Fillable MAB105 - Application For Intrastate Medical Waivers To Operate Class A B Or C Commercial Motor Vehicles 0719 - Fillable 2

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MAB105 - Application For Intrastate Medical Waivers To Operate Class A B Or C Commercial Motor Vehicles 0719 - Fillable 2

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Application for Intrastate Medical Waivers to
Operate Class A, B, or C Commercial Motor Vehicles
Registry of Motor Vehicles ● Medical Affairs Division
P.O. Box 55889 ● Boston, MA 02205-5889
P
hone: (857) 368-8020 ● Fax (857) 368-0018
1 MAB105_0719
Medical Waivers for the operation of commercial motor vehicles INTRASTATE ONLY (within the borders
of Massachusetts only) will be issued in accordance with the provisions of 540 CMR 14.05 (1)(c).
The Registrar may issue an intrastate waiver for the following conditions ONLY:
1. A VISION IMPAIRMENT if: the individual has a combined horizontal peripheral field of vision of not less than 120
degrees, provided the individual also has a distant visual acuity of at least 20/40 (Snellen) in either eye, with or
without corrective lenses, and the ability to distinguish the colors red, green, and amber;
2. A DIABETIC CONDITION if: the individual submits a written statement from his or her physician (defined on
reverse side of this application) which: provides specific reasons why the individual is not at risk or is no longer at risk
of suffering hypoglycemic spells or episodes; and recommends a specific date for the Registry to re-evaluate the
individual s ability to operate a commercial motor vehicle safely;
3. A CARDIOVASCULAR CONDITION if: the individual does not have an implanted cardiac defibrillator for a
“sudden death” event and does not have Class III or Class IV heart disease according to the American Heart
Association functional guidelines for classifying heart disease; and
4. A LOSS OR IMPAIRMENT OF LIMB so long as such loss or impairment of limb is not likely to interfere with the
safe operation of a commercial motor vehicle.
5. A HEARING IMPAIRMENT if: the certifying physician states the condition will not interfere with the safe operation
of a commercial vehicle. For vehicles with air brakes, an applicant must be able to hear the air compressor cutting out
and detect an actual air leak in the braking system- a safety precaution in case the gauges have malfunctioned.
Therefore, a profoundly deaf person would not pass this portion of the test and would be restricted to a commercial
vehicle without airbrakes.
Individuals with these specified conditions may obtain an intrastate waiver provided that the condition will not interfere
with the safe operation of a commercial motor vehicle, as certified by their physician.
Please note: Applicants who need to pass the Commercial Driver Road Test may request a reasonable
accommodation limited to additional time to perform the pre-trip inspection and maneuvers. The request for a
reasonable accommodation must be from a physician, written on the physician’s letterhead, describing the medical
need of additional time. ONLY accommodations for additional time will be granted. All applicants must pass all
aspects of the Commercial Driver Road Examination.
Intrastate waivers shall NOT be applicable to SCHOOL BUS operator certificates.
The following documentation MUST be submitted with this completed application, certified by your medical professional,
to the Medical Affairs Division:
1. A copy of the results of a recent DOT medical examination performed pursuant to 49 CFR 391.43, upon whic
h
t
he examining physician has indicated that you are only qualified to operate a commercial motor vehicle with an
intrastate medical waiver; and
2. A letter from your employer acknowledging that you have a medical waiver and that you drive commercially as
a requirement of employment within the borders of Massachusetts only.
p.2 MAB105_0719
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Date of Birth (MM/DD/YYYY)
License #
Endorsements
Expiration (MM/DD/YYYY)
Residential Address
Street
Apt. #
City
State
Zip Code
Employer/Company Name
Company Address
Street
City
State
Zip Code
Telephone #
I hold a valid Massachusetts Operator’s License, Class __________ , am engaged only in intrastate commerce within the borders of Massachusetts, and
hereby apply to the Registry of Motor Vehicles for a waiver to operate Commercial Motor Vehicles of this class.
I certify under the penalty of perjury that the information I have provided is true and correct.
Applicant’s Signature: _______________________________________________________________________ Date: __________________________
B. Authorization for Release of Medical Information
I hereby authorize the physician completing this form to discuss and release any or all medical records pertaining to its content with or to
representatives of the Registry of Motor Vehicles.
Applicant’s Signature: _______________________________________________________________________ Date: ________________________
C. Physician Certification
(Physician must complete the relevant section 1 through 5 below
and complete the remainder of the application in full.)
This part of the application must be fully completed by a physician: a medical doctor who is licensed to practice in the Commonwealth of
Massachusetts.
1. Vision Impairments: Combined Horizontal Peripheral Field of Vision (record in degrees):
Distant Visual Acuity (Snellen): Left Eye (OS) 20/ ___ Right Eye (OD) 20/___
(I
f the applicant uses corrective lenses for driving please specify visual acuity above as corrected with Rx).
Does t
he applicant use corrective lenses for driving? ........................................................................................................................
Yes
No
Is the applicant able to distinguish the colors red, green, and amber? ..............................................................................................
Yes
No
2. Cardiovascular Conditions: Does the applicant have an implanted cardiac defibrillator? ...............................................................
Yes
No
Was the defibrillator implanted for a ‘sudden death’ event? ...............................................................
Yes
No
OR
Was the defibrillator implanted as a preventive measure? .................................................................
Yes
No
Does the applicant have AHA functional Class III or Class IV heart disease (see attached guidelines)? ...........................................
Yes
No
Specify AHA functional Class and symptoms: (see attached guidelines)
Other comments:
__________________________________________________________________________________________________________________
(Continued on Next Page)
p.3 MAB105_0719
3. Diabetic Conditions: Ha
s the applicant ever had a hypoglycemic episode or spell? ........................................................................
Yes
No
The applicant is not at risk or is no longer a risk of suffering hypoglycemic episodes or spells for the following specific reasons:
___________________________________________________________________________________________________________________
R
ecommended date for the RMV to re-evaluate the applicant’s ability to operate a commercial motor vehicle safely intrastate only:
(MM/DD/YYYY)
4. Loss or Impairment of Limb: Specify limb(s) affected and nature of impairment:
________________________________________________________________________________________________
_____________________
5. Hearing Impairment: Specify degree of impairment and include any pertinent comments:
________________________________________________________________________________________________
_____________________
Please check one of the following categories:
I hereby certify that in my professional opinion and to a reasonable degree of medical certainty,
The applicant named above is medically qualified to operate a commercial motor vehicle safely.
The applicant named above is NOT medically qualified to operate a commercial motor vehicle safely.
Physician’s Name (Print)
NPI #
Telephone #
Board of Registration in Medicine #
Street Address
Street
City
State
Zip Code
Signature: _______________________________________________________________________ Date: _________________________________
Classification Guidelines:
AMERICAN ASSOCIATION FUNCTIONAL CLASSIFICATION SYSTEM
CLASS I Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity
does not cause fatigue, palpitation, dyspnea, or anginal pain.
CLASS II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest.
Ordinary physical activity result in fatigue, palpitation, dyspnea, or anginal pain.
CLASS III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at
rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
CLASS IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort.
Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical
activity is undertaken, discomfort is increased
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MAB105 - Application For Intrastate Medical Waivers To Operate Class A B Or C Commercial Motor Vehicles 0719 - Fillable 2

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Completed 20 January 2020

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