto and incorporated herein as "Exhibit A",
6, In the comments section of the form Ms McCombie stated "history of
seizure disorder on Dllantln 10 milligrams",
9, On January 4, 1999, the Commonwealth of Pennsylvania, Department of
Transportation Bureau of Driver's License sent a letter to the Appellant recalling her bus
driving privileges, A copy of said letter is attached hereto and Incorporated herein as
"Exhibit B",
10, On January 5, 1999, physician's assistant, Suzanne McCombie, sent a
letter to Appellant's employer clarifying her report, In said letter Ms, McCombie stated
that the Appellant is medically qualified for employment. A copy of said letter Is
attached hereto and incorporated herein as "Exhibit C",
11, Dr, Jay A, Townsend of Graham Medical Clinic, P,C" has submitted a
physical examination form certifying that Appellant Is medically qualified for employment
as a school bus driver. A copy of the phYSical examination form Is attached hereto and
incorporated herein as "Exhibit 0",
12, On January 7, 1999, Dr. Roger H, Ostdahl, the surgeon who operated on
the Appellant, submitted a letter stating that in his medical opinion the Appellant is not
prone to having seizures, A copy of said letter Is attached hereto and Incorporated
herein as "Exhibit E",
13, Appellant has been a bus driver for 15 years,
14, Appellant has been driving a school bus slnca 1990 seizure free and been
found to be medically qualified every year,
15, Appellant does not currently suffer from a seizure disorder or any other
condition likely to cause loss or Impairment of conscienceness or loss of ability to drive
a school bus safely,
"'.,~.." (!)
COMMONWEALTH OF PENNSYLVANIA
SCHOOL BUS DRIVER'S
PHYSICAL EXAMINATION
Whln Completed nflturn 1111. rOfl11 to:
9pncII,1 Ollvnr rrogrnm!IJ
bur.11I of Orlvnr lloenlllnu
P,(), 0.. Rn9M
HArrl.burg, ronnsvlvnnll\ '7 tOO.noM
(71711R7-9453
OATE OF DIRT"
llnlVEn'9 lICENRE IIl1MOF.n ooclAI. OF.ClInlTY NlIMDEn 1.40, OAY yn, (AnEA COllE) TF.l.EPfIONE NUMI1EI1
J. -3..3 ~ a.8 a 1. .1!1:1.:fj-'L1.S."~.L I2.!1Q,B.!Lk ~L1.:L!L.k!l~L$,0_
I.AST NAME J,,, F.ID,
Sa~~ftGE~_________
FlnST NM,lE M I,
kLtLlJ,f1_________, Ji
RlnEET AoonES9'
OITY,
STME
ZIP CODE
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AnnUAl
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EMPtYEn: D
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EMPLOYEn THEPIIONE .:
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MAnK APpnOPnlATE BLOCK:
"."mll
TO THE PHYSICIAN,
Pl.... IlIdlc.lo 'nnoollS lor Ih. dloqu.lll1c.llol1 01 Ih. porsoll bolllg oxornlllod, II Iho por.oll I. phy.lcolly Qu.llllod complolo
Form OL.742, "Phy.lc.1 E..mln.llon C.rllllcolo"
A PERSoN IS PHYSICALLY QUALIFIED TO OPERATE A SCHOOL bUS IF:
A, Th.r. 10 no Iou 0' Impol,monl 0111.. uoe 01 . 1001, a leg, a hand, o. on arm,
0, The,e 10 no m.dlcal hlotory or clinical dlagnonls 01:
I, Dlobeleo mellllu. currenlly r.qulrlng 1100 01 Inoulln or ony olher hypoglyeomlc modlcollon,
2, Myoca,dlallnlarcllon, ongll1R poolorlo, corona,y Inoulllolency, or pocemAkm IlIon,lIon,
3, Olh.r ca,dlovo.cule. dlseaoe reoulllng In .yncope, dyapllea, loso or Impslrmenl 01 cOIIBclousneos, collopse, 0' oOllgoAllve
cordloc lallure,
4, Hype,lellolon rosulllllg III syncope, dy.pnon, 10.0 or Impalrmenl 01 conociouoMOS, collapoo, or conge.llvo c.rdloc I.lluro.
5, Resplralory dyslullcllon likely 10 Impair Iha oblllty 10 drive a sohool bus solely,
0, Rheumallc, a,II"IIlc, o.Ihopodlc, ,.,uscular, neuromuscular, or vooculor dlsoaso likely 10 IlIlpalr Ihe .blllly 10 dllvo a
90hool bus .alely,
7, Solwre dloordoro or ony olhor coodlllon likely to oause loos or Irnpalrmenl 01 consclouGne.s or ony 10'" 01 obllily to lhlvo
a school bus solely,
C, Ha. no mental, emollonol or psychlat,lo disorder whelhor luncllollol or organic which m.y be moolle.led In a condiliulI IIkoly
10 IlIlpelr Ihe ablllly 10 drlvo 0 .chool buo salaly: such as Inalleellveness, despondency, aggresslvennsA, or lock 01 COIIOO'"
lor lire uloly 01 sell and olhe..,
Q, flft9 no hoa,lng loso gronter Ihon 40 doclbels In the bollor oar wllhout 0 hoarlng old, ot hOqUOIICloA 01 500, 1000 nlld 2000
^ pe,son who 10 required 10 woar s hoorlng old ShRII be lested by 0 clinically corllllod audiologist.
E, Ooeo not ohus. alcohol or ony ollror drug or oubolonco known 10 Impoh skill or luncllono which 1Il0Y bo lIl.olloAtod III any
coodlllon such a. Inolleollveness, dospondeocy, aggressiveness, or lock 01 concern lor Iho sololy 01 sell ood others
F, flft9 dlslant visual ocully 01 at IARot 20/40 In Iho bollor oye wllhouI cOllecllve lonseo or visual "cully co"octed 10 2(1/~0 1"
hellor Hu 01 10091 20/50 In 11m poo,or OyO wllhoul oOllocllva lonoeo 0' vl.unl ocully fJO"or.lod to 20/50 or holler ItnA a
"ombllled lIeld 01 vision 01 01 10001 100' 10 the horlzootol Inerldlon, e.cepllng tho oormol blind spols. flos Ihe olrlllly tu
dele,mlne Iho cotors usod In Irollle slgnolo ond devlcos alrowlng Glondord red, green or ambOl,
0, 1.los no 'yp. 01 lube,,:ulosls 10 0 Irollsmlllsblo .Ioga ond hM lakon the pro.omploylllonl tubolculln 10At nA ,oqulroll IlY
Secllon 1419(111 01 Ihe Puhllc Sohool Coda. O,lvo.. who hovo 0 documonlod nonolgolllcool tuhorcullo sklo 10AI 010 11,,1
roqulred 10 hove lu,Ihor 1001. "OIOS~lh sra e.posed 10 0 coSo 01 acllve tuborculoslo or ore dlreeled olherwlse hy Iho
Secrelory ollhe Oeporlmanl olltanllh XHIB
ntls IS TO CERTIFY TflAT SAME IS: QUALIFIED U DISQUALlnEO
Commenl" ____..6{Ll..,_St.[l\\.I:!__JJ\sli'LdLL-U\CL_\)L\C!LUIh.. I\),I ""I.( r I_I?.._ ~_
All.SfATE..INTERNATKlNAl
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CAnO~ K nOoIRON, [),O,
KAHU,UN 101, ~OHnMAN, C,I1,N,,,,
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,-JJC\1l SJ9 FAMI~Y MEDICINE
100 flaunt HIUH STAUT
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SlID. I::), JXIY\-~lluLlc vJd hl)i (aR( 1'(1/ 'f~J\- CL
hlS~\{;)'J (l ~ g)lC, (::,c,\cvkd .5e(z UI'l' /II /0q O.
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XHIBIT
Slnu "C/O )
L~;Lli.Qh~~(u~ht. p{\C/
-", ~fG'J~ tllC-
I ~.Jall 99 '
C.
,lll,sr,I.n.INTtRNA,TIOHAt
I, IlITAlfCOl"lIl_"",,
I, OMCOI"ITO_ano
CllIMIII'lI'MOWIIl
DO HOT RITURN TO ATA
PHYSlqAL EXAMINATION FORM
(MEETS DEPAR"fIoIENT OF TRANSPORTATION REQUIREMENTS)
Dale of EKamlnatlon
TO REORDER FORM con.
OAI.L 1100 ATA.LINE
'195
To Be Filled In By Medical Examiner (PteBse Print):
:~;:9Name !;;;:!:~.II:~i~~_:J)(w~{IIL, PI)
800, Seo, No, _-L'rL:. ~3 (.1-/5 '21_..___~ Date of Birth.
New Certllloatlon
Recertification
Chsck Here II Not Qualllled
u
u
u
......h Hl.'Off'
172l/ 7--.-----~
v_._________.___
-:!- 'I . ~ b _ Age <:) ,..-)
CIQ
'I' '\~
V.. NIl VII N9 V :If.. v~ ,Ie(.
a ~l!l. A.lIlm. IJ iii N.rvoulltomooh ~~ H..doropln.'lnlurlo. \ t\';.~1 (I
IJ Kidney a !f Ahou,natio lov.r B' . 9<11,u,o., lit., oonvul.lon., or I.'nling rl, \"" <,' l' v~
a Tubu,oulo.', U ~~ Mu.oul., dl.oo.o IJ E,'.n.lv. oonllnomonl by IIlno.. or Injury
U fl Byphlll. (J "' P.ycnlo~lo dbordo, (J Any 0111., noIVOU. di.o,d.,
(J M Oono"".. (J ~ C.,dovlSoul., di..... tl Ui' $ulf.,'ng f,om .ny Olho, di,o..o
a CI Dilbuto. U LI OIS~olnt..lln.1 ul"" IJ GI' P.,m.nonl dofoot hom IIlno.., dl.o... 0' Inlu,y
IfIll.wOflo .nyollho.boYOI.y... .'plaln _...:r.L~ J '>fl.~,( on I,V ttv IJe1..':.~l.wr -:Pc.:'.. (~~__~ L/!!..'.-__.
OIn...,.PP..""....ndd.v..opm.nl' Good _.._.'/::,..._~_ Fnlr _._~_._.__ Poor _______........__.....
VI.lo": For ~.t8nce: Alghl20/-2.~__l.oft 201._~_ Both ?O/__._ ~Ithoul corroctive kmso8 U Wllh corroclivo lonsos, II worn
Evldonce 01 dl..... Qr InJul)': Righi .____n__.____loll____.._,_~~___....__
~~~; :~" -'~~I;~ _lnlACL__~o'ilonl.~~~lr:,: ~::on9tYl~r:-l!liliiT::.-===.~~1 -.---_____m...._
Dlloaso Ol~ry --.:::.l'~~_'________.__._.____.____J__~____._________________~____~~__.__~.,.
