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Appendix A.
State of Utah Functional Ability in Driving: Guidelines and Standards for
Health Care Professionals

State of Utah
Department of Public Safety

Driver License Division

FUNCTIONAL ABILITY
IN DRIVING:

GUIDELINES AND
STANDARDS FOR
HEALTH CARE PROFESSIONALS

Utah State Driver License
Medical Advisory Board

1992 Edition

TABLE OF CONTENTS

Introduction

Index

Application of DOT Medical Standards

General Profile Levels & Restrictions

Medical Categories

A – DIABETES MELLITUS AND OTHER METABOLIC CONDITIONS
       PROFILE LEVEL CHART

B – CARDIOVASCULAR
       PROFILE LEVEL CHART

C – PULMONARY
       PROFILE LEVEL CHART

D – NEUROLOGIC
       PROFILE LEVEL CHART

E – EPILEPSY AND OTHER EPISODIC CONDITIONS
       PROFILE LEVEL CHART

F – LEARNING, MEMORY AND COMMUNICATIONS
       PROFILE LEVEL CHART

G – PSYCHIATRIC OR EMOTIONAL CONDITIONS
       PROFILE LEVEL CHART

H – ALCOHOL AND OTHER DRUGS
       PROVILE LEVEL CHART

I – VISUAL ACUITY
     PROFILE LEVEL CHART

J – MUSCULOSKELETAL ABNORMALITY/CHRONIC MEDICAL DEBILITY
      PROFILE LEVEL CHART

K – FUNCTIONAL MOTOR ABILITY
       PROFILE LEVEL CHART

L – HEARING
      PROFILE LEVEL CHART

APPENDICES

I –    Principles Used in Guidelines and Standards

II –   Utah Medical Code, Operators' License Act

III –  Diabetes Mellitus - Commercial Drivers

IV –  Side Affects - Common Blood Pressure Medications

V –   Suggested Reading

VI – Driver License Medical Advisory Board Members

Forward from Director Dave Beach
STATE OF UTAH

FUNCTIONAL ABILITY IN DRIVING:
GUIDELINES AND STANDARDS FOR HEALTH CARE PROFESSIONALS

Last update 05/22/00

Utah residents are individually responsible for their health when driving. All applicants for licenses will complete a health questionnaire to show their functional ability to drive. If there is a significant health problem, they will take their questionnaire, medical and/or vision forms to a health care professional, who will confirm the category as accurate or change it to be consistent with the true medical situation. The health care professional will be expected to discuss the applicant's health as it relates to driving and to make special recommendations in unusual circumstances. Based upon a completed functional ability evaluation, the Director of the Driver License Division may issue a license with or without limitations as outlined in these Guidelines and Standards approved by the Utah Driver License Medical Advisory Board. Health care professionals can increase highway safety by carefully applying these guidelines and standards and counseling with their patients' about driving.

Drivers' Responsibilities

The 1988 Utah State Legislature reaffirmed these responsibilities* related to physical, mental or emotional impairments of drivers:

1. Utah drivers are responsible to refrain from driving if there is uncertainty because of "a physical, mental or emotional impairment which may affect driving safety."
   
2. Utah drivers in such a situation are expected to seek competent medical evaluation and advice about the significance of the impairment as it relates to driving safety.
   
3. Utah drivers are responsible for reporting "a physical, mental or emotional impairment which may affect driving safety" to the Department of Public Safety through its Driver License Division or its agents in its various offices.

Health Care Professionals' Responsibilities

The same legislation applies to Utah health care professionals in these ways:*

1. Health care professionals may be requested by their patients to make reports to the Driver License Division about impairments which may affect driving safety, but the final responsibility for issuing a driver license lies with the Director of the Driver License Division.

