Submit the completed form to the certified medical examiner overseeing the individual's medical certification examination. Retain a copy for personal records and ensure that the form is submitted within the required 45-day period post-clinician signature. Send comments or additional documents required by FMCSA to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590. For assistance, contact the FMCSA office via email or their official website. Make sure to follow all instructions and meet submission deadlines to ensure compliance.

The Insulin-Treated Diabetes Mellitus Assessment Form must be submitted within the required timeframe set by the FMCSA guidelines. For 2024 and 2025, ensure to keep updated with the latest submission deadlines to maintain compliance.

The purpose of the Insulin-Treated Diabetes Mellitus Assessment Form is to evaluate whether individuals with insulin-treated diabetes mellitus meet the physical qualification standards to operate a commercial motor vehicle as per FMCSA's guidelines. The form must be completed by a treating clinician, based on their knowledge of the individual's medical history, to document the management and assessment of diabetes-related conditions. Certified medical examiners then use this form to determine if the individual is physically qualified to drive a commercial motor vehicle.

• 1. Individual's Name: Enter the name of the individual being assessed.
• 2. DOB: Enter the date of birth of the individual.
• 3. Driver's License Number: Provide the driver's license number if applicable.
• 4. State: Enter the state where the driver's license was issued.
• 5. Date insulin use began: Record the date when the individual began using insulin.
• 6. Blood Glucose Self-Monitoring Records: Indicate whether at least the preceding 3 months of ongoing blood glucose self-monitoring records are available.
• 7. Severe Hypoglycemic Episodes: Provide details of any severe hypoglycemic episodes in the last 3 months.
• 8. Hemoglobin A1C (HbA1C) Measurements: Record HbA1C measurements intermittently over the last 12 months, with the most recent measure within the preceding 3 months.
• 9. Diabetes Complications: Detail any signs of diabetic complications such as renal disease, cardiovascular disease, neurological disease, peripheral neuropathy, lower limb issues, or other complications.
• 10. Progressive Eye Diseases: Provide information about any diagnoses of severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy.

Failure to submit this form can result in being disqualified from operating a commercial motor vehicle until compliance is achieved.

• Disqualification: The individual may be disqualified from operating a CMV.
• Medical Certification Delay: Delays in medical certification examination may occur.
• Non-compliance Penalties: Possible fines or penalties for not adhering to FMCSA regulations.

• 1. Pre-Certification Examination: Before a medical certification examination for CMV operation.
• 2. Post-Hypoglycemic Episode: After experiencing a severe hypoglycemic episode.
• 3. Annual Review: For annual reviews of diabetes management.
• 4. Renewal Certification: To renew medical certification for CMV operation.
• 5. Employer Requirement: If required by the employer to verify compliance with FMCSA standards.