(II.OOlomelo, I. u.1Id 10 10., ~o.,jng) OoclOOllo.. ., 500 H, t ,000 Hz 2,000 Hz 4,000 Hz 6,000 H,
L' t..:..di..t itJ I - --- - -- "'---
-!.II..f:i!~ ""P ""', "cfu ~_--k.'L~ ~ <. I ________._____.____...______....___
~~~.nlCi.-!i!f,. ".o:~n[1t1llulI~efi~g.atOtilliJ.LlJd-'<..o:..------~::..=-~~---, ---.-----~
Blood ",...ur.: Sy.tollo . 01."0110 _ .__.___________
r~.'~ c r ,,11010'0.'0'01..12. P,flY'I Immodl.loly.IIo,.'ord'o-'~_______,_.,_
~. (,lq --~~_*____ Abnormal mas 50S _. ~- ==-=---=_ TondornoSS--=-I1"3v\..l ___-===~~~
Hornla: Yos __ No ___~ II so, whqre? _() _~____~_-:- Is Iruss worn? ____.___
Uloolltiof, 0'0111., d....o.: V.. .R- \CnD! ___..__No~ '_m__._
Scan _~_ _ ___ Urethral discharge 'f",\ I:.:> ...
Ahornborg~~v'l ~__ ,-n--,{L__
Pupilill)' ------'PL1ITYK::~" lIQhl: A n~',) ____._,__ \:,.-::-..,~.tlhA'L___.__...__.__
Ac:oommod.lion: Rlghl____._.r!J.l L_.___"""'__.____ loh __,llrJJ~_...___.._..__.._.
Knoo je,ks: Righi: NOIm.1 ..':'___._.. Inoro.,od ____.______. Absonl '_..______._
loll: No,m.1 __lIL______ Ino,o.,ed _m____ Ab.enl __'__"'..._n
Aomar1<s: '
~::"':::~:;~nd ~~:~ Spoo Gr. ., "'...1~;~~5:__-- ~~wor .=~~!i.. ===~:===--~~~':, _~~~~;~2t!E;1~J~~~~-
Olhe'Spooill OthOl Labo,.,ol)' 0.11I (Sorology, 010) ..__..___~__..________________,.__.._____._
Flndl""" A.<lologlo8l 0.,... __ Eloclroc.rd,ogr.ph .----..-...____..____m__....'_
Controlt~ Sub.'.non T"llng: (J Controllod subslanoos lesl performod. 0 In accordanco wllh Subpart H (J Not In 8cC'Jrdanoo with Subparl H
I!teonlrolled .ub.'ano.'le.1 NOT perfo,med S~"
O.n...I Comm.n,.. ......EL...J.L..!!':~~'1... _ D' ~~/~~_..1I-l'!~~CW /2 ~!'.D _, (_C~~_~~L~_t{l<LJK.uL___ ___
.._lUl.1!r lU '-~I-S-' . - '-d'
N.m. 01 ModiOlI Ellmlnor (PrIOI)::!'1'J C[(.~ W /-!.S:~ tv k ___ Slgnalu,.. IV'J
Add'H' 01 Modlo.1 Ellmln.. ,I u b ~ --l\l4~- .~\ fJ\ . .
MEDICAL EXAMINER'S CERTIFICATE TO BE COMPLI:TED ONLY DRIVER IS FOUND QUALIFIED
.....Ing I
Audlom'Irlo ,.."
Th,o.l,
Tho,..,
Abdomlll'
o..',olnl..lln."
Ollllto.U,In.rv:
R.n'.H'
MEDICAL EXAMINER'S C~RTIFIOATE
I t..t~fy ~ I h\.,.. '~arnlmtd
VI l.A I Y
ver I name f
In accord.nu wtlh Ihe ~Idtf.. Molor CarrIer Sa Regulalions (4g Cf'n 391 ,41
ltwough301 ,49) 1M ..,thknowlfdot of hlllhtf dUII'l' J400 blmJhtf QUlltilied UMfI(
h "~DOI'l'. .aplrltlon date o'c....lfle.,.:_. .ir(.:.Q9.~.
OuIlIilttd onty when WI~: 0 COfrectlve len.e tJ He.ring a~
U ~Y' unquelfttd urNII ICoompanltd by 1_ ~.._____. '__n__ wall/8(
o Utd6canr unqualW ..ne.. drl'f'l wllNn III ...mpllnlrldty lone
A completed '11mNllon m !hi. ton lion ftle In m 0 08
J~fu-'~ /.
Tho 'ollowing will bo co"~lolod only whon 1110 visual1091ls conducled by 11
Ilconsed ophlhallf'tOlogisl or (lpIO"~lrisl
---.----{nM;or~~-..R-_-__~~.-
~all.,oI~ttl.1Io'oO!oglltOfOplOft'e1'illlPllfllf)
IAdd'"loIC\)hlhlirologlllOfWO",&lfillll
tS.gn.tufe01 OIiw11
I,... '111)
EXHIBIT
INS ._12.._ DE
All_STATEIINTERNATIONAl
~~
II '., O.noIlIIMOilnooU.n, 11141 pu'pono bill.. hltlo,V
and phV.b,I"In.,.11on II 10 1101001... flI."""" 01
HD',' .',II'hyolal, "'""\ol9l01ll.nlo d"loo1.olaooh.ch....,.
lOf ."d 0"0" II Il ""oollho "l,plleanl'l .bllIlV 10
Opellt. . molOf vohlckl ..1411\1. 1ho .1I111",U0I1
I " po<lOn II phplco'V quolllod 10 d.lv. . "10101 ' 'ahould bt nlllde C!It.loIIV.nd al 1n..1.. ""'1'lIlolo ..
I wille.. \I !hI1 1'''---:- ,rl .. ". 'r' . .ldlcolod bV .., ,"oohod Io.m. 11I110It 01 ....I.ln
, (1) II.. no 10.. 011 100, . log, ,hl"d, OI.n III", cIolocl. mlV be Coo... 10, llJoellon 0' 111100" Ih.
lor h.. botll g'lIllld. wolvl< PUlMJII.11o 130l.4U; 1I0od 101 ",..100 corllln l.bOl.lo.V lo.l. 01' "',Iho"
12) HlI no ""11,""", of: .nd UlOIO 111lngool. Ul(An~nAlll)", [l()locll may be
I) "hond or nllQl< whloh ~.IOIlo,o. will. flIohon, .ooo,dod whloh cIo nol, be...u.o ollhol, dr,,"cIOf Of
IlIon Of pOWI< g'lIfI!lIg: 0' cIog'oo Indk:alo',. ..,Ulk:allon 01 phVolc.1 III'Hl"
(II) An Inn, 1001, Of log which Ioll,ln,o. wllh Iho .I",uld bo IIonlod, Howovo" "0" dol..", .hould be
obHlty 10 podOlm no....1 II..... ..lIOclllod wll.lljlO" clI!lClJ!I..d wllh Ihl appllclnl, 1.1d IHl II",uld bn Id.
atlog . ",010' vehkHi ~ Iny O'I8f tIonlfk'Afll hlUb vlsnd 10 tako '10 OOOOIflNY Ilopfl to oruwro COHoe.
""Ioct 0' Hn,l,llon wI,,,, 11110""" WI~.lIHlIIMllly 10 11011, p",Ue"ln,ly 0111"'00 wlllcIl, IIlIog'OOlod, lI;ghl
podOfm ",,11M I II"" 1....,lollKI Wi'. opollllng a Io.d 10 I ooodlloo """IV" llInol hi. Iblllty I. dllvo
motor ....hklkt: Of hu been prInted. walYGf pursuanl .udoly.
to 1301,49. O.n.r.1 'ppterenee Ind devllupmlnt. Nolo
(3) Hall no Htllbfl.hed morlcal hlalOfY Of clinical nwkod overweight No'" any posluro dulocl, fW)roo~)
c1agno8h 01 dabe'n "MJIUIUI CUH.n.y requlrlng In, UbIo Un1J, Imlnor, 01 other dolftOtI thll mlghl be
lUll" 'CM con~oI. Cltu!4Od by alcoholism, Ihyrold IntodcaUon, Of othor
(41 Hal'''' "mlfllcllnlcol dOOno,llol myocordlll Hlno....., Tho FO<l<llIl 1.40101 C.lllo, S,loty Rogul.,
Wa,,:llon, 1110111I pIOIOf., ....nory lnaul_c:y, 11or1. ",o'<ido 1111 n. dllvo, 01,"1111I<I 1 ../COlic: Of
"'ambotlt, or Iny alOOf cal(lov..~u1ar dl...ue of a olhor hablHolmlno drug,
varlely known to bl f!lccomp.nled by 'r.ncope, Hlld'IV", Whon othOf 11anthe BooUen chRrll~
fttlpnel, cotlapse, Of conoetUve cardiac Ia! urn; usod 110 r..ullll OISUctl Ioal n~Jst bo IICPtl.sed 'rl
(5) H.. no ..tabll,trod modlcal hl,IOf)' 01 dlnk:al VI'''.' COl'~II'blo 10 ~IO llonOO,d Snollon 1o'l.lIllro
dlag""oIl oil ,.."lraIOlV dyolunollon 1I.01V ., lola" oppllcMI we.,. COI,oollvo Ion..., Iho,", ,l1Ould bn
.... wi" hlubllllV 10 COIllrollndd,lvo. mo'" vohlclo 11I0011 wllllo Ippllcanl" ,1."oJ ""ulIV II bolOO 1.'lod, II
uloly: RPPfopt'lAlo, Indlctle Otllho Modlcal EIC,unfnnf'. Cer.
(O)Hasnor.t.lner,lcihllcaldlagl1o!l!:Jclhlghblood tlAr-Rlo by dlQcklng It" bOlt, 'Qunllllcw:t only whOrl
p1'<ffi9Ululllv.lly to InleriOfB ",Ith his ability 10 oporsto 8 wonting 00"0011'10 IoI1~fl9." In focordlnq dl9mrlCo 'II.
motOf' vehldo Ilfolv; 111011 1100 20 fool If! nomVlI. Rj)pOfl all vIsIon 11'I II
(7) Jias no .~IabUshud modoal hlslory Of c1lnlr..a1 lmcllon with 20 as numorator Rnd tho "maJlosI typo
dagno!ll~ ollhournlllfc, .fthllllo, Oflhopodc, mugcu, road 81 20 1001 a.'1 donornln8lor, Nolo ploslg, dls
_, OOUfonlU~Jlar, or Va.CJCUI.f (~90ano whk:h lntor. char go, \l15ual flolm, ocular f1~19Clo ImtlRlanco, color
"fe~ with hlt abUlty to oonlroland opotRtO I motor bllndnoS9, cOfflnal Acar, fllcophlhall1lo9, 0' sltablg.
whlclG nfoly: ",U9 UnoorfOotoo br. cOfrootlllo 100909. Monocular
(0) Has no 8"'labll.'ltlOd modlcal hl!'IOf'V Of dlnlCcll dri~~ul.ro not qt>alU od 10 oporRlo cOITlIl'lOrclal motm
dagnoll. olepllop"Y Of Iny olhor condUlon whldll~ vnhlcto'3 lInoor (ll(ktlng FOOmal Motof COHlef Safoly
I\oly 10 caUH loss 01 r::onBClou!lnofls or any loss 01 Rogulallon9,
alllty to conlrClII molo' vehlclo: Illho drlvor habltua1ly WCl8,'!1 comaClloI1S11S, or
(0) till! no menial, nOfVOUIl, Clfoank: or functional Intollds 10 do so whllo dflvlng, Vlore should be &lIln,
chon!MI Uf poychlalrlo d1SOfdor IIkoly k> ..rlmlmo with chml ovldonce 10 Nldlcalo Ihut ho hllll; good toloranoo
ht!llllblllly 10 drive. molaf vohlcle saklly; find 19 won adaplod kllholf USO. Tho USn 01 oolll<tcl
t101 ..., dstanl vtsual .cully 01 .IIeRlll 20/40 klllf.oO should bo nohtd on tho rocord.
