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Fillable Printable Form WH-515

Fillable Printable Form WH-515

Form WH-515

Form WH-515

______________________
______________________
DOCTOR’S CERTIFICATEU.S. Department of Labor
WageandHourDivision
OMB No. 1235-0016
Expires: 11/30/2018
This is to certifythatI have this day examined:
(Name of Driver of Migrant Workers)
in accordance with Section 398.3(b) of the FederalMotorCarrier Safety Regulations of the
Federal Highwa y Adm inistration and that I find him:
_ Qualified under said rules.
_ Qualified only when wearing glasses.
I have kept on file in my office a completed examination.
(Date)(Place)
(Name of examining doctor) (Signature of examining doctor)
(Address of doctor)
(Signature of driver)
(Address of driver)
FormWH-515 (Re v.11/15)
FOR INTERNALUSEONLY:
MedicalCertificateExpirationDate:____________________
GENERALINSTRUCTIONS
Takethisformto your doctor. Askthe doctor toreadthe followingsection,examine you, andfillin the certificate
(located on the front of thisform).After making a copy foryouremployerand yourself, submit the original withyour
FarmLabor Contractoror FarmLabor Contractor Employee application(Form WH-530).
Youmustcarryyour copywith you whenever you aredriving workerssubjecttothe Migrant andSeasonal Agricultural
WorkerProtectionAct(MSPA).
TOTHEDOCTOR
Regulations 29 C.F.R. § 500.104(b)(1)(ii)(I) and49 C.F.R. § 398.3(b) provide for the following minimum qualifications
for personswho drive any motor vehiclecarryingmigrantworkerssubjectto the regulations:
(A)
Noloss of foot,leg, hand or arm.
(B)
Nomental,nervous, organic, or functional disease,likelytointerferewithsafe driving.
(C)
Noloss of fingers, impairment of use of foot,leg, fingers, hand or arm, or otherstructuraldefect or limitation,likelyto
interferewithsafedriving.
(D)
Eyesight.Visualacuityof atleast 20/40 (Snellen)ineacheyeeitherwithoutglassesor bycorrectionwithglasses;
form field of vision in the horizontal meridianshall not be lessthana totalof 140degrees;abilitytodistinguish colors red,
greenandyellow; drivers requiring correction by glassesshallwear properly prescribedglassesatalltimeswhen driving.
(E)
Hearing. Hearingshall not be lessthan 10/20 in the betterear,for conversational tones, without a hearingaid.
(F)
Liquor, narcotics and drugs.Shall not be addictedto the useof narcoticsor habit-formingdrugs, or the excessiveuse
of alcoholic beveragesor liquors.
INFORMATIONANDUSE
The MSPAandFederal Regulations require farmlabor contractors andfarmlabor contractoremployeestosubmit a
doctor’s certificatewhentheyseekauthorizationto drive migrant/seasonalagriculturalworkers.Failuretosubmitthis
statementmayresultindriving authorization notto be authorized. The Wageand Hour Division of the U.S.Department
of Labor usesthisstatementtoverifythat those whodrivemigrant/seasonalagriculturalworkersarephysicallyfittodo
so.
The MSPAandregulations require–subjecttocertainlimitedexemptionsanyfarmlabor contractor,agricultural
employer, or agriculturalassociation (or theiremployees)providing transportation tomigrantandseasonalagricultural
workerstohave a legible doctor’s certificate (or copy thereof)onfileat the principal place of business for everydriver
employed or used. In addition, the regulations provide for eachdriver to have the certificate(orcopy thereof)inhis or her
possession while driving migrantor seasonalfarmworkerssubjectto the Act.Failuretocarry thecertificate,or a legible
copy thereof,resultsinthe driver not being authorizedtotransport migrantandseasonal agricultural workersatthattime
andmayresultin the assessment of acivil money penalty.
PUBLICBURDENSTATEMENT
Personsare not requiredtorespond tothiscollectionof information unless it displays a currentlyvalidOMB control
number. Weestimatethatitwilltakeanaverage of 20 minutestocompletethiscollectionof information, including the
time for reviewinginstructions,searching existing datasources, gathering and maintaining the dataneeded, and
completingandreviewingthe collection of information.If you have anycomments regarding this burden estimate or any
other aspect of thiscollectioninformation,including suggestionsfor reducing this burden, send themto the Administrator,
WageandHour Division, U.S.Department of Labor, RoomS-3502, 200 ConstitutionAV,NW, Washington, D.C. 20210.
DONOTSENDTHECOMPLETEDFORMTOTHISOFFICE;RETURNITTOTHEPATIENT.
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