Download dot clearance for: respiratory dysfunction/sleep apnea

DR. MARIE S. CURTIS, DC
HEMINGWAY SPINAL CARE CENTER
304 EAST BROAD ST. , PO BOX 1601
HEMINGWAY, SC 29554
PH/FX: 843-558-0056
DOT CLEARANCE FOR: RESPIRATORY DYSFUNCTION/SLEEP APNEA
Please inquire with your treating provider’s office, an office visit may be required for the completion of this form.
Patient Name
DOB
Dear Provider:
DOT Reg. Section 391.41 (b)(4) states “ A person is physically qualified to drive a commercial motor vehicle if that person: Has no
established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a
commercial motor vehicle safely”. DOT/Federal Highway Administration’s Conference on Pulmonary/Respiratory Disorders and
Commercial Drivers, May 1991, recommends that “individuals with known Obstructive Sleep Apnea be allowed to obtain certification
to drive only after successful therapy has resulted in multiple sleep latency testing values within the normal range or repeat sleep
study during treatment that shows resolution of apnea. Continuous successful therapy for 1 month usually results in major
improvements in pathological sleepiness.”
Before the patient can be cleared for driving a commercial motor vehicle, we need you to answer the following question regarding
his/her Sleep Apnea. You are not being asked to make the final determination, just a clinical opinion about the patient’s ability to
safely operate a commercial vehicle.
1. Does the patient have a current diagnosis of Sleep Apnea? Yes _______ No _______
2. Has the patient filled out an ESS? Yes ______ No _______
3. Sleep study results: Date
Normal
Abnormal
4. What is the current treatment (if necessary)?
5. Is the patient compliant with treatment? Yes _____ No _____
6. Does the patient currently have any daytime sleepiness or other symptoms that might interfere with safe driving?
 Yes  No If yes, please explain
7. Has the patient been scheduled for a regular follow-up evaluation? Yes _____ No _____
(Please complete page 2 of this form)
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8. Do you feel the patient is safe to drive a commercial motor vehicle in regard to his/her Respiratory Dysfunction/Sleep
apnea?
 Yes  No If yes, please explain
STATEMENT OF TREATING PERSONAL PHYSICIAN OR PULMONOLOGIST. Please check (A) or (B).
A) ____I have read and understand the DOT regulation cited above. I verify the above named individual has no current clinical
diagnosis of untreated sleep apnea. He/She is compliant with prescribed sleep apnea therapy and has undergone multiple
sleep latency testing with normal range results. He/She is in no imminent risk of syncopal episodes or other symptoms that
would affect his/her ability to safely operate a commercial motor vehicle.
Please attach printout of CPAP Compliance: Minimum of 4 hours use per night on 70% of nights for the past 3 months.
B) ____ I have read and understand the DOT regulation cited above. I verify the above named individual has no current clinical
diagnosis of untreated sleep apnea. He/She is compliant with prescribed sleep apnea therapy and I do not recommend
additional testing at this time. He/She is in no imminent risk of syncopal episodes or other symptoms that would affect
his/her ability to safely operate a commercial motor vehicle.
Date of Exam
Provider Name (Print)
Telephone#
Address
Provider Signature
License#
City
State of issue
State
THANK YOU FOR ASSISTING YOUR PATIENT
*Please fax or have patient deliver this form and any additional relevant information.
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