(Snollon) In eRr:h OYA wllhoul C:OHOCUVO ktf1!1M or f.n, Noto ollldol1co 01 mastoid or middle oa,
muat Iculty IGparalely 004'r8010(11o 20/40 (Sf'IOlon) di90a!l.(l, dis(.horgo, symplol1\'l of Dura vOlllgo, or
Of botuu wIll COHoollvo ktn!lOS, dls1anl binocular Mcmloro's9yndrOlM,WholllocordinghOflflllg,rooofct
lOulty of alloMI20140 (Sno.'lI1) In bolh eyo~ with o! di!l.tllnco from paUoflt 01 which 0 lOfood whhlpornd
willoul corfoollve Ionoo.'l, f1nld 01 vfil(\;) olal 1oR."i17.0 voleo r.an lirst bo hoanJ lIoudlornolor Is u90d to losl
k1 Che hOfbontlt' tnofidialllo oach oyo, Bnd lho llblhly tlflar.lg, r.O<:Ufddoc;lbolI09sal500 HI, 1,000 tll, ond
., rooogl1l10 tho cokllw ollralMo ~gfl"l-'" 8~td dovlcos ?"OOO ~lz
.howlno 'Iandard rod, groon, lInd BfnOOf, ThftNIl. Not{t ovldonco 01 disoa50, Irromodlabto
(11) FI11I1 polcfllvn.l 0 fOfcoo whhtpofoo voleo In dolotll~Ii05 01 tho throalliknty 10 Intorforo willi oallllg
IlO bottor oar.I 001 ~!llh.1n 5 fool wUh or wlthoul tho Of bfoalhlng, Of l!If.v laryl1~oal (;on(~lIofl which could
uso 01. ho.~no akior, 111fI8t9dbyuS(j 01 An oudlomol. Irllmloro with UlO MIn opmatlon 01 a t'llOtor vohlclo
00 dovlco, doe! not havo M avor800 hoarl~lo!>S III Thorn,hl.'t. SIOltlO!Coplc ollamlnaUon Is fO'
tho botMJr oa, ornalof than 40 doclbols at 0 Hz, qulrod Nolo IflUlfl'IUl!J And nnhythml..YJ and any past
1,000 tlz, and 2,000 HI with Of wllhoul a hoarhlQ aid Of protonl hh:tOlY 01 C3fdiOVI\.<lculaf di!lom.n, 01 a
"honlheaUdIOmOlrlodovlco13C.allbf"lodtoN'IOI~an varlolY knowtl 10 bo accompAnlod by syncopo,
NAtional Standard (formorly ^9^ Standard) 12"",;1 - dysJlnoll, collapsfl,onlar~odhonrt, oreongo!'lhvohoall
1951 falluro9 Eloc,tlOcardlogram!.l roqulrod whon limlmg:l
(12) 0009 nol uso a SdlOdolo I drug or 011 lor ~() IrldIC.,I",
lubstanertldnrllllloolnApponct. Uoflhlssubdlltplfll, 8100d prl..ur., Rocord with nUllor ...~dng 01
IIn amplm~mlno, ft MrcoUc, or any oltlor habit mOlC\JIY coltllll1lypo 01 sphygrnomnnol1lolor. If tho
IOfmlno dfUQ, Ol(oopl'lal II dlll/er !nAY UM! sitch" bloodpr05sufO~Consl!llOfltlyab()'I0100lOOm,"Hg,
!Iub!4ll1nco Of dr\Jg IIlhe 8ulY.ollance or drug l~ pro. lurlhor losts may bo IlOCossafY 10 oo\Orn~llo wholhor
ICflbOO by . lIamMKt moolr..al plnelll/oner who Is Iho drlvor Is quail/lad 10 operalo II motor vohldo
lamlllo,wll1lheftW8r'lmndlr.alhhllorYlllnd89~nod Lungt, II any lung dl~ue Is dotoolod, stalo
dubes and wl~ hu IICWIMd the drlvof flat the JHo. whoth.or activo Of8f10.10d; K arrosled, VOUI oplniolla9
talbod.ubslance or dfUQ wi" noladV'otHty _"ocI Iho to how long II has boon qulnsoonl
dl'lvor', Iblllty to Balnly op,nral.' a molor vnhlclo; and Olluolnt..Unllty.t.m, No'to nny dt<;Ofl!lfJ!i 01
(13)'.as no CiHmnt chl1lcal dll1gnosls 01 alcohol. Iho ga5l1rnnlos!inal !1~i(tfn
km Abdomln, NolO wound<;, IlljlJllo!l, r.l;,II!l, fir wonk
1I0Sf. 01 muscltt!1 01 nbdof1\lnill Willis sullir.ionl to
InlorlofO with 11Om..,t lunction_ Any hornl" r.ho\Jld bel
no\od II prof-onl. Slalo how long and If ft(k.quatoly
cOI\Inlllooby IIU'!l9,
Abnofm.' ma..... II prosonl, 110to locaUon. II
lonrlor _ fwd whnlhor Of noll'lpplltanl kflOWS how long
ttlny havo boon pf~of\I, litho thgnool!o &llgUMl<lthal
Iho condition nighllfllOftflrn WIUllho coolrOland salo
operation 01 . nlOtOf vohlclo, I1Y>10 sll\ngqnllosl9
"....91 be nlo1d4 bQ,IOfo U'IO appUcanl CAn 00 eOfUliod
tend.m"l, Who" OOlod, '\RIO whf)1O 10000l pIa- _
Munood, and IU!lpoC\t)d caU!M, U Ih. d1agno.'Vs lUg.
gOlll!l thlttlho ooo<lllc)(' n.O',\hiltutom with 1hlt ct;mllol
And 1-'11" OI}Ollllon 01 A molor yohkto, wen't tllllll'JOlll
Ifl~ts mu~1 bn ""do bolOfo tho applk;nflt CMl bo
cOIlltlod
'" 'DEPT;t)jI ~RAHlPORT A TlON
PIIYIICAL'OUAUFICA1IONS ..
EXAMINA110fftl OF DRIVERS,
INSTRUCTIONS fOA PERFORMING AND
RfCORDING PHYSICAL EXAMINATIONS
lhn modIcal oltamlnor shnuld fovlow IlMfl In,
!lltucUons 0010r8 pOfJoml~ 119 phynlcal o.amllla.
1100. Amiwef oadl qUMUon YO'!IOl' no whom Appropl\'
110.
lhe modeal olln1nof .houki bo lllW1I19 ollho
f!igot'0U9 phy.al domand9 and !1lonla! Andotl'l'ltk)l\al
retl4U)flt4bilUlM placod on tho M'l9rol . exHlyoorclat
motu\' VQhldo. In -tho Into,"1 of JKlbMc Mlo~, Iho
tTw'ld1ta1...rrinef tI, requlfod 10 ccw1lfy thai 1'0 dr\"OI
doo~ 001 havoRny rhvskAl, n-.tn\al, 01 Ofgnnlc I~tocl
01 IlIch a nlllufe M l(i Rflnel 1\0 dftvt'lf'ft ablllly to
opOfAIO Mklly I corrrnQfdal motor votlk:kt
O.nllo,u,ln.,v, Urlnllyoll II roqu"tel, AcUlo In'
loollons ollhe gonl"'urlnlrv I,"ct," dollood by IoClI
ol1dSI.lo,04Jblloh.,lIh IIWI, Iodloalk,,,, ."",u.lI1oly,
.1. M uI1COflI,oI(1KI dlabor.. IYlflllorilillo llbun;I1'
u'ollnlho Urll11 0' 01110' ftndl1gi "ldlooltvo 01 h.II~.
cOlldlllol1,lIkoly 10 k.Io,lo,o wllh 1110 controllnd 1410
oplllllon 01. mol.. ..hlolo, wllllloquoJlIV In Ippll,
., clnt "0m opef'l~III. maim ....hlclo.
,\\ "N,uIoIOllI.II,,1I eO'1I1v1 Rowbol\l .. ,oporlod,
",dl...1o dog,... 01 .....I"""nl, PUplll.,V ,,1Io!0.
Ihook! h. '.pOIlod 101 bellllghl ond "_lOdaion,
Knoolo,kl .,. 10 b. ,oportod Ib",nl onlV wI.on nol
oblalnlblo upon .m"" """..nllnd.. h"o..lKIwhon
rool .. oclullIV IIl10d Iro," ". n... lollowlng I Ilglrl
blow Mlho palnll_l ~flnllOfY vlb,alOfY Ind po,IIlonul
atmoflT\ollllos IhOUIO bfl nohKl.
e.tf.mWII, C",olully o..n~no uflpor el1d Iowol
flll i,emlUos. nncOfct Iho 1091 Of 1l1'lplllrnwml of tD9, 1001,
100. .rm, hand, 01 nngnrll, Nolo nny end III rlolo",~.
110!l.lho prcmnnoo(llatlophy, aon~p'f8IYI. or partly.
1111, 01 V8f~OM VOIIlS, If . hand Of flng., dolornvly
nlClnLq, dokJlmno wholhot euftldont gfatp" prtlSOnl
10 (lnablolho drlvef 10 lOCum and malnlltln R Qrlp on
the .IOOflnQ whool, "Cllog dotonnlly 4tICISt5, dolonnno
whothnr lulllclonl mobility end .Irenu., .I(~I to Ofl'
ablo Iho ddvOf to opollle podalll Pfap.911y. Pafllculaf
BllonUon should 00 olvon to Ind. rooord .hould bo
mado 01, Bny Irl'l'ltlrrflOIlI or slruclural (101001 which
may In\or'oro with tho drlvor'. ablllly 10 opOfalo a
motor vOhldotaloly,
Splnl. NolO dolormlllo9, Iln~ll1l1on 01 mollon, or
ony hlslory ", raIn, Injurlo~, C'Ir di!l8!l~JQ, ranI or pf(ln
anUy ol(porktncod In Iho corvlcal Of lumbar ,,,Ina
molon. II lIndhlIJ9 00 dlClAlo, fndtologlc and Olh",r
(>llAmlnnltong 8110ul<l bo usod 10 dlagn090 cOllgonllnl
Of Bl'A1ulfoddoloot.'l: ()( spondyloUslhosls andsoolioofJ
R.clo,u.nllll Iludl... OI5ftlt9oS Of condllloll!l
c~ufllllO dlsoom'ort should be evltluaktd cafoluU.,. b
rlolormlno Iho olltonllo which tho condition I1l/ghl bn
handk:HlpplngwhHoUIUng, puiUng, Of during pollod9 01
pfolongod drivIng Vial mlghl bel flOCOS5ary A9 part 01
Iho drll/A"9 dullml,
Llbor.lofY Indolhff lpeolllllndlngl, Ullnaly.
sls Is 'oqulrod, 89 woll as such oH1(I' "HilS as Iho
modlca! history or Anding!! upon physlc.11 o.(an~nfllioll
"illY Indlcalo aro nooossary. A oololoolcnl losl Is
roqulrod II UIO appllcanl has a history 01100110 inlocllon
0' pro!IlWI physical Ilndings 10dlcawI UlfI posslblllly 01
lal0l1l9yphllis. Olhor studios duorood advlsablo may
bo fHdOlOd by tho loodleal OlCl1Inlno,.
