- Form DS-885 - Bus Driver Add/Drop Notice - New York
- Form DS-3 - Article 19-A Annual Affidavit of Compliance - New York
- Form IRP-21 - IRP TEAR Request Form - New York
- Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
- Form DS-872 - Carrier's Annual Review of Employee's Driving Record - New York
- Form DS-19 - Motor Carrier Accident and Conviction Notification Program Application - New York
Fillable Printable Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
Fillable Printable Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
Form DS-874C - Supplement to: Medical Examination of Driver Report - New York
SUPPLEMENT TO: Medical Examination
of Driver Report Under Article 19-A
This form is to be used ONLY as a supplement to the Medical Examination form (DS-874), and should be attached to that form
when completed. This form (DS-874C) is not required to be used, but if additional space is needed by the examining medical
staff or the driver being examined, this is the proper form to be used.
HEALTH HISTORY (additional driver and/or medical examiner comments and information)
DS-874C (6/15)
PHYSICAL EXAMINATION (additional comments)
MEDICAL EXAMINER’S CERTIFICATION & REMARKS (additional remarks)
When used, this form MUST BE ATTACHED
to the completed form DS-874, Medical Examination Report of Driver Under Article 19-A.
This form, by itself is NOT a valid Medical Report.
Continued from item on form DS-874
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Driver Last Name Driver First Name M.I. Client ID # Date
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