2. In addition to making accurate reports when authorized by their patients, health care professionals are expected to counsel their patients about how their condition affects safe driving. For example, if patients are put on medication which may cause changes in alertness or coordination, their health care professional should advise them not to drive at least until a dosage is established which will not affect safe driving. Or, if visual acuity drops they should similarly be advised, at least until corrective action has been taken to improve their vision. The following quotation from the 1988 law recognizes this important function:

"Physicians who care for patients with physical, mental or emotional impairments which may affect their driving safety, whether defined by published guidelines and standards or not, are responsible for making available to their patients, without reservation, their recommendations and appropriate information related to driving safety and responsibilities." The guidelines and standards which follow will be a useful reference in such counseling.

Immunity in Reporting Potential Risks

The Legislature eliminated a major obstacle for health care professionals with its provision that "A health care professional or other person who becomes aware of a physical, mental, or emotional impairment that appears to present an imminent threat to driving safety and reports this information to the division in good faith has immunity from any damages claimed as a result of making the report"*

*Utah Code Annotated 1953: 53-3-303 (12) and 53-3-303 (14)(c).

Utah Driver License Medical Advisory Board

A Driver License Medical Advisory Board was created to advise the Director of the Driver License Division and to recommend written guidelines and standards for determining the physical, mental and emotional capabilities appropriate to various types of driving. Members of the Board have been appointed by the State Health Director to represent a variety of special areas.

If patients are uncertain about interpretations of these guidelines and standards or have special circumstances they may request a review by a panel of Board members. All of the actions of the Director and Board are subject to judicial review. The Board operates under bylaws approved by the Commissioner of Public Safety.

The Advisory Board has developed the following functional ability profile guidelines and standards in an effort to minimize the conflict between the individual's desire to drive and the community's desire for safety. Through education, medical assistance and cooperative efforts, an ideal balance may be reached. Principles followed by the Advisory Board in developing the guidelines and standards are shown in Appendix I.

Functional Ability Profile Categories

Functional ability to operate a vehicle safely may be affected by a wide range of physical, mental or emotional impairments. To simplify reporting and to make possible a comparison of relative risks and limitations, the Medical Advisory Board has adopted physical, emotional and behavioral functional ability profiles including 12 categories, with multiple levels under each category listed below. Vehicle operation history should be included as a significant part of a complete medical history.

CATEGORY A DIABETES AND OTHER METABOLIC CONDITIONS

CATEGORY B CARDIOVASCULAR

CATEGORY C PULMONARY

CATEGORY D NEUROLOGIC

CATEGORY E EPILEPSY AND OTHER EPISODIC CONDITIONS

CATEGORY F LEARNING, MEMORY AND COMMUNICATION

CATEGORY G PSYCHIATRIC OR EMOTIONAL CONDITIONS

CATEGORY H ALCOHOL AND OTHER DRUGS

CATEGORY I VISUAL ACUITY

CATEGORY J MUSCULOSKELETAL ABNORMALITY OR CHRONIC MEDICAL DEBILITY

CATEGORY K FUNCTIONAL MOTOR IMPAIRMENT

CATEGORY L HEARING

Use of the Functional Ability Profile:

When requested by the staff of the Driver License Division, applicants must report information regarding their physical, mental and emotional health. This may be in the form of a short screening questionnaire or a more extensive profiling outline. On completion of this and other requirements, a license may be issued immediately or the applicant may be requested to take the profile record to his or her own health care professional for confirmation of the profile or change as the health care professional believes is indicated.

These guidelines and standards contain twelve sections, one for each functional ability category. Each begins with a short narrative summary of basic concepts, definitions and working ground rules. Each summary is followed by a chart showing: (1) twelve profile levels based upon history, laboratory findings or other information; (2) profile levels which must be confirmed (or modified) by a health care professional; (3) intervals between health care professional confirmation of the profile; (4) license class and restrictions will generally be used by personnel of the Driver License Division to issue licenses consistent with the functional ability profile.