Ol,b.'.., II Insulin Is floco!l~alY to control n
dll.1bollc conftiHon, Iho drlV'nr Is nol quaMliod 10 opor 1)10
a motor vohlclo.1I n~ld dlabolOs Is notod olltlo limo 01
olCall1inaliol1. and It Is stablllzod by uso of it
hypoglyoomlc drug and a dlotlll~t CiUl bo oblalned
whllo IhoJ drlvor Is on duly, II should not bel cormldoroo
dl!1qlJlllllyillg, HO'Nltvor, tho dIll/or musl romaln undol
adoquato modlcal supOIvlslon
Conlroll.d Sub"lne.. Tilting, II 8 tost lor
conllollocf substancos 19 pmfoll11od as parI 01 Iho
modlcal olCamlnAllon, 'ho modk"..al 01C8nllnof Is 10
chock 1110 bOll nOli I 10 Ihn !ItalOfoonl. "Conl1ollod
flubstallco 109t pOlIC'rmodo on Iho modical ollamlna.
lion 10rll1 II a lfI9t lor conl1ollod subslanoo~ Is not
porlolmlJd, tho modlcal fllCOlHlllOl ill 10 dlOCk Ihfl ball
flolllla Iho nllltolTlont, 'Conl1ollod substanoo 10:.1 nOI
pOllofIJ'IOd' II R cOII!toUod sub9ttlrlCG5 IQStls por.
10(11100 undor lho fOqulfomnllls 01 Subpar' H ollhls
pml, thon Iho modIcal nlCamlnor must also week tho
001( 1101C110 Iho llalOmonl, "'n Rccordance with Sub.
pnfl H,' and mlJ!lloblaln lnlormdllon Ihlt tho resulls 01
such losl wore novallw prlor b oortliylll9 Ihat Iho
drlvo' Is othorwlso n;oocally qualilloo. II a conlfol1od
9ub!ltaflco 1091 Is porlolfood, bul nol In accOfdalloo
with Subparl H, ih(l modical Ollan~nflr lT~sl al!",o
chock tho bo. fl".llo 1M Btatnmonl, "1101 III accor.
danco with Subpa,t H,' and unsulO lhaltho losulls 01
tho lo~I woro 110gaU'o'o plkJI lQ eOfdlying thai ~10 dtil/or
In OlllOlwlso nl9dk:ally qual/Aod,
1ho modical QllaJnhlof must data and sign his
llndlng!l upon ool11plulion ollhn oumlnaliofl.
A Iicollsod ophlhalmologlst ()( optomolllsl molY
poflOrlTlOI(Rmlnatlof19 pof\alnillQ lovtsual acuity, Iiold
01 vl910n find ability to rocognlzo oolor.:!.
IIlho mo(jcat Ql(umloor finds "at the polSOIl he
(lltalllllod ~ physically quallllod 10 drive _ 11'10101
yohlclo, 110 Ihall comptoto 110 Modeat r:ltRmlno(s
CmUllcJ\kt and furnish onu oopy 10 '10 pe/'lOtl ollom.
\IIod and Of'~ copy 10 I'ft molot'CNlle, on~yef
varioly Mown 10 08 .CCUll1p.mv... "', "'''V~I'_'
ltt5pnea, collapse, Of cong01lUY, Cllfdlac falluro;
(5) H.. no ..\abU,hod modl",,1 hl..ory '" dlnlr.,1
ds9nosl!l 01 . rupllOtory dY'91uncllon IIkoly 10 Inlm.
tofo with hit abillly 10 conllol Rnd dri'l81t mo\or vllhkto
OIII.'y:
l6) HaB no (;.UHfH,t clllilcal dagno!Jb cf hIgh b1eod
PUffi!.u18likoty 10 lnlorloro wUII hl!l6bUily to oporBto '"
molor vohldo lololy;
(7) Hal no o!llabllshod modlcal hlslory Of clinlc.11
dagnosl!l ollhoumatlc, l\llhrllk:, ofthopodic. mu!',cu.
\ar, nouromUSCUk1r, Of va.qcular dlf.oa!'.o whIch Inlor.
telOS Wlltl his ability \0 conllot and opefato a molor
'tOhk;Io saloly;
(0) Has no o9tabllshod modical hI51O('" or clinical
dagno&hl 01 epllop9Y or any 011101 condillot1 wtllcll hl
~lJly \0 Cc1USIJ toBS 01 conscloUSf1095 or any loss 01
abl1lty \0 cC\ntrol B molor ....fllllclo:
(9) Has no mental. nurvoUS, organic or Junelian,,1
chonoo Of psydllaltlc di!lordQr llktlly 10 intmltlro with
his ablllly 10 drIve B mok>( V41hkJo safely:
(10) Has dlslanl visuat Bcully 01 Al lon!!t ~O/40
(SlInUon) In eAch nyn wilhoul corroctlvo ten!ltl!l or
visual acuity sop8raloly COHOClod 10 20/40 (SnoUon)
or bollel with cOffocllvQ loll~.cm. dislanl binocular
lCully 01 BlIoasl20/40 (91101l0n) In both oyos wilh Of
WlUloul COffOCUVO lonoo!\, flold 01 vl.!llon 01 DIIl/a.'!1 70'
il tho hollzonlal n"lOfidiaflln each oyo. and Iho flbility
k> rocoQIlizo Iho colol's ollratrlc nllJnnl~ and dllVlco!l
showing slandard 100, gf()Qn. 8Ild ambor:
(11) Flrsl peHcolvo3 a lorcod whl!lpomd voico In
tho bollor oal al nolloss thyn 5 1001 with or withoul tho
usn 01 ahoarlng aldor.ll1f1sl\ld byu!WJ 01 an audiornol
rk: d(lvico, dOO9 nol havo nn aVllrRgo hllRfln<j to!'..'lln
U1Q OOIlOf 0<11 grnalor 111M 40 doclbols nl 500 Hz.
, 000 Hz and 2 000 Hz with 01 wllhoUI a tloflllng nid
w'hon the 'audlot1lotlfC devlcol!\callblOlod II') Ivnollcnn
Nnlional Slandmd ('armorly ^SA S!nndo1fcl) 724 5-
1951
l1~) Doo!! nol U!l9 n SchodulQ I drug or OUlOf
gUb~lt.lflCf)11onUhnd In Apponcfl.: U 01 Ihl!\ !luhctll1plf1r
an amphotamhm. a n,ucolic:. 01 Any OHlor habil
101fnilll~ drug, (})(oopllhnt A dllvor IT\I1Y U!>ft suc:h a
'JlJb!lUUlCO O( dfug 11 !he 9u~la"oo or dn.Hl1!l 1110'
SCtlbod by a llconsod mooical prnC',lllionol who i5
lamih,u wllh 1M driver''' mod(cal hlslolY Rnd a.'l~Qnod
duho! hnd who hAft ndvlood rho dflvor ItlAllho plO'
sal00d5ub91ance or druQ will not Advornoly flllocllho
drlvo(s ability 10 Sollnly opmalfJ" molO! yulllelo; ilnd
(' 3) H,1S no cullonl clinicnl diagnOSIs 01 A~:(Jtlol.
tllT'
INSTRUCTIONS FOR PERFORMING AND
RECORDING PHVSICAL EXAMINA liONS
11m modi;;:al o."mlnOl stlOuld loviow UlO,:,,o in.
StlllctiOflCl 001010 po"ofIT~fl9 lho phyqjcal OHlfTlina.
tion An!\wer o"ch quostlon yes or no 'tI'tll'fO nppff1prj.
nlo
1ho modlcal ol.an.nm !ihQtlld bo ",wnro 0\ Ihll
llt]OfO\I!\ pt1V!\k'..'lldOlnalld9 and l1"1Ofllal ar'ld""l~I~}Il;'\1
lflSpOflf~bihl~ pw..oo 01\ Ihn ""flU 01 "colT'I1wlldnl
rmlO1 vnhle!". In tho Inlnronl 01 p\.blk: !I.1lnly, !tlO
ml<1l(:al n"l\n~nef l~ lnqulmd 10 cOI\lly that ~10 lId...1ll
don<; !'IoI havo "flY phyrJt:al.l1111n1..11. 01 olqank: dnllld
01 !\uch iI MturO A9 10 alfnd dlll rtrtvfW''l AhUlIy 10
opnr alO MlnlV 11 COfTlIIl'Iord,11l1Y110r vnhlcl"
",.a..y... HIlU" v"'v, ....... "'~ -. ._..-.. _..-
used. the fosults ollUch legl mu!ll be QlCpreuod In
valul'I!I compBm~ to tho Iland.lld Snellon \Osl.lI the
a~pllc.1nt WOalS conocUvo Ion009. '''Me should bo
worn whllo 8ppllc.1nl's vlsunl &Cuily t9 beino !o9\Od.1l
nopropfllllo, Indlcalo Dn the Modlcal E.:amnol'g Cor.
lllicalo by r:hl)cking If\J box, 'Qu!1l1ti0'<1 ollly whon
woarlnC] t;orrocllvO Ions09,' In focordlng (1I9tnf1co vi-
sIon uso 20 1001 19 normal, Roporl "It vision A'l n
Imotion wilh 20 8S numeralor and !ho smallost typo
road at 20 1001 B9 oonomlllalol. Nolo plosis. dig.
chargo. visual liol(~. ocular musclo hllbalancfl. 001(1(
blindnoss. cornoal !}CA.lr. O.oplllhal"~9. or suabis.
mus. uncorlflclod by cono<:tlvo 191\509. Monocular
(ldvllr!l ato nol qualHiod 10 opomlo cOlnrnolclal molor
vnl1lclll:) undol O.:l9li"g Fodollll Molar Cnffio' Sa(oty
ROo;llJlallon<J,
II tile ddYfH habilUally Wliars conlacl lonsllr.. or
lnlontk 10 do 00 whllo drivIng. "1010 should be r,u(f1.
clonl ovldoflCO to hldicalo Ihat ho han good lolornflCll
and l!l woll adaplod 10 Uloif uso. 1110 UM 01 corllact
IOfl!109 r.hould bo lIolod on Iho rocotd.
EllfI. Noto ovidonco 01 fI\.1.slold or middle ~ltH
dlsoaSO. discharge. !IymplOrT\'I of Dura vorllgo, ('I!
Ml1nloro'g Stndromo. Wholl rOCOfditlg hearing, rocold
dislanco Irom pauonl AI which il 10lced whlsperod
voioo Cc1n Illsl 1.10 hoard, II nudiomolOI Is usod to 1091
hnallll? rocord decibolloss al500 Hz. , .000 Hz. and
7..000 Iz.
