B.06.05 Attachment 13 - CDL, Insullin Treated Diabetes Mellitus Assessment Form MCSA-5870.pdf
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MCSA-5870 OMB Control Number: 2126-0006 Expiration Date: 11/30/2021 U.S. Department of Transportation Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements. **
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 8 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
INSULIN-TREATED DIABETES MELLITUS ASSESSMENT FORM
Name: _________________________________________________________________ DOB: ______________
Driver’s License Number (if applicable): ____________________________________ State: ______________
This individual is being evaluated either to determine whether he/she meets the physical qualification standards of the Federal Motor Carrier Safety Administration (FMCSA) to operate a commercial motor vehicle or because the individual has recently experienced a severe hypoglycemic episode. A treating clinician should complete this form to the best of his/her ability based on his/her knowledge of the individual’s medical history. Completion of this form does not imply that a treating clinician is making a medical certification decision to qualify the individual to drive a commercial motor vehicle. Any determination as to whether the individual is physically qualified to drive a commercial motor vehicle will be made by a certified medical examiner on FMCSA’s National Registry of Certified Medical Examiners.
FMCSA defines a treating clinician as a healthcare professional who manages, and prescribes insulin for, treatment of the individual’s diabetes mellitus as authorized by the healthcare professional’s applicable State licensing authority.
Instructions to the Individual:
When you are being evaluated prior to a medical certification examination, the certified medical examiner must receive this form and begin the examination no later than 45 calendar days after a treating clinician signs this form.
When you are being evaluated after a severe hypoglycemic episode, you must retain this form and give it to the certified medical examiner at your next medical certification examination.
Insulin-Treated Diabetes Mellitus Diagnosis
1. Date insulin use began:
Blood Glucose Self-Monitoring Records
2. Has the individual maintained at least the preceding 3 months of ongoing blood glucose self-monitoring records while being treated with insulin that are measured with an electronic glucometer that stores all readings, records the date and time of readings, and from which data can be electronically downloaded?
_____Yes _____No
3. Has the individual provided at least the preceding 3 months of electronic self-monitoring records while being treated with insulin from his/her glucometer to the treating clinician for review?
U.S. Department of Transportation Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements. **
If no, provide details:
Note: The individual is not physically qualified to operate a commercial motor vehicle for up to the maximum 12-month period until he/she provides a treating clinician with at least the preceding 3 months of electronic blood glucose self-monitoring records while being treated with insulin. At the certified medical examiner’s discretion, the individual who does not possess at least the preceding 3 months of electronic blood glucose self-monitoring records while being treated with insulin may qualify to operate a commercial motor vehicle for up to but not more than 3 months.
4. How many times per day is the individual testing his/her blood glucose? ____________________________________
5. Is the individual compliant with blood glucose self-monitoring based on his/her specific treatment plan?
_____Yes _____No
Comments (if necessary): ______________________________________________________________________
Severe Hypoglycemic Episodes
6. Has the individual experienced any severe hypoglycemic episodes within the preceding 3 months? FMCSA defines a severe hypoglycemic episode as one that requires the assistance of others, or results in loss of consciousness, seizure, or coma.
_____Yes _____No
If yes, provide date(s) of occurrence, whether the cause has been addressed, and associated details (attach additional pages as needed):
Hemoglobin A1C (HbA1C) Measurements
7. Has the individual had HbA1C measured intermittently over the last 12 months, with the most recent measure within the preceding 3 months?
_____Yes _____No
If yes, attach the most recent result.
Diabetes Complications
8. Does the individual have signs of diabetic complications or target organ damage? This information will be used by the certified medical examiner in determining whether the listed conditions would impair the individual’s ability to safely operate a commercial motor vehicle.
a. Renal disease/renal insufficiency (e.g., diabetic nephropathy, proteinuria, nephrotic syndrome)?
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:
U.S. Department of Transportation Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements. **
b. Diabetic cardiovascular disease (e.g., coronary artery disease, hypertension, transient ischemic attack, stroke, peripheral vascular disease)?
_____Yes _____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable: ___________
c. Neurological disease/autonomic neuropathy (e.g., cardiovascular, gastrointestinal, genitourinary)?
____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable: ___________
d. Peripheral neuropathy (e.g., sensory loss, decreased sensation, loss of vibratory sense, loss of position sense)?
____Yes ____No
If yes, provide the date of diagnosis, location, type of involvement, current treatment, and whether the condition is stable:______________________________________________________________________________________
e. Lower limb (e.g., foot ulcers, amputated toes/foot, infection, gangrene)?
____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:____________
f. Other? (specify condition)______________________________________________________________________ ____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:
Progressive Eye Diseases
9. Date of last comprehensive eye examination:_____________________________
10. Has the individual been diagnosed with either severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy?
___Yes ____No
If yes, provide date of diagnosis: ___________________________________________
U.S. Department of Transportation Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements. **
11. Has the individual been diagnosed with any other progressive eye disease(s) (e.g., macular edema, cataracts, glaucoma)?
____Yes ____No
If yes, specify the disease(s), provide the dates of diagnoses, current treatment, and whether the condition is stable:
12. Additional Comments (attach additional pages as needed)
I attest that I am a treating clinician (as defined above), that this individual maintains a stable insulin regimen and proper control of his/her insulin-treated diabetes mellitus, and that the information provided is true and correct to the best of my knowledge.
Date
Printed Name and Medical Credential Signature
Professional License Number and State
Phone Number Email
Street Address City, State, Zip Code
| Individuals Name: |
| Name: |
| DOB: |
| Drivers License Number if applicable: |
| State: |
| Date insulin use began: |
| Federal Motor Carrier Safety Administration: |
| If no provide details: |
| with insulin may qualify to operate a commercial motor vehicle for up to but not more than 3 months: |
| undefined: |
| Comments if necessary: |
| pages as needed 1: |
| pages as needed 2: |
| undefined_2: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable: |
| Federal Motor Carrier Safety Administration_2: |
| Individuals Name_2: |
| undefined_3: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 1: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 2: |
| undefined_4: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 1_2: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 2_2: |
| If yes provide the date of diagnosis location type of involvement current treatment and whether the condition is: |
| undefined_5: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 1_3: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable 2_3: |
| undefined_6: |
| If yes provide the date of diagnosis current treatment and whether the condition is stable_2: |
| Date of last comprehensive eye examination: |
| If yes provide date of diagnosis: |
| Federal Motor Carrier Safety Administration_3: |
| If yes specify the diseases provide the dates of diagnoses current treatment and whether the condition is stable 1: |
| If yes specify the diseases provide the dates of diagnoses current treatment and whether the condition is stable 2: |
| If yes specify the diseases provide the dates of diagnoses current treatment and whether the condition is stable 3: |
| 12 Additional Comments attach additional pages as needed 1: |
| 12 Additional Comments attach additional pages as needed 2: |
| 12 Additional Comments attach additional pages as needed 3: |
| 12 Additional Comments attach additional pages as needed 4: |
| knowledge: |
| Date: |
| Printed Name and Medical Credential: |
| Professional License Number and State: |
| Phone Number: |
| undefined_7: |
| Email: |
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