In almost all cases, a health care professional caring for a patient will have adequate information to confirm or modify the profile. However, if there is a significant problem affecting driving which is outside their area of capability, ordinary medical practices should apply. For example, a condition requiring a specialized diagnosis or opinion would suggest a referral to an appropriate specialist before completing the profile. On the other hand, a specialist who has seen a patient only for a limited or technical service may: (1) decline to complete the full profile (especially if there are multiple problems); (2) suggest patients see their personal health care professional; and (3) provide pertinent information to help in completion of the profile. In some circumstances where the limited condition is the only one affecting driving, a health care professional may confirm the profile based upon history without extensive examinations or tests if they are satisfied with the patient's reliability.

Where non-commercial driver applicants' self-reported profiles contain no indication of a significant impairment other than in the Visual Category, they may be sent for an eye examination without confirmation of the rest of the profile.

Reports should be based upon reasonably current information. In case of doubt, medical common sense should prevail.

Since no special tests are required by the guidelines and standards beyond those needed by a health care professional for adequate diagnosis or treatment, no additional expense should result except in unusual circumstances or in cases where individuals may wish to submit additional information, such as a review by a recognized specialist in specific medical conditions, in preparation for review by a medical panel.

Reports of profiles must be signed by a health care professional licensed to practice, although they may rely upon portions of examinations done under their supervision. The Certificate of Visual Examination may be reported by licensed optometrists as well.

Relation of Functional Ability Profiles to Driving Risk/Responsibilities

The table on Page 6 shows, in general, the relationship between functional ability profile levels and the type of risk and responsibility involved in driving. The relationships to profile levels are based upon available data and input from public hearings as interpreted by the Medical Advisory Board.

Operators of commercial vehicles come under different licensing requirements. As far as possible, these have been incorporated into appropriate profiles. All Utah school bus operators and operators of most commercial motor vehicles must meet Federal Department of Transportation Medical Standards. In 1992, the division will be pilot testing the use of these guidelines and standards and report forms as a substitute for federal forms. The Federal Medical Standards have been interpolated without change into these revised guidelines and standards for this purpose.

Setting limitations on driving for persons with impairments of functional ability works to increase public safety and at the same time to permit individuals a maximum degree of freedom of movement in two ways. First, in cases of decreased vision or motor control, avoiding high speeds will reduce the number, as well as the seriousness, of accidents. Second, in situations of some increase in the chance of an accident occurring, cutting down on the extent of exposure on the highway by limiting driving areas or times of day will reduce the total number of accidents and yet allow a person perhaps enough mobility to maintain a job with a single round trip each working day. These factors are difficult to define and measure but an effort has been made to accumulate and develop accurate data in order to refine limitations in the interest of safety.

In some cases, functional ability profiles indicating driving impairment in more than one category may be the basis for a more limited license than if there is only one impairment, but generally any limitation will relate to the single profile showing most impairment. As these functional ability profiles are used in determining driver licenses, data will be gathered as to the driving safety record of various groups as a basis for revision of the levels. Data secured from other sources will also be used.

Denial of driving privileges based upon medical reasons does not constitute a "disability" as defined by the Americans With Disabilities Act.

Changes in Functional Ability

After a driver is licensed, they need not report short term illnesses or abnormalities lasting less than three months to the Driver License Division, provided they refrain from all driving until recovery to the previous level of function for which they were licensed. When a condition persists beyond three months or it becomes apparent that it will persist, it should be reported to the Driver License Division. The license may be revalidated as soon as the condition has become stable at a level appropriate for driving.

Suggestions and Questions

Health care professionals who use these guidelines and standards are invited to direct questions or suggestions to the Driver License Division or to any of the current members of the Medical Advisory Board.

Aspects of Licensing and Medical Certification of Commercial Drivers

For the foreseeable future, these guidelines and standards will apply to the licensing of drivers of commercial vehicles, both for interstate and intrastate driving.

The Utah State Driver License Medical Advisory Board has reviewed the Federal Department of Transportation requirements for commercial drivers and worked out an appropriate profile level for each category. The examining health care professional will need only mark the profile in the usual fashion. In general, a profile of 1, 2, 3 and 4, depending on the category, will qualify the applicant for a commercial license.

