Form DS-874 "Medical Examination Report of Driver Under Article 19-a" - New York

What Is Form DS-874?

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

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the New York State Department 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 fillable version of Form DS-874 by clicking the link below or browse more documents and templates provided by the New York State Department of Motor Vehicles.

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Download Form DS-874 "Medical Examination Report of Driver Under Article 19-a" - New York

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MEDICAL EXAMINATION REPORT OF DRIVER UNDER ARTICLE 19-A
dmv.ny.gov
INSTRUCTIONS TO MEDICAL EXAMINER:
The complete standards and instructions for conducting this examination are found in Section 6.10 of the Commissioner’s
Regulations, 15NYCRR6, and can be found at dmv.ny.gov/art19. They are also available from the driver’s carrier named below or from the Bus Driver Unit. For New/Initial
Examinations and Recertification–review/complete ALL items on the form and sign where indicated on last page. For Follow-up Examinations–complete ONLY those
items which require follow-up information and/or evaluation from a prior examination. Sign the form where indicated. If additional space is required for further comments and
information, use form DS-874C, and attach it to this form.
1
DRIVER/CARRIER INFORMATION (to be completed by the driver and/or driver’s carrier)
Driver’s Last Name
First
M.I.
Date of Birth (Month/Day/Year)
Age
Sex
o
o
Male
Female
Street Address
City
State
Zip Code
License ID Number
State
Class of Driver’s License Endorsements Restrictions
Expiration Date
(from Driver License)
Carrier/DBA Name
Legal Name (if different)
19-A Business ID Number
HEALTH HISTORY (to be completed by the driver and reviewed by the medical examiner)
2
Yes No
Yes No
Yes No
o o Any illness or injury in the last 5 years?
o o Kidney disease, dialysis
o o Stroke or paralysis
o o Head/Brain injuries, disorders or illnesses
o o Liver disease
o o Missing or impaired hand, arm, foot, leg,
o o Seizures, epilepsy
o o Digestive problems
finger, toe
o o Eye disorders or impaired vision (except corrective lenses)
o o Diabetes or elevated blood sugar controlled by 
o o Spinal injury or disease
o o Ear disorders, loss of hearing or balance
(check all that apply): o diet o insulin o other medication
o o Chronic low back pain
o o Heart disease or heart attack; other cardiovascular condition
o o Incident of hyperglycemic or hypoglycemic shock
o o Regular, frequent alcohol use
o o Heart surgery (valve replacement/bypass, angioplasty, pacemaker)
o o Loss of, or altered consciousness
o o Narcotic or habit forming drug use
o o High blood pressure
o o Fainting, dizziness
o o Tuberculosis
o o Muscular disease
o o Nervous or psychiatric disorders, e.g., severe depression
o o Other
o o Shortness of breath
o o Sleep disorders, pauses in breathing while asleep, daytime
o o Lung disease, emphysema, asthma, chronic bronchitis
sleepiness, obstructive sleep apnea, loud snoring
For any YES answer, the driver should indicate the condition, onset date, diagnosis, treating medical examiner’s name and address, and any current
conditions or comments here:
List all medications (including over-the-counter medications) used regularly or recently.
o
Additional comments/medications on attached DS-874C
I certify that the above information and any other information on any accompanying DS-874C, if used, is complete and true. I understand that
.
inaccurate, false or missing information may invalidate this examination
X
(Driver’s Signature)
(Date)
Medical Examiner’s Comments:
TESTING (SECTIONS 3 THROUGH 8 TO BE COMPLETED BY THE MEDICAL EXAMINER)
VISION
3
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
Numerical readings must be provided.
Applicant can recognize and distinguish among traffic control signals and
devices showing standard red, green, and amber colors.........o Yes o No
FIELD OF VISION
ACUITY
UNCORRECTED
CORRECTED
°
Right Eye
20/
20/
Right Eye
Applicant meets visual acuity requirement only when wearing corrective
°
lenses.......................................................................................o Yes o No
Left Eye
20/
20/
Left Eye
Does applicant have monocular vision?.................................o Yes o No
Both Eyes
20/
20/
Complete next two lines only if vision testing is done by an ophthalmologist or optometrist.
Date of Examination
Name of Ophthalmologist or Optometrist (print)
Telephone Number
X
License Number/State of Issue
(Signature of Examiner)
BLOOD PRESSURE/PULSE RATE
Standard: If the blood pressure is consistently above 160/90 mm. Hg., further testing may be necessary to determine
4
whether the driver is qualified to operate a bus. Numerical reading must be recorded. Medical Examiner should take at least two readings to confirm BP.
Systolic/Diastolic
Systolic/Diastolic
Blood Pressure
1)
2)
o
o
Pulse Rate:
Regular
Irregular
Record Pulse Rate:
Readings
PAGE 1 OF 2
Date of Examination
