Fillable Printable Cdl Diabetes Waiver Interim Assessment Form

Cdl Diabetes Waiver Interim Assessment Form

Name:

NCDL#

Date:

Page 1 of 1

CDL Diabetes Waiver Interim Assessment

If you agree with the statements below, initial them.

If you cannot confidently and truthfully agree with any statement, do not initial it.

I certify that the information available to me is sufficient to determine that this driver is able to safely operate

a commercial motor vehicle.

I certify that I have reviewed the patient’s daily glucose logs.

I certify that the driver’s glycosylated hemoglobin A1C is ___________ A1C test date:__________

I certify that the driver’s diabetic condition is currently well controlled.

I certify that, to my knowledge, during the last 3 months the driver has not experienced any hypoglycemic

episodes which would interfere with the driver’s ability to safely operate a commercial motor vehicle.

Additional comments regarding physical and mental ability to perform driving and non-driving job tasks, risk of

altercations in mental status, or the need for additional medical evaluation prior to making a fitness determination:

I certify that I am a board certified or board eligible physician, nurse practitioner, or physician

assistant and am competent to evaluate the driver’s medical condition, including diabetes, as it

pertains to driving fitness.

Medical Provider’s Name (printed) and

License Number

Date of Examination

Address

City, State, Zip Code

Signature

Area Code and Number

Date

Cdl 30