Thrall. Nolo ovi~lflCO 01 disooso, Irrnf1\odinblo
OO(OflllitioS ollho Ihroal hknlt 10 I"Imlmo wilh oal!llg
or blotlthlrllj. or "fit lalyngoal condltlon which could
inlorlnro wilh UlfI Sollo oporallon 01 a "nolor vohlclo
Thorn-hurt. SIolhoscopic oxnmini1!lol1 Is ro-
qlJilftd Nolo mUlmurs and arrhyltlmina and nny pas I
or fllosonl hislOlY 01 r.AidIOVIL'iClllar olr.oaso, 01 a
vnrioty known 10 be Accornp;H1lod by syncopo.
cty~pnoa. COUilp~, onliuQed hna/I. or congo:.INo Ileafl
l,lilurHa EIn<:lrOC.1rdiog!arn is loquifod wllun fil\(liflg~;
~I') Imiir'1lf.
Olood pnuuft. RucoHl wtltJ oittlOr !;pllon or
fTlOfcury r.OIUrllf\ lypo 01 sphygmOrn.1l10f1'oOIm- II tho
blood pl~ISUfOI~cOllfJ~lflf1l1t nbovo 1 ('.om mrn tig .
l\lrlhm Insls rn..'y 00 nOCOS5AfY 10 ck1lormino wlH'Ilhor
If\u ddvnll!\ qllatillod 10 opomlo 8 roolor vohlclo
lung.. U any lung dlSbMQ 15 doloc10d. 51.110
whOlMr I1CtlvOOf aHoslod; II hf1nSI{\(1, your opinion flS
10 how tong II hl\.'I boon Quloscont
al'lfolnt'111neltystem. Nolo i1ny f!i5I'<l!lnS 01
1110 fp.!ltsolrllostinnl !l'f"llr;orn
Abdomen.Nolowlltmd'l. if1lurlll<;, ~,l;ilr!i, 01 wI)a"
flO~..:. 01 mU5ctll!l 01 ah(!oJf1lltlal W<l!lt. !lullkionl 10
inlnllorfl wllh ilOrmlllunclioll Any homla 511OUIc\ ~l
nolnd 11 pH!!lonl Slillo how lonl) And il acloquilloly
c04\Iilinnd by 'russ
Abno,mll mou". \I pro50nl. nolf> 10('..111011. 11
IfJl1dlH. !lnd wtl(llhOI Of nol Applic3/l1 know!', !IOW bill)
Ihny havnboonpn~enl." lhodiaqn~~ f.uggo5\.<ilha\
lhO l:-on<1I!ion niQh' lrllllflnlo WlUl Iho cOIlI/ol <lnd ....JIll
Oflnllllloo 01 a lrolOf VOlllc'oO. WO!O !ilrlllglJnl _\o!',I'.
milsl bo mada ooloto \he appllf'..nn' Cc1n bo r;()1llhltd
Tlfld,,"'''. Whl)n nolt'ld. :It.lln whoro 11'I0'11 pro'
nr,Uflood. :l,nd ~p4'clod cnlr.M, 111ho diagoo..,j!l !\ulJ.
~ll'll'l IhAI Iho OQ41dilloo mlghtll\\mlo(O wl1h 1l1b c:o"lfOI
.111l1 !lalo oprll,Ukln 01 <1 mo\or vohlclo, 1110ro !ilr\ll~flIll
IO'lL" rnll~ll bo m.ldo boloHl 1110 l\pplc<ml C;ln ho
l:llllltllHl
8\10nOon should be glvnn to Ind I lOCOfO 9110Ul0 on
mado 01, any lrnp"lrrnonl Of SltUCIUlal (kJlocl whIch
may Inkulor6 wllh Ihe drlvor's abUily kJ opomlo a
lnolor vol1klo 5lI101y.
9pln.. Nolo dolormHlo9, hmilatlon 01 mollofl. 01
any hislory o! raln.lnj~rlo~, CI.- d:n()~:J. pn~I Of pro!:
onUy Oll'porlollcod In Iho cervioal or lumbtlr s~lno
roglon. 11 Ilndlng9 so dte!..,lrJ, fodlologlc And olhor
o..amlnalloM should bo used 10 dlagnoso congunilal
Of ocqulroddolllC1.9; or spondyloll.!llhost!\ andllooU09~
R,cto-g,nU.1 .'Udl... OI50n!l0l1 Of cOlldltlons
Calming discomfoll should bo oVlllualod calofully 10
dolOff11ino Iho o)(lonllo which tho coCldHlon nughl bo
handlcappinQwhilolilllng. pulling. or dUlinQ Pflr\od901
prolol\god drlving Ulat mighl bO nocoSSflry liS parI 01
1M ddvnr's du1ios.
1.IborelofV end 01her speclelllnding!, Urlflnlt"
!lIs Is requlled. as won as suen olhor losls as Ihn
rno<l(CIlllllslory or Ondlng9 upon physical o~ilmln;Jllon
en,IY lndicalo are nocOSs.lry. ^ serologlc.,1 1091 is
roquhod II Ul0 appli~nl has 0 his lOry 01 luollc intocllon
N pro!lunl phyn(cnl !lnding9 tndlcnlo Iho po':Jsibllllt of
lalonl sypllili!l. Olllor 51udi09 6!(~mod AdvisAble ",ay
bo ordmfld by Iho modical ())(funinor
Olabe'u. II Insulin Is floco9s..lry 10 conl10l a
diabolic conclilioll.lho dllvor is nolqualiliod to opo111;)
a rnotor vehlclo, II mild diabolos Is (1olod .11 tho !inv) 01
OXiHlltllnlIOIl, And II I~ slabilizod by U!l{l 01 i1
hYIXH}lycolTlic rllUg and a di(J1 Ihal can be oblaillod
whilo Ih;J drlvof is on (jUlY, II should 1\01 be COllsloollX'!
disqunUlyillg, tlo'NlIvor, tho drlvnr musl rOI1\<l111 undor
adoqufllO modical supmYlslon
Conuolled subslencfS Testing. II f\ tosl 'Of
conl/ollod subslnncos 19 porlomlOd as p;lIl 01 ltlfJ
Inodical OJ:amlnalion. 1M modlf'..-11 oXaIllinor is to
ch('lck tllQ box I1Qxl to 1110 stntornonl. 'Conlroll.~d
subSI<1f1CO losl podNfllOd' on 1110 modw,al o.af1lina.
tion for III " A losl lor cCfluol1od SUIl!llarICl'S Is mIl
pf1flolf1\pd. Iho I1ll,lClic..1! oXfunhlllr Is 10 chock 111(' bOI
1111.1101110 5lalOmol1t, 'Conlfollod 5lJb!>lanCfl lor,1 nol
porlorl1WJd' II a conlrollod SUb51JllCOS 10'>115 POI'
!OfflHlClllfldor tllO fOl\ulrllml1f1ts or Subpar' H olltlls
pml. Ihon lho n'll>dlcal olH,mlnm mus! also du>ck th()
box noxl 10 Iho 51.11011'1Onl. 'In l1ccoldanC(l Wllh Sub
pili I H.' "nd musloblaln Inlomlo1l1on Ihalll10 rt1sults \11
such 1051 worn MqUllVO priO! 10 cOf1lf{ing Ihal Ihn
<hivo' Is olh{lrwiso modicnlly qualiliod. II a r,onl,ollf}d
!lub!1l,lflCfl losl is pfHlotfl'lOd. bul nol In accordanCfl
willi Subpnll H, 1110 1T'Ifl'<lIC:11 oxmniflHf Ir111s1 a\!'.o
I:IH~ck lho hm nn~l 10 1110 st;'\loHlonl, '1101 ill ,11;(:01
(l,lnCn wllh Subpall tI.' and lHl!HJfl1lhnl 1M fIl!'.ull!i 01
lI1lllos\ wOlflllogativo prior 10 cHftifying Ihat Ihe drl'fOr
1!1 oltlllfwiso InodlC,ll1y QIJilliOod
1 hn n\l)fjical oxamlflor 11\lj!',1 t\.ltfl ;!IId slqn his
flfldlfl\l'l upon cOIl\plotion 01 Iho oxlllTllnallOn
^ 1iC10n'lfld ophlhnlrnoloqi<Jt 01 ()plomohi~il n"'l~
porlormoxilrlllnalion5 p4.lI\aining 10 v1!1u,,1 acuily .lield
01 Vi!l10n nnd ability 10 rocognllu oolam
II Iho nVldical o.amlnor l~\oo that IhQ p4l!SQIl 110
O_i111linod 15 phyo.;iClllly qllaHliod 10 dlivo II rmlOl
't'l'hldn. !lo shalt Cllll~llolfl Ulll Mndkal r~lIrnil1n(n
COrllli(;alo and lurni!'Jl ono copy 10 Itln pnrson lU 11m.
Inod llll(1 ono copy 10 Ihn molor cn"IOI Olllployrt!
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Tum Law Offices
32 SaUUI Bedford Slrcet
Carlisle. PClulsylvania 17013
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Robert J. Mulderlg, Esquire
Turo Law Offices
32 South Bedford Street
Carlisle, PA 17013
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Turo Law Offices
32 South Bedford Street
Carlisle. Pennsylvania 17013
Commonwealth of Pennsylvania
Department of Transportation
Office of General Counsel
Harrisburg, PA 17123
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LINDA J, SALINGER,
Appellant
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
v,
: NO, 99.
COMMONWEALTH OF
PENNSYLVANIA, DEPARTMENT OF : CIVIL ACTION
TRANSPORTATION,
Appellee
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PETITION FOR APPEAL FROM
liCENSE SUSPENSION
"
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AND NOW, comes Appellant, Linda J, Salinger, by and through her attomey,
Robert ,J, Mulderig, Esquire, and files the following Petition:
1, Appellant is Linda J, Salinger, an adult individual currently residing at 504
Shed Road, Newville, Cumberland County, Pennsylvania,
2, Appellant is a school bus driver employed by Deitch Bus Company, 2212
I' Newville Road, Carlisle, Cumberland County, Pennsylvania,
3, In '1990, Appellant underwent surgery for repair of her ruptured intracranial
aneurysm,
4, She had some brief seizure activity associated with bleeding from this 1
aneurysm prior to surgary,
5, She has had no subsequent seizure activity and is not prone to having
seizures,
6, As a precautionary measure to avoid possible future seizures Appellant
has been taking Dilantin,
7, On December 14, 1998, Suzanne McCombie, a physician's assistant with
Graham Medical Clinic, P,C" 100 South High Street, Newville, Pennsylvania, submitted
a physical examination form stating that the Appellant was qualified to operate a school
,
il bus, A copy of said form is attached hereto and incorporated herein as "Exhibit A",
II
I
,I
II
8, In the comments section of the form Ms McCombie stated "history of
seizure disorder on Dilantin 10 milligrams",
9, On January 4, 1999, the Commonwealth of Pennsylvania, Department of
Transportation Bureau of Driver's License sent a letter to the Appellant recalling her bus
driving privileges, A copy of said letter is attached hareto and Incorporated herein as
"Exhibit B",
1 0, On January 5, 1999, physician's assistant, Suzanne McCombie, sent a
letter to Appellant's employer Clarifying her report, In said letter Ms, McCombie stated
that the Appellant is medically qualified for employment. A copy of said letter Is
attached hereto and incorporated herein as "Exhibit C",
11, Dr, Jay A. Townsend of Graham Medical Clinic, P,C" has submitted a
physical examination form certifying that Appellant is medically qualified for employment
as a school bus driver. A copy of the physical examination form Is attached hereto and
Incorporated herein as "Exhibit D",
12, On January 7, '1999, Dr. Roger H, Ostdahl, the surgeon who operated on
the Appellant, submitted a letter stating that in his medical opinion the Appellant is not
prone to having seizures, A copy of said letter is attached hereto and incorporated
herein as "Exhibit E",
13, Appellant has been a bus driver for 15 years,
14. Appellant has been driving a school bus sinca 1990 seizure free and been
found to be medically qualified every year.
