Road-Test Exemption Form
for drivers with monocular vision — 49 CFR §391.44(d)(3)
To be completed by the driver:
I, __________________________________________(driver name) hereby certify that I have a
vision deficiency in one eye that prevents me from being medically certified under 49 CFR
§391.41(b)(10), and that this deficiency began on ___________________(date). I was physically
certified under the standards in 49 CFR §391.44 for the first time on ___________________(date),
and I further certify that I operated a commercial motor vehicle with the vision deficiency for the
three-year period immediately preceding this date.
Signature: _____________________________________________________ Date:____________
To be completed by a motor carrier representative:
I, ____________________________________________________(name) as a representative of
_________________________________________________ (motor carrier name), have determined
that the above-named driver, for the three-year period immediately preceding the date he or she was
physically qualified for the first time under §391.44 (as shown above):
Possessed a valid driver’s license, and
Operated a commercial motor vehicle in either (a) intrastate commerce or (b) interstate
commerce but was exempt from needing a medical certificate under §390.3T(f) or §391.2.
Based on these facts, I have determined that the driver is exempt from needing a road test to verify
safe driving with the vision deficiency, per §391.44(d)(3).
Signature: ___________________________________________ Date: ______________________
Notes: _________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Provide a copy of this form to the driver. Keep the original in the driver’s qualification file for the duration of
employment plus three years.
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