Fillable Printable Cdl Sbus Limb Waiver Packet
Fillable Printable Cdl Sbus Limb Waiver Packet
Cdl Sbus Limb Waiver Packet
AN EQUAL OPPORTUNITY EMPLOYER
STATE OF MINNESOTA
DEPARTMENT OF PUBLIC SAFETY
HOW DO I OBTAIN A LIMB IMPAIRMENT WAIVER
TO DRIVE A SCHOOL BUS OR TYPE III SCHOOL BUS IN MINNESOTA?
Step 1:
If you have not already done so, you must have a medical examination by a licensed physician at some point within the two years
preceding the date of application to assure that you have no other disqualifying medical conditions. The complete medical
examination must include a review of all items listed in Code of Federal Regulations, title 49, section 391.41.
Include a copy of the MEDICAL EXAMINATION REPORT-For Commercial Driver Fitness Determination
with your waiver
application.
Step 2:
Complete the attached School Bus and Type III School Bus Driver Medical Waiver Application.
Step 3:
Submit one of the following:
1. A legible copy of both sides of your current commercial driver's license, OR
2. A legible copy of both sides of the license you last possessed to operate a commercial motor vehicle, OR
3. A certification from the State licensing agency showing the type and effective date of the most recent license you have held.
Step 4:
Complete the attached Limb Impairment Waiver Application.
Step 5:
Submit the Physician's Examination of Limb Impairment completed by a board-qualified or board-certified doctor of physical
medicine or orthopedic surgeon.
L1 (Limb Impairment Cover Letter revised 2015)
Mailing Address:
445 MINNESOTA ST., SUITE 180
ST. PAUL, MN 55101-5180
Phone: (651) 297-5029 | TTY: (651) 282-6555
Fax: (651) 282-2110
Email:
After these steps have been completed, forward all application information for the limb impairment
waiver to the address above. The information will be reviewed and you will be notified of the
department's decision by mail. If a waiver is issued, you must comply with its terms and conditions.
Incomplete applications will be returned and may result in a waiver not being issued.
NOTE: If you have been granted a waiver by the regional director of Motor Carriers from Code of Federal Regulations, title 49,
section 391.41, (b) (1) or (2) (loss of a limb or limb impairment), an original or photo copy of the waiver issued by the United
States Department of Transportation may be submitted in lieu of the state limb impairment waiver.
Print Form
School Bus and Type III School Bus Driver Medical Waiver Application
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
G (General Application revised 2015)
(over)
I am applying for a waiver of the medical condition described in this application, as provided for in Minnesota Rule
7414.1410. Except for the condition described herein, I am otherwise medically qualified to operate a school bus or Type
III school bus within the state.
B. Medical Condition Information
1. Specify the physical qualifications for which a waiver is requested.
2. Describe your disability or impairment.
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
• This application is to be used for waiver requests of the requirements in Minnesota Rules 7414.1200 and Code of Federal
Regulations, title 49, section 391.41.
• Additional application information and forms must be completed if the condition involves a limb impairment, insulin-dependent
diabetes, or vision. No waiver is granted for the hearing requirement.
• Incomplete applications will be returned and may result in a waiver not being issued.
• Attach additional information as needed.
• If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
A. Driver Applicant Information
Full Name
Street Address City / State / Zip Code
Date of Birth (mm/dd/yy)
Daytime Phone (include area code)
License Expiration Date (mm/dd/yy)
Email Address
Driver's License Number
- -
- -
Waiver Applicant's Signature
Date (mm/dd/yy)
G (General Application revised 2015)
Attach additional information as needed.
X
3. Describe the school bus or Type III school bus you intend to drive, including passenger capacity and gross vehicle weight,
if known.
4. Estimate the period of time, per day, that you will be driving and on duty.
5. Provide your driving record for the last three years, including driving records from other states, if applicable.
6. Provide the medical examination performed according to Minnesota Rules part 7414.1200 and Code of Federal
Regulations, title 49, section 391.41 -- and a copy of the certificate from the examining physician attesting that you are
otherwise qualified, except for the disability or impairment for which a waiver is requested.
7. Provide a copy of your road test as prescribed by Driver and Vehicle Services.
8. Describe the alternative measures; modification of policies, practices, or procedures; or the provision of auxiliary aids or
services that will be taken to ensure there is no significant risk to the health and safety of the public and pupils, should the
waiver be granted.
School Bus and Type II School Bus Driver
Medical Waiver Application
Limb Impairment Waiver Application
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
A. Driver Applicant Information
Full Name
Street Address City / State / Zip Code
Date of Birth (mm/dd/yy)
Daytime Phone (include area code)
License Expiration Date (mm/dd/yy)
Email Address
Driver's License Number
- -
- -
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
B. Limb Impairment Information
• This application is to be used for a waiver request of the requirements in Minnesota Rules 7414.1200 and Code of Federal
Regulations, title 49, section 391.41.