Because of the greater responsibilities involved, this program will differ from the usual licensing procedures for private vehicle drivers in four ways:

(1).A copy of the Abbreviated Health Profile should be retained by the examining health care professional. The remaining two copies should be given to the driver. One of these must be submitted to the Driver License Division. Drivers may retain the final copy for their use.

(2) For a commercial license or medical certificate, a check on hearing is required (though not for a private vehicle). Thus, an additional profile Category L has been added. For a commercial license, an ability to perceive a forced whisper at five feet in the better ear, with or without use of a hearing aid, is satisfactory. Loss of between 40 - 65 decibels in the better ear may qualify for an intrastate commercial license. Loss of more than an average of 65 decibels in the better ear is disqualifying (ANS 224.5-1951).

(3) Recognition of red, green and amber used in traffic lights may be tested with simple color cards, rather than more complex test devices.

(4) Rather than simply marking the profile for a single category in question, assuming the others to be satisfactory, for commercial licensing the health care professional will be expected to check off all categories after they have satisfied themselves by history or examination of the proper level. In appropriate cases, a report from an ophthalmologist, optometrist, other health care professional, or an audiogram may be attached.

Some experienced drivers have been "grandfathered" with slightly less rigid standards, but future drivers may not be.

Some profile levels recommend "intrastate" commercial driving restrictions. Whether such restricted driving privileges may actually be issued is subject to federal and state approval.

Health care professionals may use their own routine forms for recording their examination on which the profile is based. The Licensing Profile Worksheet may be used for their records or disregarded at the health care professional's discretion.

In these guidelines and standards, notes have been placed at the end of the narrative for each profile category to assist in understanding the basis for reporting for commercial drivers. As before, the administrative responsibility for granting licenses rests with the State Driver License Division based upon medical information provided. This relieves the health care professional from vulnerability in having to certify the driver as "qualified to drive" under a complex set of regulations.

It is believed that these relatively minor modifications of our previous Functional Ability In Driving: Guidelines For Physicians which have been in use for over eleven years will be simpler than establishing a whole new system to handle licensing of both intrastate and interstate commercial vehicle drivers.

Application of DOT Medical Standards

The 1992 Functional Ability in Driving: Guidelines and Standards for Health Care Professionals has incorporated the DOT Medical Standards as applying to ALL commercial driving, irrespective of the type of vehicle or cargo involved, i.e., Class A, B, C, and D of Utah's Classified License System.

(1) Federal Standards are applicable to all commercial drivers, both interstate and intrastate who are subject to standards contained in Part 391 of the Federal Motor Carrier Safety Regulations.

(2) Use of profiles will provide the only meaningful method of gathering data on health aspects of safety of commercial drivers.

(3) Hence, for the "Utah Medical Pilot Project", present DOT Standards have been integrated into the new Guidelines and Standards, similar to the first edition, when the state issued intrastate chauffeurs' (commercial) licenses. Commercial drivers must be profiled in all twelve categories in order to meet federal standards for examination.

(4) Since present DOT Medical Standards leave a great deal to the discretion of the individual examining health care professional, they have been interpreted by the Board to show the proper profiles appropriate for a commercial license.

(5) Since DOT Standards allow only "one medical standard" to drive all commercial vehicles, no differentiation has been attempted, although use of profile methodology will facilitate a more meaningful equating of profiles with the degree of risk or responsibility for various vehicles, passengers or cargoes. For example, at a future date, it may not be necessary to hold a taxi driver to the same standards as one who drives an interstate bus or multi-axle truck.

(6) Since DOT Standards allow for waivers for absence or impairment of extremities, this feature has been retained by using the members of the Driver License Medical Advisory Board as the approval mechanism, if it is recommended by the examining health care professional and the applicant passes driving skills tests administered by specially trained Driver License Examiners.

(7) There appears to be no medical reason to carry a separate medical examiner's certificate, if a license has been issued based on medical information.

