LA DPSMV 2219 2003-2024 free printable template
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Louisiana Department of Public Safety Corrections Office of Motor Vehicles CDL PHYSICAL EXAMINATION FORM Meets Department of Transportation Requirements Date of Examination New Certification Re-certification Follow up 1. DRIVER S INFORMATION Driver completes this section* Driver s Name Address Soc* Sec* No* Date of Birth Age Race/Sex Driver s License No* Class State Telephone 2. HEALTH HISTORY Driver completes this section but medical examiner is encouraged to discuss with driver. Yes No Any...
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How to fill out cdl physical form
How to fill out Louisiana CDL Physical Form:
01
Obtain a copy of the Louisiana CDL Physical Form, which can be found online or at the Department of Motor Vehicles (DMV) office.
02
Carefully read the instructions provided on the form to understand what information and documentation is required.
03
Fill in personal information such as your name, address, date of birth, and contact details in the appropriate sections of the form.
04
Provide your driver's license number and any other necessary identification information.
05
Fill out the medical history section, including any conditions or medications you may have, along with the dates of treatment or diagnosis.
06
Have your healthcare provider complete the required medical evaluation portion of the form, which may include a physical examination and other tests.
07
Ensure that the healthcare provider signs and dates the form, indicating their confirmation of your medical fitness.
08
Submit the completed form to the appropriate authority, such as the DMV office or your employer, depending on their specific requirements.
Who needs Louisiana CDL Physical Form:
01
Individuals who hold a commercial driver's license (CDL) in Louisiana.
02
Those who operate commercial vehicles for a living, such as truck drivers, bus drivers, and taxi drivers.
03
Individuals who are seeking to obtain or renew their CDL license in the state of Louisiana.
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What is louisiana cdl physical form?
The Louisiana Commercial Driver License (CDL) Physical Form is a document that must be completed by any driver who wants to obtain a Louisiana Commercial Driver License (CDL). This form is used to assess the physical, mental, and emotional fitness of a driver before they are allowed to operate a commercial motor vehicle. The form must be completed by a medical professional and submitted to the Louisiana Office of Motor Vehicles (OMV).
What is the purpose of louisiana cdl physical form?
The Louisiana CDL Physical Form is used to ensure that commercial drivers are in good physical health and have the physical and mental capacity to safely and responsibly operate a commercial vehicle. The form must be completed by a certified medical examiner who has been trained and certified in the Federal Motor Carrier Safety Administration’s physical qualification standards.
What is the penalty for the late filing of louisiana cdl physical form?
The penalty for the late filing of a Louisiana CDL physical form is a fine of up to $250 and/or up to 30 days in jail.
Who is required to file louisiana cdl physical form?
In Louisiana, commercial drivers are required to file the Louisiana CDL Physical Form to obtain or renew their Commercial Driver's License (CDL). This form verifies that the driver meets the medical qualifications set by the Department of Transportation (DOT).
How to fill out louisiana cdl physical form?
Filling out the Louisiana CDL physical form requires the following steps:
1. Obtain the form: You can download the Louisiana CDL Medical Examination Report Form from the Louisiana Office of Motor Vehicles (OMV) website or pick up a hard copy from a local OMV office.
2. Personal information: Provide your personal information at the top of the form, including your name, address, date of birth, driver's license number, and Social Security number.
3. Medical examiner's information: Fill in the medical examiner's information, such as their name, address, phone number, and National Registry number if applicable.
4. Self-certification: Indicate your self-certification status by checking the appropriate box. This refers to whether you are a non-excepted interstate driver (subject to medical certification) or an excepted interstate driver (not subject to medical certification). Check with the OMV or federal regulations to determine your required self-certification status.
5. Medical history: Answer the questions regarding your medical history, including any past or current medical conditions, surgeries, medications, and disabilities. Be honest and thorough in your responses.
6. Blood pressure: The medical examiner will assess your blood pressure. If it is above the normal range, you may be provided with a temporary medical certificate to obtain further medical evaluation.
7. Vision: The medical examiner will test your vision to ensure it meets the required standards. You may need to bring corrective lenses if you wear them.
8. Hearing: The medical examiner will evaluate your hearing to ensure it is adequate for safe driving.
9. Drug and alcohol testing: Indicate any drug or alcohol testing you have undergone as required by federal regulations.
10. Physician's certification: If you meet all the necessary requirements, the medical examiner will certify that you are physically qualified for a CDL.
11. Signature and date: Sign and date the form to complete it.
Remember to bring any required documentation, such as your driver's license and medical history records, when you go for your CDL physical examination.
What information must be reported on louisiana cdl physical form?
The Louisiana CDL physical form, also known as the Medical Examination Report (Form 367), requires the following information to be reported:
1. Personal Information: This includes the driver's full name, date of birth, address, phone number, and social security number.
2. Medical History: The driver must disclose any past or current medical conditions, surgeries, hospitalizations, or medications they are taking.
3. Medical Examination: A licensed medical examiner must complete this section, which includes assessing the driver's general appearance, vision, hearing, blood pressure, pulse rate, respiratory system, and other vital signs.
4. Physical Examination: The examiner should record measurements such as height, weight, and the presence of visible abnormalities or limitations in the driver's mobility.
5. Urine Test: The form also includes a section for reporting the results of a urine test, which screens for the presence of illegal drugs and controlled substances.
6. Certification: The medical examiner will certify whether the driver meets the Federal Motor Carrier Safety Administration (FMCSA) physical qualification standards for operating a commercial motor vehicle.
7. Examiner Information: The examiner must provide their name, address, medical license number, and the date of the examination.
It is important to note that this information may vary depending on any specific updates or changes to the Louisiana CDL physical form. It is always advisable to consult the official form or seek guidance from the Louisiana Department of Public Safety and Corrections for the most accurate and up-to-date requirements.
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