• Except for the limb impairment described herein, I certify that I am otherwise medically qualified to operate a school bus or Type III
school bus within the state.
• Incomplete applications will be returned and may result in a waiver not being issued. Attach additional information as needed.
• If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
L2 (Limb Impairment Waiver Application revised 2015)
Impairment
Amputation
Full
Partial
What is the specific condition for which you request a waiver? (
check all that apply)
Arm: Leg:
Hand:
(incl. fingers)
Foot:
Do you use a prosthetic or orthotic device? If so, please describe.
L R
L R
L R
L R
C. Vehicle Description
Vehicle Type to be driven
Transmission:
Automatic
Manual
Number of Forward Speeds Type of Brakes
Steering:
Power
Manual
Does the vehicle have special modifications? If so, please describe.
Application must be accompanied by the following documents before it can be processed:
1. A copy of your MEDICAL EXAMINATION REPORT-for Commercial Driver Fitness Determination form
(certificate should state that it is only valid with a waiver).
2. A copy of your most recent ROAD TEST and CERTIFICATE (if you hold a CDL, you may enclose a legible photocopy of that instead).
3. A copy of your driving record from all states in which you have been licensed or permitted to operate a motor vehicle within the past
three years.
4. The attached LIMB IMPAIRMENT MEDICAL EVALUATION.
The information I have provided in this application is true and correct to the best of my knowledge.
Signature of Waiver Applicant
Date (mm/dd/yy)
X
Physician's Examination of Limb Impairment
Dear Licensed Physician:
The patient below, who is applying for a driver's license endorsement to drive a school bus or Type III school bus in
Minnesota, is being referred to you for a medical evaluation of a limb impairment as required by
Minnesota Rules part 7414.1430. The waiver is of the physical requirements specified in 49 CFR 391.41, (b) (1) or (b) (2).
You are being requested to:
Patient Name (please print)
Patient's Driver's License Number
- -
- -
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
Incomplete applications will be returned and may result in a waiver not being issued.
If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
1. Assess the patient's physical capabilities as they relate to the patient's ability to perform the normal tasks
associated with the operation of the school bus in question.
2. State whether the patient is capable of safely performing the normal school bus or Type III school bus driver
operations required.
3. Provide an assessment and medical opinion of whether the impairment or disability is likely to remain medically
stable over the patient's lifetime.
Copies of the applicant's School Bus and Type III School Bus Driver Medical Waiver Application and Limb Impairment
Waiver Application are attached. These describe the type of school bus the patient intends to drive and the period of time
operation will occur.
Physician Name (please print or type) Specialty Examination Date (mm/dd/yy)
NoYes
Board Certified:
NoYes
Board Eligible:
Office or Clinic Name Daytime Phone (include area code)
City / State / Zip CodeOffice Street Address
L3 (Limb Impairment Physician's Report revised 2015)
Based on the above information and your examination of this applicant, please determine whether patient has:
1. Adequate MUSCLE STRENGTH to perform the tasks required?
2. Adequate MOBILITY of the extremities and trunk to perform the tasks required?
NoYes
If no, please indicate the impaired extremity:
Upper:
Lower:
Left Right
RightLeft
NoYes
Right
Right
Left
Left
Lower:
Upper:
If no, please indicate the impaired extremity:
Trunk
(over)
Examination of Limb Impairment
L3 (Limb Impairment Physician's Report revised 2015)
3. Adequate JOINT and TRUNK STABILITY to perform the tasks required?
NoYes
Right
Right
Left
Left
Lower:
Upper:
If no, please indicate the impaired extremity:
Trunk
NoYes
4. If a partial hand amputee, has POWER GRIP and PREHENSION FUNCTION
of the rest of the hand and fingers?
5. If this patient is an amputee, does the patient have:
a. the appropriate type of TERMINAL DEVICE?
b. the appropriate type of PROSTHESIS?
c. If yes, does the prosthesis fit satisfactorily and is it in good operating condition?
NoYes
Yes No
Yes No
If your answer to any of the above is "no," what is your recommendation?
6. Will any medical conditions other than the indicated physical disability interfere with the patient's ability to perform normal
school bus or Type III school bus operations?
NoYes If yes, list:
7. The length of time that this limb impairment waiver is valid is (check one):
Other (as determined by physical).
Two years from date of last physical
Please list waiver ending date:
Physician Signature
Date (mm/dd/yy)
X