(8) U.S. DOT Regulations permit drivers who were driving in Exempt Intracity Zones during the one year preceding November 18, 1988, to continue such driving as long as the drivers medical condition(s) has not "substantially worsened" since November 18, 1988. Such drivers, even though their medical condition may not have met DOT Standards, are required to have a Medical Certificate issued only for twelve months or less if the examining health care professional so determines. These drivers must furnish the health care professional, the medical data first used by a health care professional to determine the driver could operate in an Exempt Intracity Zone. The current examining health care professional should mark the box at the top right of the Functional Ability Evaluation/Medical Certificate Report indicating "Exempt Intracity Zone" when applicable. Under the Medical Pilot Program some of these drivers may now qualify for intrastate only restrictions for commercial driving, thus broadening their opportunities. This decision is dependent upon the profile level indicated by the examining health care professional.

INDEX

Alcohol and Other Drugs --  Category H
Alzheimer's Disease -- Category F
Amphetamines -- Category H
Amputations -- Category J
Antidepressants --  Category H
Antihistamines -- Category G
Antipsychotics -- Category H
Aphakia -- Category I
Aphasia -- Category F
Astigmatism -- Category I
Barbiturates -- Category H
Benzodiazepine -- Category H
Cataracts -- Category I
Cardiac Surgery -- Category B
Cardiovascular -- Category B
Cataplexy -- Category E
Cerebral Palsy -- Category D
Chronic Medical Debility -- Category J
Color Vision -- Category I
Commitment -- Category G
Communication -- Category F
Compensating/Nonstandard/Adapt --  Category K
Compensating/Personal Devices -- Category K
Compensating/Standard accessories -- Category K
Congenial Abnormality -- Category J
Coughing -- Category C
Cough Syncope -- Category C
Dark Adaptation -- Category I
Depression --  Category G
Diabetes Mellitus -- Category A
Drug Use -- Category H
Emotional Instability -- Category G
Epilepsy -- Category E
Episodic -- Category E
Functional Ability Changes -- Introduction
Functional Ability Profiles -- Introduction
Functional Motor Ability -- Category K
Glaucoma -- Category I
Haloperidol -- Category H
Hallucinogens -- Category H
Head Injury --  Categories D, F
Heart Disease -- Category B
Hearing -- Category L
Heterophoria -- Category I
Hyperopia -- Category I
Hypertension -- Category B
Hypoglycemia -- Category A
Immunity in Reporting -- Introduction
Intelligence --  Category F
Joint Limitations -- Categories J, K
Learning -- Category F
L.S.D. -- Category H
Laws Related to Driving Ability -- Appendix II
Marijuana -- Category H
Medical Advisory Board -- Introduction
Medical Illness -- Category J
Memory -- Category F
Menier's Disease -- Categories L, E
Mental Retardation -- Category F
Metabolic Conditions -- Category A
Methadone Use -- Category H
Monocular Vision -- Category I
Mood Altering Drugs -- Category H
Multiple Sclerosis -- Category D
Musculoskeletal Abnormality -- Category J
Myocardial Infarction -- Category B
Myopia -- Category I
Narcolepsy -- Category E
Neurologic -- Category D
Nystagmus -- Category I
Osteoporosis -- Category J
Pain -- Category J
Panel, Medical Advisory Board -- Appendix VI
Parathyroid -- Category A
Parkinson's Disease -- Category D
Phenothiazines -- Category H
Presbyopia -- Category I
Psychiatric -- Category G
Ptosis -- Category I
Pulmonary-- Category C
Responsibilities, Drivers' -- Introduction
Responsibilities, Health Care -- Introduction
Rhythm, Cardiac -- Category B
Retardation -- Category F
Schizophrenia -- Category G
Seizures -- Category E
Sleep Apnea -- Category C
Sleeping Pills -- Category H
Stereopsis -- Category I
Strokes -- Category D
Syncope -- Category E
Telescopic Lenses -- Category I
Thyroid -- Category A
Vascular -- Category B
Visual Acuity -- Category I
Visual Fields -- Category I

CATEGORY A: DIABETES MELLITUS AND OTHER METABOLIC CONDITIONS

Revised 11-18-98

1. Disturbances in function of the endocrine glands cause many symptoms from generalized asthenia, muscle weakness, and spasm or tetany to sudden episodes of dizziness or unconsciousness. Individuals so afflicted should not drive a motor vehicle until these symptoms have been controlled by appropriate therapy.