Become an Organ Donor! Visit donatelife.ny.gov
DS-874 (1/19)
MEDICAL EXAMINATION REPORT OF DRIVER UNDER ARTICLE 19-A
dmv.ny.gov
INSTRUCTIONS TO MEDICAL EXAMINER:
The complete standards and instructions for conducting this examination are found in Section 6.10 of the Commissioner’s
Regulations, 15NYCRR6, and can be found at dmv.ny.gov/art19. They are also available from the driver’s carrier named below or from the Bus Driver Unit. For New/Initial
Examinations and Recertification–review/complete ALL items on the form and sign where indicated on last page. For Follow-up Examinations–complete ONLY those
items which require follow-up information and/or evaluation from a prior examination. Sign the form where indicated. If additional space is required for further comments and
information, use form DS-874C, and attach it to this form.
1
DRIVER/CARRIER INFORMATION (to be completed by the driver and/or driver’s carrier)
Driver’s Last Name
First
M.I.
Date of Birth (Month/Day/Year)
Age
Sex
o
o
Male
Female
Street Address
City
State
Zip Code
License ID Number
State
Class of Driver’s License Endorsements Restrictions
Expiration Date
(from Driver License)
Carrier/DBA Name
Legal Name (if different)
19-A Business ID Number
HEALTH HISTORY (to be completed by the driver and reviewed by the medical examiner)
2
Yes No
Yes No
Yes No
o o Any illness or injury in the last 5 years?
o o Kidney disease, dialysis
o o Stroke or paralysis
o o Head/Brain injuries, disorders or illnesses
o o Liver disease
o o Missing or impaired hand, arm, foot, leg,
o o Seizures, epilepsy
o o Digestive problems
finger, toe
o o Eye disorders or impaired vision (except corrective lenses)
o o Diabetes or elevated blood sugar controlled by 
o o Spinal injury or disease
o o Ear disorders, loss of hearing or balance
(check all that apply): o diet o insulin o other medication
o o Chronic low back pain
o o Heart disease or heart attack; other cardiovascular condition
o o Incident of hyperglycemic or hypoglycemic shock
o o Regular, frequent alcohol use
o o Heart surgery (valve replacement/bypass, angioplasty, pacemaker)
o o Loss of, or altered consciousness
o o Narcotic or habit forming drug use
o o High blood pressure
o o Fainting, dizziness
o o Tuberculosis
o o Muscular disease
o o Nervous or psychiatric disorders, e.g., severe depression
o o Other
o o Shortness of breath
o o Sleep disorders, pauses in breathing while asleep, daytime
o o Lung disease, emphysema, asthma, chronic bronchitis
sleepiness, obstructive sleep apnea, loud snoring
For any YES answer, the driver should indicate the condition, onset date, diagnosis, treating medical examiner’s name and address, and any current
conditions or comments here:
List all medications (including over-the-counter medications) used regularly or recently.
o
Additional comments/medications on attached DS-874C
I certify that the above information and any other information on any accompanying DS-874C, if used, is complete and true. I understand that
.
inaccurate, false or missing information may invalidate this examination
X
(Driver’s Signature)
(Date)
Medical Examiner’s Comments:
TESTING (SECTIONS 3 THROUGH 8 TO BE COMPLETED BY THE MEDICAL EXAMINER)
VISION
3
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
Numerical readings must be provided.
Applicant can recognize and distinguish among traffic control signals and
devices showing standard red, green, and amber colors.........o Yes o No
FIELD OF VISION
ACUITY
UNCORRECTED
CORRECTED
°
Right Eye
20/
20/
Right Eye
Applicant meets visual acuity requirement only when wearing corrective
°
lenses.......................................................................................o Yes o No
Left Eye
20/
20/
Left Eye
Does applicant have monocular vision?.................................o Yes o No
Both Eyes
20/
20/
Complete next two lines only if vision testing is done by an ophthalmologist or optometrist.
Date of Examination
Name of Ophthalmologist or Optometrist (print)
Telephone Number
X
License Number/State of Issue
(Signature of Examiner)
BLOOD PRESSURE/PULSE RATE
Standard: If the blood pressure is consistently above 160/90 mm. Hg., further testing may be necessary to determine
4
whether the driver is qualified to operate a bus. Numerical reading must be recorded. Medical Examiner should take at least two readings to confirm BP.
Systolic/Diastolic
Systolic/Diastolic
Blood Pressure
1)
2)
o
o
Pulse Rate:
Regular
Irregular
Record Pulse Rate:
Readings
PAGE 1 OF 2
Date of Examination
Become an Organ Donor! Visit donatelife.ny.gov
DS-874 (1/19)
}
Driver’s Name: Last
First
MI
Driver’s License ID #
5
HEARING
Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB
o
o
Check if hearing aid used for tests.
Check if hearing aid required to meet standard.
a) Record distance in feet from individual at which forced
b) If audiometer is used, record hearing loss in decibels.(acc. to ANSI Z24.5-1951)
whispered voice can first be heard.
Right Ear
Left Ear
OR
500Hz
1000 Hz
2000 Hz
500Hz
1000 Hz
2000 Hz
Right ear
\Feet
Left ear
\Feet
Average:
Average:
URINE SPECIMEN
