Transcription of Medical Examination Report of Driver Under Article 19-A
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Medical Examination Report of Driver Under Article 19-A
Medical Examination Report OF Driver Under Article 19-AINSTRUCTIONS TO Medical EXAMINER:The complete standards and instructions for conducting this Examination are found in Section of the Commissioner sRegulations, 15 NYCRR6, and can be found at They are also available from the Driver s carrier named below or from the Bus Driver Unit. For New/InitialExaminations and Recertification review/complete ALLitems on the form and sign where indicated on last page. For Follow-up Examinations complete ONLY thoseitems which require follow-up information and/or evaluation from a prior Examination . Sign the form where indicated. If additional space is required for further comments andinformation, use form DS-874C, and attach it to this s Last NameStreet AddressLicense ID Number(from Driver License)StateClass of Driver s LicenseEndorsementsRestrictionsExpiratio n Date( Driver s Signature)(Date)CityStateZip of Birth (Month/Day/Year)AgeSexoMale oFemaleI certify that the above information and any other infor
sleepiness, obstructive sleep apnea, loud snoring ooStroke or paralysis ooMissing or impaired hand, arm, foot, leg, finger, toe ooSpinal injury or disease ... the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is …
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