2. Problems associated with metabolic diseases such as muscular weakness, muscular pain, visual disturbances, dizziness, intractable headaches, and/or fatigue propensity should also be shown under other appropriate profile categories.

3. Since persons with metabolic disorders may be affected in very different ways, the health care professional should counsel with the patient about any special precautions, limitations or recommendations appropriate to their case. These should be reported by the health care professional.

4. DIABETES MELLITUS: In the past, diabetics have been involved in almost twice as many motor vehicle accidents as the medically normal driving population. Careful evaluation and medical management can increase their safety. Even diabetics whose disease is well controlled with insulin or oral hypoglycemic drugs may occasionally suffer a hypoglycemic episode. It is important that the health care professional ascertain the cause of these occasional episodes and change management of the patient. Before deciding the patient's condition is again stable enough for them to drive a motor vehicle, the health care professional should observe the patient under the new program to be sure that it is effective.

5. Certain insulin requiring individuals with diabetes are much more likely than average to have altered consciousness from hypoglycemic episodes. These individuals have "hypoglycemic unawareness"...that is, a lack of the adrenergic warning signs of nervousness and sweating which should alert the person to eat sugar and reverse the insulin reaction.

6. A typical profile of such individuals includes previous episodes of hypoglycemia induced unconsciousness, long duration diabetes and possibly autonomic neuropathy or beta blocker therapy. The health care professional should take these factors into account when profiling. Also, many episodes of altered consciousness (requiring the assistance of another person to reverse) are treated outside of health care facilities and may not come to the health care professional's attention. Inquiry into such events should be made.

7. It is strongly recommended that health care professionals counsel all insulin or oral antidiabetic medication requiring individuals to store in their vehicles, at all times, a source of rapidly absorbed carbohydrate. Further, blood glucose monitoring just prior to driving should be urged for any diabetic driver with a history of limited awareness of hypoglycemia.

8. Visual acuity decreases with marked increase in blood glucose concentrations, due to osmotic swelling of the lens. The patient should not drive until the blood glucose level is brought under control. Diabetic retinopathy may affect visual acuity and should be checked by the primary care health care professional, ophthalmologist or optometrist and be reported under appropriate profile categories.

9. PARATHYROID DISORDERS: Hyperparathyroidism with muscular weakness and hypotonia is a contraindication to driving any motor vehicle, unless symptoms are mild or well controlled by therapy. Individuals suffering from acute hypoparathyroidism with increased neuromuscular excitability, cramps, spasm, and generalized tetany should not drive unless symptoms are mild.

10. THYROID DISORDERS: Hyperthyroidism or hypothyroidism may be accompanied by severe psychic disturbance, lethargy, muscular weakness, extreme restlessness, and/or tremors, which would preclude any driving. Depending upon the degree of impairment, operation of a private vehicle may be permissible. No medical follow-up is necessary for a thyroid only.

11. HYPOGLYCEMIA: Individuals suffering from recurring spontaneous attacks of hypoglycemia causing faintness or unconsciousness should be carefully evaluated as to cause before being given a profile comparable to those under diabetes.

12. COMMERCIAL DRIVERS: Health care professional should refer to Appendix III in this manual for information regarding special qualifications for Commercial Driver.