15, Appellant does not currently suffer from a seizure disorder or any other
condition likely to cause loss or impairment of conscienceness or loss of ability to drive
a school bus safely,
.~".., 0 J
COMMONWEALTH OF PENNSYLVANIA
SCHOOL BUS DRIVER'S
PHYSICAL EXAMINATION
Wh.n Coml1l.lld "..Iuflt 1hll rUft" to:
9"801.., O,lvor rfnQrnm~
8uftall ot Ollv~r Ur.fUlllnu
",0, Uo, 00004
I'hurl,burg, "of1nlylvnl1In 1110n.nnn~
(111) 707,0463
DATE OF 0U1T11
DfIIVEn's LiCENSE NUMUEn SOCIAl. SEClJfIITV NUMOEn Mo, DAV vn, (AnH CODE) HlEI'II0NE NlJM(1l'fl
.1 ..3 ..3 .a fl .a Ii 1. ..1. [1 :1.11 Ii _L S: r2, L .Q.!l Q a !L ~. :J. L :.L 1. !1 k s.. !L .f ~
lAST NAMe J", Elo,
SA~~ftGEe_________
FlnST NAME
.t. .z:. tY. .D. 11
M I.
J!:
SlnEET ADDRESS'
CITV:
Sr^rE
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liP COof:
",umll
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AI1f11ml
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N GWV LLti
EMRC;;j
I JAR[) S, DGr.Ic.lL..
EMPLOVER TElE"'IONE .:
'1 Itl- f).llq -1f491';
J /1 ':2!LL
TO THE PHYSICIAN,
P'enso lndlcnlo 'DAttons tor lhg dl!lqunllllcnllon 01 tho porson bnlng nlUIIIllrlOd. II lho pnr!lon I~ physlcnlly qunllllod cOl1lfllrlo
Fo,m Ol.742, "F'hy.lcol Exomlnollon C.rllllo.'n,'
A PERSON IS PHYSICALLY aUAlIr-IED TO OPERATE A SCIIOOl nUs Ir-:
A, Th.,. I. no 1000 or ImpAI"n.n' 01 Ih. UOA 01 A 1001, 0 I.y, A hAnd, 01 on A'm,
9, Th.,. 10 no m.dlc.1 hl.lolY 0' cliniCAl dlogno.'s 01,
I, OIAb.l.s ",.IIl1us curr.nlly Il,qtllrlng 'ISA 01 Insulin 01 ony olh.r hYPol/lyoomlo modloAllon,
2, MYOCA,dIAI InlArcllol1, angllla paclorl" ooronAry 11I01l1l1olancy, or poonrnokor In "" 11011 ,
3, OlhAr OAldlovA9olllal dloAA'O rosulllng III aynonpa, dyspnOB. loso or Impolrmol1l 01 00I1SOI0U.IIO.', oollopso, or oOI1Q","vn
cA,dlao IAllllre,
4, Hyp.,IAnslon ,.oulllng In sy"cnp., dy,pnoA, los. 1f ImpAI,m.1I1 of con'olou,"osa, oollorsIl, 01 oOllgosllvo o.,dlao lallu,o
5, R.SpIrAloIY dyalllnollon likely 10 I",polr Iho Ahlllly 10 drlvA A ochool hilS saloly,
6, Rhoumatlc, Allh,llIc, o'lhopodlc, muooulor, nou,omuaouIAr, or VA soul., dl,oaoA IIkoly 10 ""polr Iho ohlllly 10 dllvo a
aohool bus o.loly,
7, S.Izulo dloorders or .I1Y olhAr coudlllollllkoly '0 couoo loos or ""rol",,"11 of oorwolousllass 0' Any Iu.s 01 ohlllly I" rlrlvo
A ochool bllo AAI.ly,
C, HAO no mAIIIAI, .mollonnl or psyohlnlllc dlsord.r wholhor lunolloll81 or o'golllc whloh mAY bo ,nol111osled III 0 oomlill,," likr'ly
10 ImpAir tho Ablllly 10 drlvo A oohool buo sAfoly; OUch Aa InAllollllvAIIOOS, dospondency, AUl/rAs.lvono.a, or laok 01 eon"o,"
lor 'h. .Aloly 01 0011 And olhoro,
[), HAS no hOArlllY loaa y,oolor IhAII 40 rloclbols III Iha bolio, 00' wllhulIl a hOA,IIIl/ old, olho'l',ollolo. 01 500, 1000 olld 2111I0
A p.,son who I. 'Aqulrod 10 woo, 0 hOArlllg Aid ohall ho '.o'.d by a cllnloAlly oorllllad audlolo!!I,!.
E, 009S nol Ahus. Alcohol 0' Any olhnr drug or Stlh.'Allca known 10 Impolr ,kill or Iunolloll' whleh mAY ha mal1lh..",,111I ,lI'y
condlllon ouch os Inoll.nllvonAss, dAspondonoy, aggr.oslvon.oo, 0' look of oOl1com lor Iho sAlaly 01 soli allrl 011'0'"
F 1100 dlslallt ViSUAl ar.ully 01 AI Innsl 20140 In Iho hallAr oya wllhoul co".cllvo 101lS09 or vlsllal aeully o"rroolod 10 2(11.\11 '"
h.tlo" IIA' A'I.nsl 20/50 III Iho poora, aYA wllholll oorroollvo lOllS.. or vlol1ol ooully oorraolod 10 20/50 0' hollo' 110'. 0
comblll.d lIald 01 vlsloll 01 01 I.AOI 100'111 IhA ho,lzonlAI 'oo,ldlan. a,carllng '"0 no,mAI blind spols lI.s 1110 alrfllly '"
d.IAI",lnA Ih. colors usod Inl,olllc olg,,"ls And dovlcAs showlllg .londArd r.d, g,..n 0' Amlrar,
(l, H.o 110 Iyp. 01 luhorculosls In A Ilans",IIIAblo .Iogo ond hAS IAkon Iho pra,omploymonl luborollllll Insl oa "'<1ulrotl hv
Sacllon t4tA(h) ollh. ""bllr. Sr.hool Corio, O,lvOls who hOVA a dooumonlod 11011.lonllloonl luho,,:ulln aklll losl /100 ''''I
,nqullful 10 hAV8 furth,,' In!ll~ tJ"ln~~, III run ftxpo8nd 10 R COllO 01 Aollvn lubnrculonl!1 or me dhoiilocl olhnrwl~n hy "If~
SOC'.'A'y ollh. OepArhnAfl' of HOAllh EXH BIT
TIllS IS to CERTIFY TIlAT SAME IS' QUALIFIED U DIS(lUALlFlED \ )
Comm.nl., _.b( U__~U.tl\l:L_._LA)litl:.I.l.C___i.lv..\,_tjdUlA.l\h-1,lt\X"K ...1 I,... , ~6-_
AU.STAU'INTERNATIONAl
"nOVIDEn INFonMATIOlllrl.... PI'"' or 'vI'.1
fl."", ^ '
-StHOI /'v\C Ilffihl../
SIr..1 Addl." \ '\
\00 s. ~~~ 5
" 0.1<1..'. Slonll",. .' J '
1 ( 1\ 1-(1
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(11\~/
Slhlr.tnlllv ) !lInln llr.nn'!n'. ._
__JellUI ill '\~l'hL!.__._1J~ Ji~'~)"'<2_LL___
(1 vl\\ ,,_ r\~~ "''\ll~ 1..\ \
t 11.1. ---:-- -inl"I"""'" 0 \ \ l
\'L.,\l_\.'~ /\'1 "1"1(., Co \
CtJCI
--
Wtaluun .A((lt/leal l(Ij/';nt'.. d7J r.o
'-'J iJ'~. lIl.
JAV A, TOWNSEND, M,O,
JOSEPH A, PION, DO,
CAROL K, ROBISON, 0,0,
KATHLEF.N M, LOHRMAN, C,R,N,P,
1-
-J Ja.() ~)9 FAMILY MEDICINE
100 IOUTlt ..tla~i S'''U;T
N!WVH.LR, PA. 1724 I
Tr;Lfi:f'HONt.: (7171 716.3114
FA"~ C 117. ""0.8003
'DCM 'KiC~rJ 1Xi+dl
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-Tht-, i~ d kj-k" (OjILP>I1IOl~ mIl pi1l1fd-
J ",,;ta Sd,v<~~/, -Ihls Iclh TIIii" 3S lldlco..1
t ~ Icel t (l VI CL_(i''< \w ( '1D )VG) /( I
J.wJc\. i,s n \J?o~i col!y\ (+ U6 I i{;f;.d. .(eV
:=.-::,1 tQ. 'is, I:fl~\..~l Ico_lcc{J v0d 1\1)1 IOftll'M
hisw;,,,, c( (\ 0~ (jYl(' (~c,k~,kck .5(I'ZLlIL' /II
) ..-----, ~
S ~(J \'lAS b~e n ~f rL U vr -((~c('.., '(0'( 6 (:::flU vs SlY) (j
1::('1 ~ 6Y' -I hi \ "",cI i =h tJl(, - I hi \ ,:",,1 ,wh bVl "'::
, I L, ---""\1 ' t'l.~\...'k (v'" liL) (t\{~/~' !!J
N\ 4 fl-(((\l\.flO~'\L.U1,.L I I \{,n::, -- " "
o I II O' I ell' TICVi6V-~ '1~{IIJISICr?-
(11 h", "-0-1 t h. hh -, -' ,,-"-.- '
E?xmll.<-' lw ve b c.r V\.. o. rrJ \K'J .
I I~ I t)"i
(plc.(.I.~ {~Q {lu -(\J ((w:'{)C
&t~O' -/\ 61(.5. ' \ -1/1 }rKc "5 II ~ f
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EXHIBIT
S(nU ,,(Id )
(~;LQO t\~.~:l~)\t, \\I\C/
~~lC;4J.-W( {ilC--
( .!:2 ') jkll ~/)
-C---
AlL.sTAn' t~TEANATlONAl
I, IlITAltCCWTII IWI__'UI,
I, GIVI CCWTTU,mlUlII TO
MvIlIlI_OIIIl.
DO NOT RITIJRH TO ATA
PHYSICAL EXAMINATION FORM
,
TO RBORDBR rORM C0730
C^ll 1 100 ^ U,lINI
"Ill
.,.
