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Fillable Printable Limb Waiver

Fillable Printable Limb Waiver

Limb Waiver

Limb Waiver

North Carolina Division of Motor Vehicles
CDL Waiver Program
Commercial Driver’s License Limb Waiver Application
Name of the Driver (Printed)
Driver’s License Number
Date of Birth
Date
Address
City
State
Zip Code
Area Code and Phone Number
I, the undersigned driver, am applying for a waiver from the qualifications of49 CFR Sec. 391.41(b)(1) or (b)(2)(i) or (b)(ii),
noted below.
(b)
A person is physically qualified to drive a commercial motor vehicle if thatperson
1)
Has no loss of a foot, a leg, a hand, or an arm, or has been granted a waiver pursuant to Sec.391.49 (limb
waiver provision);
2)
Has no impairment of :
i)
A hand of finger which interferes with prehension or power grasping; or power grasping;or
ii)
An arm, foot, or leg which interferes with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or any other significant limb defect or limitation which
interferes with the ability to perform normal tasks operating a commercial motor vehicle; or has
been granted a waiver pursuant to Sec.391.49.
My limb impairment or loss is as follows:
I, the undersigned, hereby authorize Dr. to give any examination deemed necessary to
assess my limb deformity, impairment or amputation and its impact onthe safe operation of a commercial motor vehicle. I
also authorize this physician and any other physicians, health care providers, hospitals and clinics involved in my care to
release to the Division of Motor Vehicles or its representatives any information concerning my condition. I do hereby
release, waive, and relinquish all claims against the Division ofMotor Vehicles, its agents and employees, for any cause
whatsoever arising out of this release of said medical information.
DateSignature of theApplicant
Instructions to the Driver:This page containsyour instructionsfor completing the waiverapplication. Complete all of the
steps below before mailing it to DMV. An incomplete application will not be processed. Any missing or incomplete
information will therefore delay processing of your application until all partsofthe application are fully completed and
received by DMV.
1)
Provide a copy of a valid DOT physical certifying that you are otherwise physically qualified to drive a commercial motor
vehicle.
2)
Sign the above consent for examination and release of medical information.
3)
Have an examination by an orthopedics or rehabilitation medicine physician to evaluate your limb impairment and its
affect on the safe operation of commercial motor vehicles.
4)
You or your employer must complete the Vehicle and Driving Conditions Report enclosed withthese forms. This report
should reflect any circumstances in which you expect to be driving, and include information about all types ofvehicles
that you may be driving. If you are not currently employed, please indicate on theform.
5)
At the time of and during your examination you must do the following:
a)
Describe to your doctor any prostheses, assistive devices, restrictions, vehicle modifications, or compensatory
strategies you use for driving.
b)
Review the Vehicle and Driving Conditions Report with yourphysician.
c)
After your examination, be sure your doctor completes the Limb Medical Report.
North Carolina Division of Motor Vehicles
CDL Limb Waiver Program
PHYSICIAN’S REPORT
Name of the DriverDate of BirthDriver’s LicenseNumber
Description of limb amputation deformity or impairment.
Medical condition that resulted in the above limb problem.
Functional limitations caused by the limb problem (without prostheses, vehicle modifications, etc.) and the adverse affect on the
operation of a commercial vehicle.
Prostheses, assistive devices, restrictions, vehicle modifications, or compensatory strategies currently being used by the driver.
How the above aids compensate for the adverse impact of the impairment and whether the impairment is fully compensated.
Any recommendations for additional aids necessary to enable the driver to safely operate a commercial vehicle. (For example,
power steering or brakes, automatic transmission, wheel knob, grasping hook, electric signals, or an altered or different prosthesis.
Stability or progression of the impairment expected over the next two years.
Other conditions of which you are aware, that might contribute to increased driving risk.
1.
I am board certified or board eligible in orthopedics or rehabilitation medicine. (Circle the
appropriate status and specialty.)
2.
I have reviewed the Vehicle and Driving Conditions Report, and understand the type of
vehicle driving conditions, andnon-driving jobtasks the driver will berequired to perform.
The information available to me at the time of this exam is sufficient to determine the physical ability of the
3.
driver to operatea commercial vehicle with the current impairment with appropriateprostheses, vehicle
modifications, or restrictions.
Printed Name and License Number Signature Date
Address City State Zip Code Area Code and Number
1
North Carolina Division of Motor Vehicles
Commercial Drivers License Waiver Program
Vehicle and Driving Conditions Report
Status of the driver
Applied/accepted to truck driving school Currently enrolled student in truck driving school
Unemployed Hired pending exemption Currently employed
Employer Address City State Zip Code Area Code and Number
Name of the DriverDate of BirthLicense Number
FORM COMPLETED BY
Printed Name Signature Date Completed
If the driver operates more than one type of vehicle, check all that apply.
Number of axles
Number of manual forward speeds
TRUCK
Gross
Vehicular
Weight
Drive Train
Information
Number of auxiliary forward speeds
Number of rear axle transmission forward speeds
Transmission type: Manual Automatic
Braking Manual PoweredAirbrakes
Steering Manual Powered
For passenger vehicles, seating capacity:
TRAILER(S)
Gross
Vehicular
Weight
Number
towed atone
time
1 2 3
Van Flatbed
BinTanker
Pole Other
MODIFICATIONS MADE
FOR THE DRIVER
(if applicable)
(include relevant photographs)
TIME AND DISTANCE
Average
Maximum
Round trip
distance
Hours per 7
day week
Hours per 24
hour day
Daylight hours per
week
Nighttime hours
per week
TRAFFIC AND ROAD CONDITIONS
TRANSPORTED CARGO
List
Secondary roads Rural
Interstate highway Urban
NON-DRIVING ACTIVITIES
Hitching and unhitchingLoading and unloading
Covering or tying down Filling or emptying tankers
Other (describe)
TYPE OF DRIVER OPERATION
Number of years of driving experience:
Relay
Single driver
Sleeper team
Owner-operator
Non-driving individuals accompanying the driver
Total years driving experience
Number driving the vehicle described above
Division of Motor Vehicles, Medical Review Unit, 3112 Mail Service Center, Raleigh NC 27697-3112 ver 1//17
CDL WAIVER COVER SHEET
ATTENTION: THIS PAGE MUST BE COMPLETED AND INCLUDED WITH
ANY WAIVER DOCUMENTS THAT ARE SUBMITTED
NAME
DATE OF BIRTH
DRIVERS LICENSE NO.
CIRCLE TYPE OF WAIVER: DIABETIC VISION LIMB
MAIL OR FAX INFORMATION: MEDICAL REVIEW UNIT
3112 MAIL SERVICE CENTER
RALEIGH, NC 27697
FAX NO: (919) 733-9569
IMPORTANT!!!
PLEASE INCLUDE THIS PAGE WITH YOUR COMPLETED FORMS WHEN
FAXING OR MAILING WAIVER DOCUMENTATION TO DMV.
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