CATEGORY A: DIABETES MELLITUS AND OTHER METABOLIC CONDITIONS

1. Or as recommended by health care professional, longer or shorter according to stability.
2. Driving only with specific recommendation by health care professional.
3. If driver is a commercial applicant profiled at level 4 for diabetes, a written health care professional approval must accompany evaluation (see special qualifications in Appendix III)

CATEGORY B: CARDIOVASCULAR

1. Cardiovascular disease may affect a driver's ability in a variety of ways. For this reason, profile guidelines and standards are shown for four of the more common circumstances. Although an individual may have more than one abnormality, the one which causes the most limitation is the one under which they should be profiled for this category. It is essential that all aspects of their condition be evaluated in an appropriate profile.

2. GENERAL HEART DISEASE: This profile is made for any patient having had any diagnosis of heart disease. The levels are based on the functional classification of the American Heart Association.

Class I. Patients with heart disease but with no limitations of physical activity. Ordinary physical activity causes no undue dyspnea, anginal pain, fatigue or palpitation.

Class II. Patients with slight limitations of physical activity. They are comfortable at rest and with mild exertion. They experience symptoms only with the more strenuous grades of ordinary activity.

Class III. Patients with marked limitation of physical activity. They are comfortable at rest, but experience symptoms even with the milder forms of ordinary activity.

Class IV. Patients with inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present, even at rest, and are intensified by activity.

3. RHYTHM: Patients with rhythm disturbances should not be given profile levels 2 or 3, except when the arrhythmia has been so remote and well controlled, or of such a minor nature, that the patient is expected to drive without presenting a risk to the public.

4. AFTER MYOCARDIAL INFARCTION OR CARDIAC SURGERY: No patient in these categories should drive until six weeks after the event or until the condition is stable, as determined by a health care professional. Because of the risk of infarction, recurrence or other cardiovascular events, such as arrhythmia, after infarction or surgery if the health care professional believes a patient has an unusually mild condition, a profile 3 may be given on his recommendation. A treadmill stress test should be repeated after six months.

5. HYPERTENSION: Apart from its complications, hypertension is largely an asymptomatic condition and in itself does not impair fitness to drive. Medications which may have a sedative side effect or cause unexpected orthostatic hypotension must be assessed by the health care professional as to their effect on the profile (see Appendix IV). Visual, neurological or cardiovascular complications should also be profiled under other categories. Usually, mild and stable hypertension may qualify for a profile 3 even if on medication upon recommendation of the examining health care professional.

6. Other less common cardiovascular conditions such as fistula, coarctation, cardiogenic syncope, severe peripheral arterial or venous vascular disease etc., should be profiled in a fashion comparable to those listed, based upon anticipated functional ability while driving.

7. COMMERCIAL DRIVERS: If initial blood pressure is 161-180 systolic and/or 91-104 diastolic, the commercial applicant can be medically certified for a period of three months. The driver is given this 3 month period to reduce their blood pressure to less than or equal to 160/90. If the driver is subsequently found qualified with a blood pressure less than or equal to 160/90, the certificate may be issued for a one year period but the continuing acceptable blood pressure of 160/90 or less must be confirmed during the third month of this one year period. The individual requires annual certification thereafter.

If the initial blood pressure is 181/105 or greater, the driver cannot be certified for commercial driving even temporarily, until their blood pressure has been reduced to less than 181/105. The examining health care professional may temporarily certify the individual once their blood pressure is below 181/105. The driver would then be given the three month period of time to reduce their blood pressure to below 160/90 as stated above. If the driver is subsequently found qualified with a blood pressure less than or equal to 160/90, they may be certified for a six month period. Documentation of continued control should be made every 6 months (biannually) thereafter.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY B: CARDIOVASCULAR

1. Or as recommended by health care professional, longer or shorter according to stability.
2. See narrative for consideration of unusually mild or stable cases.
3. If medication does not interfere with alertness or coordination (See Appendix IV).
4. Or Class III with long term stability.
5. Levels 8 and 9: Type II second degree heart block or trivascular block.
6. See narrative to establish expiration dates for medical certification.
7. HCP = Health Care Professional

CATEGORY C: PULMONARY

Last update 05/22/00

1. Although impaired pulmonary function is seldom the cause of sudden death, it may seriously affect operators of vehicles in the following ways:

• Sudden severe coughing while driving may result in an accident
• Cough syncope may occur while driving
• Impaired cerebral oxygenation caused by impaired pulmonary function may result in mental confusion and/or impaired judgement.