,(MEETS DEPARTMENT 0;: TRAI4SPORTATION REQUIREMENTS)
Date 01 Examlnallon
___ New Cerllllcallon
Recertlllcallon
Check Here II Not Qualllled
u
o
CI
To Be Filled In By Medlaal Examiner (Please Print),'
Driver's Name 4/I1~l fA s(',I/ /it V)
Address ~l <)ht4LfuJ.., "lltN vilu_, PH in (I {
Soc, See, No, __/1/- 3Lf -/5 2} Dale 01 Birth --7-' <j . ~ h
_ Age_.5.:,L__
CIO
'I' ,\\
Vaa ~ v.. N9 V j~ Vl/q,
(J fjel. Allltma (J II NorvoulllomllOh t1~ H..d oroplnlllnlurlo. >Jf' t,1,i)j 1\
o Kidney 0 r:J RhlUm.Uo lov., If [Solzur.., III., eonvul.lon., Dr lalnllng 1'1, \ s ~ VI
o ;:J Tubareulool. CJ ~ MUleul., dl.o..o 0 e,l.n.lvo conhn.monl by IIIno.. Dr injury
(J UI, Syphlll. (J '" P,ychl.lrie dl.ordo, (J Any oth., n.rvou. di,ordor
(J GI Gono""". (J 'Ji. Clrelov..eul., di.o..o (J iY' Sullorlng Irom .ny .Ihor dl,...o
(J a Dlobal.1 CJ a Oal~.lnl.,lInal uloo, U I:iI' Pormanonl d.locll,om IIInl..,dl.oo.o or Injury
lIanlw."o.n~ollholboY8I'~ol,a,plaln:_ 1'1. l,oJ J S(''Z~(/-(_tlnlLl-llcu ben., SdHII7--Pu_ (l~ fie/VI'
GII1..lllpp..'ln..lnd dlvllopm.nll Good ---L___ Fnlr Poor _. .
VI.lonl For DlllanCQ: Rlghl20/....)_~loft 201~ Both 201_l!fWlthoul corroclivo lons81 0 Wilh corrocUvo lonsas,lf worn
Evldenoo oldl....o or Injury: RighI ,_ Loll
Color TOil ''''''I('.~ ...,..__ Ho,l.onlalliold 01 ,I.ion: Ri~hl Loll _
RighI.., "'1'" ~hlf'I- L.II"'_'jt~Hj,./._~(,I__
OliO.'" or Ir'I)ury _l'~ __ __4____,.____~
II/Iudlom"., I. usod 10 I." "..ringl Ooclbello,s 01500 H. _ 1,000 H. _._ 2,000 H. '__' 4,000 Hz __ 6,000 H, __.
. WNLpO,pl.....'" e~ ~itJ.s..~____ __
tl~~nIC i~:~!;I' ",o:'n~~lod1>~''<W'" -::.. ------'-_----:=:
Blood pressure; Syslollc I {) Oiaslolic. .......
Pulse; . t\ Boloro ollorclso 'I L 'ot' ,n lmmodiately ..Ilor ollorciso ----.!2.MO
Lung. c f "
Scan~ IlIt.., I\l'rll Abnormal ma3sos;.r Tendornoss __~I..(.
Hernia: Yes No ~ II so, whqro? Is lruss worn?
Uloetatlon or other diseasoa: Yos=-.a:. \C' ~tl)'() No~- -----~.-.~
$enr. 1.,n _ Urothral dischargo ""10
Rhomberg J'ilm'" "~lN C. ~
Pupillary ~_=,; - ,Liqht: R _ n<:\Yl'N>\' C---.-T-
AccommodliiiOn RTgiiI----op, I I "-- -- LoII__l1nr'k. ----=-_=
Knoo jo,k.: Righi: Norm.1 I< Incro..od _____, Absnnl ___.__
Loll: No,mnl __~L-_ Incron.od __._____ Abs.nl _____._._
Romarks:
e,'romltl..: Uppo, - ~_ ___ Low", _ !AJNT:----- Spino ( .t.r'-'~l",T~~=
loborllorVlnd Urino:Spoo.Or, _~I2..J..~ Alb, ,,~"", Sugnr ----.l2..()'~_ ____
Olher Spoelll aliter Labor.lory Data ISorolog~, olcl _._____ ..___..
Finding" Raelologk;ol Dolo ___ Eloclrocardlograph __.___
Controlled Sub,'.ncH T..Ungl LJ Controlled substanoos lost porlormod. CJ In accordanco with Subpart H [J NOlIn accordance with Subpart H
l!rConl,ollod sub'l.neo, 1051 NOT po"ormod Slv
G.n,,"1 Commlnlll --.::EL_lL~ D, !:oldl ~ (<x_ ,-t"$C0:l:<..i! 6\'D'!J)'__1 'c'so~",-~l.{I<,J-LWL__ .__ ._.
'!CI;U,( ..t;rI_~1 Q. c_~J-S'-' ____ ~~
Nam. 01 Modl..1 Enmln.. (Prlnl) .J.~ j"'"')' <--' IV /-' $ C ~ Slgnalu,o _ . _ I V' ..../
Add'.lI of Modlcal Eumlnar ...JJlQ "t 1\/ wVII~ ..
MEDICAL EXAMINER'S CERTIFICATE TO B~OMPLETED ONLY I DRIVER IS FOUND QUALIFIED
MBDlCAlIXAMINBR'S c~nT1FICATE
l . _'.J I certify Ih U ~Y'& tlltlmlned
--J..U'-'l. 01 U \1 'r'
. "'Ie, . name II
In ICCQl'danc:t wllh lheFtdetal MolorCa"ler Sa Rogul"tion5 (49 ern 391 ,<11
Ihloovh3lJt.4gllndwilh knowledg. 01 hltlhM dUli.t.~nd blfT\lh" t!ualilied under
"'" ..g"""""', I.p/rot.... dll' OI"rllllcot"_I. -Q..';>.__
Outlined only when n.mo: a CO/lech,lenl. U Hearing Aid
lJ ....dieally unquaNI'Id""'.. ICooml)al1led by . ___M'___.__. WRiver
o Medically unquaMAtd ..n... drt~nv wllhin An ,.ampl inltacHy lone
,Acompt!led.~aminlllol.' m OI'~I. 5Onl,onnlelnm 1C{J
t 0,1
H..lth HI.,Urv'
H..rlng,
Audlomllrlc I....
Th'Oll,
Thor..:
Abdomon,
G..I/olnl..llnlll
GlI1lto-Urlnlrvl
R.Il....'
The 'allowing will he cornplOlod only when Iho vIsuAl 1051 Is condUClod by 11
licorlsod ophthalmologist or oplornotlisl
(O'-htorElatn,rul'0l11
IN.tmllol o.)/llh.tlmofogl.l 0' ()plofmlrltl (f'lIfl!H
l"ddrlN' 01 ~hth"IroIOllSI 01 ~h)(f'QII.1I
tSIQn.tlu,u~DrI"'1I
7
(,,'w.
, ,r.1l'm:''':,:,,:,,~.
Itll
EXHIBIT
("ddr...01 o.r...rl
INS
1)
D~
ALL.STA.TE-INTERNATIONAl
6fspn08. collapse, or conQ05UV8 c.."lrdlac falllJro;
15) Ha. no ..labll.hod modlcal hl5lory Of dlnlcnl
dagno:lle of .. r9splmlory d'f9luncUon likely 10 In\ot-
(mo wllh his ability 10 control alld drivo ti molor vohldQ
..Ioly:
(6) Has no t.U"onl cHnlcul cf:aqno9b cfhlgh blood
prml3Ulo IIkoly to lnlorloro with his ability to opomle I)
motor Vflhldo safoly;
(7) Has no 89labllsthKt modic...,l history or dlnlcul
da.gno~s of Ihoomatlc, arthrHlc, orthopedic, "",1!>CU-
lat. nouromuscuklf, or vascular dlSURSO which Inlol-
kilns with his ability 10 control And OpOloto a molor
'fOhlclo saloly;
(0) Has no osl.ablishod modical hl~'o(y Of dinical
dagno!Us of opll6p9Y or any oHlOr condi1lon wtllch Is
Iwl)' \0 C3USO loss 01 conSCIOU5I10S9 Of any I09!i 01
ability \0 coolIol a n'<ltor 'Iflhlclo:
(9) Has no menIal, nervoUS, o(gonic Of (uncllorlill
dsoaoo Of psychiatrIc disordof likoly to (nlm/uro wilh
his abUlty 10 d,lvu a molar vehlclo safoly:
(10) Has distant vfsual acully 01 atleasl 20/40
(Snolfon) In GAdl eyn withoul corrocllvo lon501 or
yj!',ual acuity ooparaloly corroctod 10 20/40 (SnnUon)
Of boiler wilt! cotrocllvo lon!'..:l'9, dislanl binocular
acuity 01 alloasl20J40 (Snolfen) I~ bolh OY9~ with o~
withoul cOHocllve lonoo!l, field 01 vtllon 01 alloasl 70
~lthQ horizontal rnoridlanln oach avo, and lho ..biUly
'" fOcoQnlz9 Iho cotors oIl' alRo signals and dovlcos
showing 91rmda,d ,od, gr09n, and ambor:
(11 j First pOfcolv03 A lorcod whl~pofOd \loico III
tho oolhlr ea, al nollosg Ihan S loot wilh or wllhoullhl1
tlSO 01 a hoaring aldor, II \Osl~dby use 01 an audlotOOI-
tic dovico, doos nol have an avorAgo hoaring loss In
1110 bollar Oat groalor limn 40 decibots al 500 Hz,
1,000 Hz, and 2,000 Hz wilh or wilhout a hearing aId
whOn Iho audlomotrlc deylcolscaUb(nled 10 f\mOlican
~Jallonal Standmd (Iormorly ASA SlandarrJj l24_5 ~
1951
(12\ 0009 nol use Q SctlU(julol dnJg or ollH)(
sub91;mco IdMllllooin ^pplJlldix U 0111119 SlJoctHtpln.r,
an arl1phOlilmillO, it narcotic, or any olhor habit
!onning drug, olloopl that tI dri....or m.1Y US<l:t 'Juctl il
~lJbslanell or drug H 'ho 9u~tanco or drug Is pro.
salbod by iI 1fCOr1sod loodical prncHtionof who Is
famtliar wllh tho drivar-" lTV'Klicai his lOry And asslgnod
dullos ..nd who hM ilml9fJd !hn drivo( lnallhe pro.
ncribod 9ubslanco or dfug will not adl,fornoly <lfloet lho
drlyor'!l ability to !"'.ailJl'( oporalo il motm 'lOhlclo: and
I1J} HilS no curlOnl clinICal dii\C}n09Is nl illcohol.
l!!In
INSTRUCTIONS FOR PERFORMING AND
RECORDING PHYSICAL EXAMINATIONS
Tho JTIO(flcal o.iunlnm ~J\ould rOVll1W UlO',O in.
slluCti0f19 I:K1tor9 porfOf11'1lf1<'}lho ph'(!\lC,11 l)lcnrnlf\a-
Hon_ ,"nswor oadl qlJOslion yr~ or no whoro appropn.
a\o
Tho rnodical oX<UllinOI ~ould bo !lW<UO 01 ttm
Ik]OfO~~ p4:1'1!!I~1 domafloo and l1'lOfllaland ~ml~nat .
