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Right Ear Left Ear Neither Acuity Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test: Right Ear Left Ear Whisper Test Results Right Eye: 20/ 20/ Right Eye: degrees Record distance (in feet) from driver at which a forced 20/ 20/ Left Eye: degrees whispered voice can first be heard Left Eye: Both Eyes: 20/ 20/ Yes No OR Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors Audiometric Test Results Right Ear Left Ear Monocular vision 500 Hz 500 Hz 1000 Hz 2000 Hz 1000 Hz 2000 Hz Referred to ophthalmologist or optometrist Received documentation from ophthalmologist or optometrist Average (right): Average (left): PHYSICAL EXAMINATION The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment.. 2126-0006 First Name: Middle Initial: DOB: Expiration Date: 8/31/2018 Exam Date: Please complete only one of the following (Federal or State) Medical Examiner Determination sections: MEDICAL EXAMINER DETERMINATION (Federal) Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49): Does not meet standards (specify reason): Meets standards in 49 CFR 391.41 qualifies for 2-year certificate Meets standards, but periodic monitoring required (specify reason): Driver qualified for: 3 months Wearing corrective lenses 6 months 1 year other (specify): Wearing hearing aid Accompanied by a waiver/exemption (specify type): Accompanied by a Skill Performance Evaluation (SPE) Certificate Qualified by operation of 49 CFR 391.64 (Federal) Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal) Determination pending (specify reason): Return to medical exam office for follow-up on (must be 45 days or less): Medical Examination Report amended (specify reason): (if amended) Medical Exam
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