Medical Declaration Form

On March 30, 1999, Transport Canada and U.S Federal Highway Administration (FHWA) entered into a reciprocal agreement regarding the physical requirement for Canadian driver of a commercial vehicle in the U.S., as currently contained in Federal Motor Carrier Safety regulations, Part 391.43, and vice-versa. The reciprocal agreement removes the requirement for a Canadian driver to carry a copy of medical examiner’s certificate indicating that the driver is physically qualified. (In effect, the existence of valid driver’s license issued by the province of Ontario is deemed to be proof that a driver is physically qualified to drive in the U.S)

However, FHWA will not recognize an Ontario license if the driver has certain medical conditions, and those conditions would prohibit him from driving in the U.S.

I certify that I am qualified to operate a commercial motor vehicle in the U.S. I further certify that
a. I have no clinical diagnosis of diabetes currently requiring insulin control
b. I have no established medical history or clinical diagnosis of epilepsy
c. I do not have impair hearing (A driver must be able to first perceive a forced whispered voice in the better ear at not less than 5 feet with or with the use of hearing aid, or does not have an average hearing loss in the better ear greater than 40 decibels at 500Hz, 1000Hz or 2000Hz with or without hearing aid when tested by an audiometric device calibrated to American National Standard Z24.5-1951.)
d. I have not been issued a waiver by the province of Ontario allowing me to operate a commercial motor vehicle pursuant to Section 20 or 21 of Ontario Regulation 340/94.

I further agree to inform Sarai Trucking management immediately should my medical status change, or if I can no longer certify conditions A to D, described above

Driver's First Name Driver's Last Name

Date:

Witness: Date:

Your Email (Copy of this form will be sent to this email)