When a DOT medical exam shows a driver takes medications that may impair safe driving, the certified medical examiner can send this optional two-page form to the prescriber. Page 1 describes the driver's job and quotes 49 CFR 391.41(b)(12) on controlled substances; page 2 asks the prescriber to list medications and conditions and give a yes or no safety opinion.
The medical examiner completes and signs the request on page 1. The prescribing health care provider completes the Prescribing Healthcare Provider Data on page 2, questions 1 to 4, and signs with state of licensure.
Download the current version from the source each time; forms change without notice.
391.41 CMV Driver Medication Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. Use of the form by the certified medical examiner is voluntary. It is a tool examiners can use to collect the prescriber's information and opinion; the final decision on whether the driver is physically qualified to operate a commercial motor vehicle rests with the examiner.
Page 1 describes commercial driving demands so the prescriber can judge medication effects: relay, long-haul and team schedules, irregular sleep, long hours, heavy loading and unloading, coupling trailers, chaining tires, and the perception and judgment needed to control a large vehicle in traffic.