Registry Of Motor Vehicles/department Of Public Utilities School Bus And School Pupil Transport (7d) Operator Diabetes Medical Evaluation Form
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1
2Registry of Motor Vehicles/Department of Public Utilities
School Bus and School Pupil Transport (7D) Operator
Diabetes Medical Evaluation Form
Driver Instructions: Please fill in your personal information below.
License Number: _____________________________
DOB (MM/DD/YY) ________________
Name:
______________________________
__________________________
_______
Last:
First:
M.I.
Address:
____________________________
____________________
__________
Street:
City/State:
ZIP:
Endocrinologist Instructions: The following section is to be completed only by a board certified
or board eligible endocrinologist.
This applicant is applying for a license to drive school pupils in Massachusetts. The applicant
either uses insulin to manage her/his diabetes or has had a serious hypoglycemic event in the
past. Under the Code of MA Regulations (540 CMR 2.15), people who use insulin or who have not
had a serious hypoglycemic event in the last 3 years are eligible to drive school pupils if they meet
certain standards. This applicant is asking you to determine whether s/he meets those standards.
For this evaluation, a serious hypoglycemic event is defined as an episode of hypoglycemia so
severe that it interfered with ongoing activities or required the assistance of another person.
Hypoglycemic unawareness is defined as the inability to recognize the early symptoms of
hypoglycemia such as sweating, anxiety, forceful heartbeat, light-headedness, and/or confusion.
The applicant’s examination is valid for 6 months from the date the examination was performed.
Applicants are required to submit a new examination to the Registry of Motor Vehicles or
Department of Public Utilities every 6 months from the date the former examination was performed.
o
o
1)
I am board-certified in endocrinology
OR
I am board-eligible in endocrinology.
If you are neither board-certified nor board-eligible, do not complete this assessment.
2) Date of Applicant’s Physical Examination (MM/DD/YY) __________________
3) I am familiar with the patient’s medical history for the past 3 years, either through actual
treatment over that time or through consultation with a physician who has treated the applicant
during that time. Review of a complete written medical history for the past 3 years may be
o
o
substituted for actual consultation with the other physician.
YES
NO
o
o
4) The applicant is diagnosed with hypoglycemic unawareness.
YES
NO
5) If the applicant is on insulin to control her/his diabetes, the insulin regimen is stable as of the
o
o
o
date of this examination.
NA
YES
NO
6) In the past 3 years, the applicant has experienced a serious hypoglycemic event or altered
o
o
consciousness as a result of her/his diabetes.
YES
NO
7) The applicant has complications of diabetes, such as neuropathy, visual impairment, or
cognitive impairment that will adversely affect her/his ability to operate a school bus or a school
o
o
pupil transport vehicle.
YES
NO
T21841-0909
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