Diabetes is a condition in which the body is unable to control the amount of sugar in the blood. Diabetes has a high cost for individuals and the NHS. …
Dear Medical Examiner:
As a result of Act 18, 2003 Session Laws of Hawaii, certain insulin-using
diabetic drivers who do not meet the federal minimum health standards for a
commercial drivers license, will now be able to apply for a restricted
intrastate only CDL These drivers will need to meet the requirements for
an intrastate medical waiver adopted by the director of transportation To
comply with these requirements, applicants must submit a completed
Application for Intrastate Medical Waiver, DOTH 2061
We appreciate your help in fully completing all portions of the form
Please call 808-692-7656 if you have questions
INSTRUCTIONS FOR APPLICANT
Complete the top portion of the application
Provide a copy of your drivers abstract
You must have an eye examination by an ophthalmologist or an
optometrist Take the application with you to have the ophthalmologist
or optometrist complete part II
You must be examined by an endocrinologist or an internist Take the
application with you to have the endocrinologist or internist complete
part III
Mail or deliver all information to the HDOT Motor Vehicle Safety
Office,
601 Kamokila Boulevard, Room 511, Kapolei, HI, 96707
APPLICATION FOR INTRASTATE MEDICAL WAIVER DOTH 2061
4/04
Original ? Renewal ?
Name
last
first
middle
Address
Phone
number
DLN
Date of
birth
Having failed to meet the physical requirement of 49 CFR 39141 b
3, I certify to operate commercial vehicles exclusively in
intrastate commerce and meet all waiver requirements
Applicants signature
I DRIVING RECORD Attach certified copy of drivers abstract
The applicant shall not, in the three years preceding a waiver
request, have:
Suspensions or revocations of driving privilege for operation
of any motor vehicle, not
including withdrawals due to non-
payment of fines;
Involvement in a reportable accident for which a citation for a
moving violation was issued;
Convictions for a disqualifying offense under Section 286-240,
Hawaii Revised Statutes or more than one serious traffic
violation as defined in Section 286-231, Hawaii Revised
Statutes; or
More than two convictions for any other moving traffic
violations
II MEDICAL EVALUATION BY OPHTHALMOLOGIST OR OPTOMETRIST
Applicant does not have active or untreated proliferative diabetic
retinopathy and has stable visual acuity at least 20/40 [Snellen]
in each eye separately, with or without corrective lenses
Date Name of certifying ophthalmologist or optometrist Signature
State license number
III MEDICAL EVALUATION BY ENDOCRINOLOGIST OR INTERNIST
Yes No
? ? 1 Reviewed drivers medical history, including all
hospitalization reports, consultation notes, diagnostic
examinations, special studies
pertaining to the diabetes,
and follow-up reports
? ? 2 Certifies the applicant with Type 1 diabetes has
been using insulin to control the applicants diabetes two
months prior to the date of the application, or if Type 2
diabetes, one month prior to the date of the application
? ? 3 Ophthalmologic or optometric confirmation of stable
visual acuity at least 20/40 [Snellen] in each eye
separately, with or without corrective lenses, and absence
of active or untreated proliferative diabetic retinopathy
? ? 4 Assessed at least one result of glycolysated
hemoglobins/HbA1C during the last three months:
A lipid profile, urinalysis and CBC
Blood pressure readings at rest, sitting and standing
Elevated blood pressure, medication for hypertension or
other evidence of any cardiovascular abnormality will
require a maximal exercise stress EKG
? ? 5 Examination and tests to detect peripheral neuropathy
and/or circulatory deficiencies of the extremities
? ? 6 Certifies the applicant has not had a hypoglycemic
reaction within the
past three years, ie, episode of altered
consciousness requiring the assistance of another person to regain
control
? ? 7 Certifies the applicant has attended a comprehensive
diabetes self management training program, and has demonstrated
understanding of the disease and procedures which must be followed
if for day to day changes in routines and for managing changes in
blood sugars and other complications
? ? 8 Certifies the applicant has the ability, willingness, and
equipment to properly monitor and manage the diabetes A blood
glucose monitor with electronic memory is required
? ? 9 Verifies the applicant can demonstrate self-blood glucose
measurement capably
? ? 10 Certifies the applicants diabetic condition will not
adversely affect his/her ability to operate a commercial motor
vehicle
Additional comments Please attach a separate sheet if more space is
needed
Date Name of certifying endocrinologist or internist Signature State
license number
IV MONITORING AND REEVALUATION OF APPLICANT
The applicant agrees to perform the following monitoring and reevaluation
procedures, which may be supplemented with additional conditions specified
by the examining endocrinologist or internist:
1 One hour prior to driving, again
within fifteen minutes of driving,
and approximately every two hours while driving, drivers shall test
their blood glucose concentration and record those concentrations
electronically
2 Upon request, make records of self-blood glucose concentrations
available to any authorized enforcement personnel
3 Annually, or more often as indicated by the endocrinologist or
internist, submit a complete medical reevaluation including readings
of glycosylated hemoglobin/HbA1C to the examining endocrinologist or
internist This requires the driver to submit any new data on the
drivers medical condition, driving record or accident involvement and
the glucose records Use of a new examining health care professional
will require the insulin-using driver to follow the procedures set
forth for a new applicant
4 At each visit, the endocrinologist or internist will verify that the
insulin-using diabetic can demonstrate self-blood glucose measurement
capably
5 Annually, have ophthalmologic or optometric confirmation of the
absence of visually significant retinal disease
6 While driving, should circumstances
preclude a particular blood
glucose test, intake of an appropriate snack or other source of
glucose is an acceptable alternative; however, no two consecutive
tests may be replaced by the ingestion of glucose or food
7 Carry necessary supplies in the vehicle, including as a minimum, blood
sampling lancets, personal blood glucose monitor and strips, a
plentiful source of rapidly absorbable glucose All dated materials
must be within their expiration dates Drivers with Type 1 diabetes
should carry a glucagon emergency kit
Source:avon.nhs.uk
