Commercial drivers who use insulin need this four-page form, revised 3/26/25, completed by the clinician who prescribes their insulin before each DOT medical exam. It documents glucose self-monitoring, severe hypoglycemia, HbA1c, complications and eye disease, and ends with an attestation of a stable insulin regimen. The certified medical examiner, not the clinician, decides whether the driver qualifies.
The treating clinician, defined by FMCSA as the health care professional who manages and prescribes insulin for the driver's diabetes under state licensure, completes questions 1 to 12 and signs the attestation with license number and state.
Download the current version from the source each time; forms change without notice.
Insulin-Treated Diabetes Mellitus Assessment Form
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The certified medical examiner must receive the form and begin the physical qualification exam within 45 calendar days of the treating clinician's signature. A completed form is needed before each exam, so the clinician visit should be timed close to the driver's DOT physical.
The health care professional who manages and prescribes insulin for the driver's diabetes, as authorized by that professional's state licensing authority. Completing the form is not a certification decision; only a certified medical examiner on FMCSA's National Registry decides whether the driver is physically qualified.
The driver is not physically qualified, for up to the maximum 12-month period, until a treating clinician receives at least 3 months of electronic self-monitoring records. At the examiner's discretion, the driver may be certified for up to 3 months in the meantime.