msponfoibi\ili~ placod on Ih.o drllfflf 0111 ctlf1vnofCll11
rmmf vuhkio, In -Iho Inl<HM\ l1t pUbUC !".nl(ltv,lhO
1111.l<1IC.l1 Oll."mlnor t, 1000lmd 10 ('OfIlfy lhat Iho 1111'.'0f
ooor. nol lI:\vo AllY pllYI\lcal, 1111,"t.-,1, Of ofg;iillC dnlnet
ol slIch " nalurn {l!l 10 nllocl lhO drr/Of1 "bill I, 10
opnraln '),1101y a COfMlOf('j,11 moW '/lIhldo
l\'l9~i,~Uto '05u115 o( $Ud11051 must bo cUCprABlMJd In
voluoscomparab40 10 tho s\andaldSnollon Iost.lllho
oppllcanl wears COffOCUV9 Ionses, Ih090 ~hould bo
worn whllo appflcanl's vl!/'unl acuity Is bolng I09tad, II
appropriate, Indlc.alo on 1t19 Modlcal EIlRmlnor's Gar-
IIl1calo by r:Mcking tn:l boll., 'QunIlJlM Nlly wl10n
wonrlng CO/fDCt!VO lons09.' In ,ocordlng dlSk11lCO VI'
II10n uoo 20 fool as norm.-11. Hoporl all vision as Il
Imotion with 20 8S numoralot and tho ~moJI091 typo
road at 20 1001 a.'I oon(lmlnaIOI. Nolo plosis, dis.
ct\JlgO, ylsualllotds, ocular muscle 100tllllllncn, ool,or
blindno5..'1, comoal SC4\r, oll.opt1\halmos, O( nt/obIS-
mus, uncorHlclod by conoclivn lon!ms. Monocul,1(
drivOr!l aro not qualitlod 10 oport'to cOO1n\lIfclal motor
vl)lIjctQ~ under oll.isting FodOlal Molor Caffinr Safely
Rll<Julalions
If lho dli'/or habitually wuars OOfHact l~lI1s0S, or
In!(Jncl9 to do so whilo drivi/1g, l1\Oro Shoufd bo wln.
ciont ayidonco 10 Indicate ItlUl110 has C)ood lolornnco
and 15 woll adaplad to thoir uso. TIIO Wlll 01 conWcl
IflflS05 shoufd be nolrK! on lho roco/d.
Eers, Nolo oliidonco 01 rn.15told or rnic.kllc Ollr
disOi\so, di!lchargo, symptoms 01 aura '101111)0, or
Monioro's Syndromo, Whon locouliflg hORring, rocord
distanco Irom pa~onl at which a for cod Whlsperorl
yoico eMIII/sl bo hoald. II audlomotor (s lI~{}d 10 lost
tloa,ing, rocorndccibolloss at 500 Hz, 1 ,O<XJ Hz. and
2,000 Hz,
Thro.t Nolo oyidom.:o 01 disoas(), !rlon'lOd:ablo
doforl11l1\05 ollho lhloal hkol'( 10 lntodoro wilh oatill(j
01 bWillhini), or any laryngoaf condilion whictl could
inlorhuo wilh tho sofo opmallon ot a roolor 'loll/cia
Thoru'htllrt. Stolhoscoplc o.ammation is ro-
qulflld Nolf! murlllurs and .'HIhyUmliaG and illlY past
or prosonl hl510fY ot cardlo'lascular oisoaso, of a
vllflllly known 10 bo accomp<lnlllU by syncopo,
dy~IJtloa. CX'ltapse, onlargod hoart, or congo SINO hoart
f;lIlur(Js. Eloctrocmcllogmm i':; loquimd WI1Ufl fill(llIllP
~o il1rlit:';'11;>
Blood pteUlUI. Roco/d wi III Ollho( ~prll1f) or
rMrcury r:olurnn IyPO 01 spt1ygrnor/l.-lI10(f)f}10f, 111110
blood prMsuro iscon!>l5tonlly abOv" 1 ('.0,'90 mm. Hg.,
furthor lnsts rnay bel floccssary to OOlorO\ll1o WI1fHhnr
1M drivor i9 quaJiliod \t) opera Ie a molor vohido.
Lungs, II any tung disoa~ Is dOIl1Ctod, slalo
'NMtllot nellvo ~ :ulOstod; 11 afto5tod. your opInion as
10 how fong il tl.1-.'1 0090 quio~lConl
Gultolnlutlnal SY'lem, Nolll i\fly (JisoaSII!l 01
lhll lJ<\S\(oinlOSlillal syslem
^bdom.n,Nol~wouno-,>.l(llurllls. ~,G.:lr<;, or wIJ!.1k.
nil!'';' of mllsclos at :lb(lollun.:l1 w-nll!, 5uHiclont to
Inlmlom wllh nomlclllunclion AllY hmnia sl1()\jld Oil
nolotl it pr~9on'- StaIn !low long and il "doqualot'(
COf\lilill~d by truss
^bnormll mil''', \1 pfO!i-Onl. nolo IOc.1llon ii
lnflftN, and wholhr" or nol applic..lll1 know!"'. 110W ~)f1q
thoy havo boon prJt!,(1ll1. II tho dlaQ!loc,n !",uq90~l!llhal
tlw condition rTllqhlllllorlolO wilh 1110 coni(ol and 'j.,ltil
OplHilllon 01 .) motO( vol1icto" mOIll sltlnqQlll,lllst'i
m\tsl ho mad!' oolow Iho apphc"lIt can 00 ertrllrtrKl.
Tend.,"".., Whon no\od, ~""O wlUlro rDl"Jr.tp'o,
I\<1Un(;(Ic1. and SU!\lKlclod C31rne. It lho diaqno!li~ !\uQ'
I)n<;l!lltl<11 thll oO'ldlllon 1ll19hlhillldftrnWllh 1t1~ tonlrol
imd :.atll opomtton 01 amolOlllohicln, l!lorn !',tdl1'loflt
lo<;L'l n1\J<;1 00 ",ado b<\IOIn 111(1 "pplic<1lll call bo
l;nflllllk1
anonllon onoUla 00 IJIVflll IU "111..1" . ""'''''' ....'v,,'......,
made of, lIny w\1pahmonl 01 structural 001001 which
may InlOllo(o wllh Iho d,lvor's ability 10 opOlalo a
molot \lohlcll'l 5<1181'(,
Spin.. Noto riolomlillos, lImHaUon 01 motion. or
any Ilislory ~f rain, lnjvr!o!:. ~r d!lJo!'.:JU, iln~t -:r pr~!l
onUy oll.porloncod In Iho cOIvlcat or iumhar !HJlno
rogion. II nndl(\gs so dlclalo, radiologic ilnd olhGI
oll.8mlnntlon5 should bo uood 10 dtagnoso congoni!.al
or ocquiroo dotOOt9; or3pondylot~ltlOsi9 and 9col109toJ
Alcto,g."llll sludl.., Qlsoasos Of condWons
cil\Jsing dlscomfQrt 5tlould brJ ovatualod carolully to
dolofmino Ihe oll.lontlo which Iho condition 1Ilk]~t bo
hanrlicnpplng whit" lilting, pulling, or dllling pOliods oi
prolonCJlld drlYln!} U1al might bo flCCOSsary a9 part 01
Iho drlvnr's dUllng.
Laborlttory llnd olher 'pecllIl findings, Unnnl,
!!is Is roqultod, as wolf as sucn olhor 10SlS as tho
modiCdt his lOry or Onding!lupon physicalo;<amlllilllQIl
m'lY Indicalo om nOCO!lSIHY. ^ serological lost ,~
IOquirodft lhoapplJcanlha5 0. ~liSlOfyolloolicinloClion
Of profoonl phY9lc,,1 :inclings indicnla tho flOSmbtlity of
talonl syphilis. Olllo( StUdi09 doomed nclvmablo rmy
bo ordorod by lho modlc.,l mcrunlnor,
Oli,b.I.., II InsuUn (s flOCOgs,lry to conlrol ;',
diabolic colldlliofl.lho drlv"r Is nOI<\ualWod to opQr"ll<l
a molot vohiclo.1I mild diabetos Is 1)0100 allho t1n-.o 01
oxaminntlon, and it Is !ilnbililed bv u~o 01 ,1
hypoglycomic druCj alld a diol Ihal COlli bo ohlaillM
wllllo III,) drivor is on dUly, II sho,.,td nol bo cof15idoll,(j
disqllalit'(ing, HO'Nuvtlf, Ul0 dtiYor mu!!l tomain un<jm
adoqtHUO modicat 5UPOlylsioll
Controlled Substances Tutlng. If II lost for
controHod subslnnco$ Is porkrmod ,,:I pilrl of tho
modlc.11 OImminahon, Iho modk:al Qxaminor is 10
Chock Iho box nexI 10 lhe statemonl, .ConlroHlJ'J
SUt)SlnrlCO 1091 porfC'flllOd' on Iho fI~JdirA.ll n.amina
lion forrn, II a tosl lor ecnl1ol!od 'lUhSlanoos Is n'Jl
pmiolfnfJd, Iho rnodiC<11 o.aminO( I~ 10 ch(X;k lhl.' bQl
/lIlxllo Iho slatmnonl, 'Conttollod !lubst;'\f\co losl not
pmlarmod." II a conl/oUod subslanco!> tosl is por.
IO/mod undor tho roquiroroonts 01 Subparl H 011111$
pm!. thon Iho rnodicaf oxaminor must also chock !tll)
box noxlto 1110 slalomonl, 'in tlccordanco with Sub.
pall H,' and musl obtain tnloflnalion thalltlo rosulls 01
such losl WOfO nogatlvo prior to corllt'/lng Ihat 1110
driyo~ is olhOlwlso medically QUillHiod, If a cClnlloll!:d
!iubslanco 1051 I!! pmlormod. bu\ nol in aCCOrdJf1C1
wilh Subpart H, 1110 mo<lic..11 olamifwr mwll also
d\ock lhe txu; no.llo tho slatorllf'Jrl!. '1\01 III iv:cr,r
daneo with Subp;ul fl,' and onSUlfllhat 11m rO~HlIl5 Of
lho tost wom nogiluvo priol to CortilYlllg th:}llho dri-/fJI
Is olhorwi~o rHndicall'( qtlahn~d
1110 modical o-.a.miIlOf musl dalu and siqn hiS
limlinqs upon colllplolion 01 Iho o-..:anlinahon.
A .\icon!:\cd ophtlmlrnolOQi!ll 01 oplofTl(}I(1~11 rr;l'l
poflorl11o."minilIIOrl9Il<1rlilining toYl!lual aC\llly. !,f)I(j
01 yision rind nbHlly to rocoqnllO oolors.
It \110 rmdlcal o([lfnlnor lImh I1mlltHII>4115iJn 110
OlilrnmOtI i!i ph'('1ieillly q\l<tHl1od to {irivo a ""'"ltOI
Yfll1icll1. 110 'itlall cott\{lllltO UH' ModlC::ll r:..ill11il\f;r"
CtHlllil;.,'jlo ilncllurnish OfHI copy \0 lh{l PflMon U_ fUll
Inod nlHI Oil!' COllY ICllhn molOf Cmr1tH omplOYflt