Form VSC103 "School Bus and School Pupil Transport (7d) Operator Cardiovascular Medical Evaluation Form" - Massachusetts

What Is Form VSC103?

This is a legal form that was released by the Massachusetts Registry of Motor Vehicles - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Massachusetts Registry of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form VSC103 by clicking the link below or browse more documents and templates provided by the Massachusetts Registry of Motor Vehicles.

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Download Form VSC103 "School Bus and School Pupil Transport (7d) Operator Cardiovascular Medical Evaluation Form" - Massachusetts

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School Bus and School Pupil Transport (7D)
Operator Cardiovascular Medical Evaluation Form
Instructions: The form must be completed in its entirety and signed by a licensed physician. The form must then be submitted in conjunction with a
completed 7-D School Pupil Transport Certificate Application.
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Current Massachusetts Learner’s Permit or Driver’s License #
Date of Birth
(if applicable)
(MM/DD/YYYY)
/
/
Residential Address (Where you actually reside)
Street
Apt. #
City
State
Zip Code
Mailing Address
(same as above)
Street
Apt. #
City
State
Zip Code
B. Physician Information and Attestation
The above applicant is applying for a driver’s license to drive school pupils in Massachusetts. The applicant has an implanted cardiac defibrillator
(AICD). Under the Code of MA Regulations (540 CMR 2.15), people who have an implanted cardiac defibrillator are eligible to drive school pupils if
they meet certain standards. This applicant is asking you to determine whether s/he meets the following standards.
1. The AICD was implanted for a “sudden death event” and has not fired in a six-month period. ..............................................................
Yes
No
Date AICD was implanted: ____________________________________
2. The AICD was implanted for prophylactic reasons and has not fired in a six-month period. .................................................................
Yes
No
3. The applicant is classified as either AHA functional Class I, Class II, or does not have heart disease. ................................................
Yes
No
4. To a reasonable degree of medical certainty, the applicant is medically qualified to operate a school bus or school pupil
transport vehicle safely and fulfill any and all of the duties and responsibilities associated with such operation. ..................................
Yes
No
Last Name
First Name
Suffix
Board of Registration in Medicine Number
Address
Street
Apt. #
City
State
Zip Code
NPI #
Email
Applicant’s Signature: __________________________________________________________ Date: _______________________
I attest that, to a reasonable degree of medical certainty, the applicant is safe to operate a vehicle transporting school pupils as outlined in
regulation 540 CMR 2.15.
Physician’s Signature: _________________________________________________________ Date: _______________________
p.1
VSC103_0118
School Bus and School Pupil Transport (7D)
Operator Cardiovascular Medical Evaluation Form
Instructions: The form must be completed in its entirety and signed by a licensed physician. The form must then be submitted in conjunction with a
completed 7-D School Pupil Transport Certificate Application.
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Current Massachusetts Learner’s Permit or Driver’s License #
Date of Birth
(if applicable)
(MM/DD/YYYY)
/
/
Residential Address (Where you actually reside)
Street
Apt. #
City
State
Zip Code
Mailing Address
(same as above)
Street
Apt. #
City
State
Zip Code
B. Physician Information and Attestation
The above applicant is applying for a driver’s license to drive school pupils in Massachusetts. The applicant has an implanted cardiac defibrillator
(AICD). Under the Code of MA Regulations (540 CMR 2.15), people who have an implanted cardiac defibrillator are eligible to drive school pupils if
they meet certain standards. This applicant is asking you to determine whether s/he meets the following standards.
1. The AICD was implanted for a “sudden death event” and has not fired in a six-month period. ..............................................................
Yes
No
Date AICD was implanted: ____________________________________
2. The AICD was implanted for prophylactic reasons and has not fired in a six-month period. .................................................................
Yes
No
3. The applicant is classified as either AHA functional Class I, Class II, or does not have heart disease. ................................................
Yes
No
4. To a reasonable degree of medical certainty, the applicant is medically qualified to operate a school bus or school pupil
transport vehicle safely and fulfill any and all of the duties and responsibilities associated with such operation. ..................................
Yes
No
Last Name
First Name
Suffix
Board of Registration in Medicine Number
Address
Street
Apt. #
City
State
Zip Code
NPI #
Email
Applicant’s Signature: __________________________________________________________ Date: _______________________
I attest that, to a reasonable degree of medical certainty, the applicant is safe to operate a vehicle transporting school pupils as outlined in
regulation 540 CMR 2.15.
Physician’s Signature: _________________________________________________________ Date: _______________________
p.1
VSC103_0118