6
LABORATORY AND OTHER TEST FINDINGS -
SP. GR
PROTEIN
BLOOD
SUGAR
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any
underlying medical problem. Other Testing (Describe and record):
7
PHYSICAL EXAMINATION (to be completed by the medical examiner) -
Height
Weight
(lbs.)
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to
treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the
necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.
Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect
the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been
compensated for.
BODY SYSTEM
CHECK FOR:
Yes* No
BODY SYSTEM
CHECK FOR:
Yes* No
7. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, bruits, hernia,
1. General appearance Marked overweight, tremor, signs of alcoholism,
significant abdominal wall muscle weakness . . . . . . . . . . . o
o
problem drinking, or drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . o o
8. Vascular System
Abnormal pulse and amplitude, carotid or arterial bruits,
2. Eyes
Pupillary equality, reaction to light accommodation, ocular
varicose veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o
o
motility, ocular muscle imbalance extraocular movement,
nystagmus, exophthalmos. Ask about retinopathy, cataracts,
9. Genito-urinary System Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o
o
aphakia, glaucoma, macular degeneration and refer to a
specialist if appropriate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o
10. Extremities- Limb
Loss or impairment of leg, foot, toe, arm, hand, finger,
impaired.
perceptible limp, deformities, atrophy, weakness,
3. Ears
Scarring of tympanic membrane, occlusion of external canal,
perforated eardrums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o
paralysis, clubbing, edema, hypotonia. Insufficient
grasp and prehension in upper limb to maintain steering
4. Mouth and Throat
Irremediable deformities likely to interfere with breathing or
wheel grip. Insufficient mobility and strength in lower
swallowing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o
limb to operate pedals properly. . . . . . . . . . . . . . . . . . . . . . o
o
5. Heart
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o
11. Spine, other
Previous surgery, deformities, limitation of motion,
tenderness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o
o
musculoskeletal
Abnormal chest wall expansion, abnormal respiratory rate,
6. Lungs and chest,
abnormal breath sounds including wheezes or alveolar rales,
not including
12. Neurological
Impaired equilibrium, coordination or speech pattern;
impaired respiratory function, cyanosis. Abnormal findings
breast examination
asymmetric deep tendon reflexes, sensory or positional
on physical exam may require further testing such as
abnormalities, abnormal patellar and Babinski reflexes, ataxia. o
o
pulmonary tests and/ or xray of chest . . . . . . . . . . . . . . . . . . . . . . . o
o
* MEDICAL EXAMINER’S COMMENTS:
o
Additional comments on attached DS-874C.
o
o
o
8
MEDICAL EXAMINER’S CERTIFICATION:
New/Initial Certification
Recertification
Follow-Up
I certify that I have examined (Print Driver’s Full Name)__________________________________________________________ in accordance with the Commissioner’s
s. In accordance with Commissioner’s Regulation 6.10, I find:
Regulations and with knowledge of the driver’s dutie
o
the person named above is physically or medically qualified.
o
the person named above IS NOT physically or medically qualified because____________________________________________________________
o
the person named above is physically or medically qualified with Restrictions and/or Follow-up as detailed below:
o
o
Qualified only when wearing corrective/contact lenses.
Qualified only by use of prosthetic devices or equipment modifications.
o
Qualified - Certification required every six months for diabetic condition.
Description/Type: _____________________________________________
o
o
Qualified only when wearing a hearing aid.
Qualified, other: _______________________________________________
o
REMARKS:
Additional comments on attached DS-874C.
Print name and check title of:
}
Date:
o
Examining Physician
X
Signature of Examiner:
o
Nurse Practitioner
o
Physician Assistant
*
Address of Examiner:
o
Advanced Practice Nurse
License or Certificate No./Issuing State
(who is not a Nurse Practitioner)
*
If the examination is conducted by an Advanced Practice Nurse, who is not a Nurse Practitioner, the Supervising Physician must certify as follows:
I certify that the individual who conducted the above examination was acting under my direction and supervision and, if applicable, in accordance
with a written practice or protocol agreement.
X
Print
(Name of Supervising Physician)
(Signature of Supervising Physician)
License or Certificate No./Issuing State
THE CARRIER MUST KEEP THE ORIGINAL EXAM INATION REPORT (NOT A PHOTOCOPY) IN THE EM PLOYEE’S 19-A FILE
DS-874 (1/19)
PAGE 2 OF 2
ANY PHOTOCOPIES M UST IDENTIFY THE LOCATION OF THE ORIGINAL
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