2. For these and similar reasons, it is important to obtain an accurate picture of the pulmonary status of all applicants for driver licenses who have a history of problems or are observed to have respiratory difficulties at the time of examination.

3. In assessing the severity of pulmonary impairment, effort is made to limit the tests to those found in most medical offices, although occasionally more sophisticated studies may be needed (e.g. arterial blood gases, maximal voluntary ventilation, etc.).

4. The objective of classification according to pulmonary capacity, as in other functional categories, is to allow as much latitude as is consistent with the safe operation of a motor vehicle.

5. The basic function tests (FVC and FEV) are the principal guidelines and standards currently recommended. These are subjective/objective tests. When they are required, three graphs should be made and every effort should be made to elicit the full cooperation of the examinee. A bronchodilator may be used if the examiner feels it is safe and justifiable. The best reading, with or without bronchodilators, should be used.

6. In more severe cases of pulmonary impairment, measurement of arterial blood gases may be needed. If there is any question about the need for arterial gas measurements, the applicant usually would not qualify for profile levels 1 through 4, but the blood gas determinations may support a higher functional level than might otherwise appear indicated. They may also help in defining profiles appropriate to limited private driving.

7. COMMERCIAL DRIVERS: A commercial driver meeting the requirements of profile level 1, 2, 3 or 4 will qualify for a license or medical certificate except that in level 3 and 4 one year re-evaluations are required. If oxygen is required, even intermittently, the driver will be limited to a Class C or D license and may not carry hazardous material. If the driver is carrying passengers a NO SMOKING sign must be prominently displayed in their vehicle. 

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY C: PULMONARY

1. Or as recommended by health care professional, longer or shorter according to stability.
2. If supplemental oxygen is required to maintain PO₂ over 50, constant use of oxygen is required while driving.

CATEGORY D: NEUROLOGIC

1. A wide variety of neurological conditions may affect driving safety. A partial list includes: strokes, head injuries, Cerebral Palsy, Multiple Sclerosis, Parkinson's disease, progressive conditions such as muscular atrophies and dystrophies, myasthenia gravis and other spinal cord and brain diseases. Epilepsy is considered as a separate category.

2. The common element in all of these is the disturbance of sensory, motor or coordinating functions sufficient to affect driving. Some of them will be considered as stable conditions for which a driving test showing adequate performance in the type of vehicle to be driven will be sufficient. However, other conditions that have not yet stabilized or have a probability of progression or need for medication may require a medical report initially or at intervals. The usual interval for reconfirmation is as shown or may be increased up to the time interval since the last significant change in status. No medical confirmation will be needed after the condition has been stable for three years if the health care professional so recommends.

3. In general, those impairments shown in the AMA Guide to Evaluation of Permanent Impairment for 5 to 15% impairment relate to profile levels 4 and 5, for 20-45% impairment to profiles 6 through 10 calling for limitations on driving and for over 45% to profile 12 for no driving, unless skill with compensating devices is demonstrated, in which case an appropriate suffix will follow the profile number.

4. Persons with neurological disorders with motor impairment will also be given a profile as appropriate under Category K, (Functional Motor Impairment) in relation to driving, regardless of whether function is restored by use of compensatory devices. The health care professional should indicate by checking the appropriate box on the Functional Ability Evaluation form if a driving skills test should be given.

5. In some neurological disorders, there may be other problems which impair driving. For example, a head injury may not only result in paralysis, but in visual field loss and impairment of learning and memory. These should be shown as profiles in the other appropriate categories as well. In evaluating late effects of head injuries, careful inquiry into the duration of coma or amnesia will be found helpful in evaluating the likelihood of persisting effects which may impair reaction time and thus be important in considering limitations on driving speeds. Similar considerations may apply in the use of a variety of medications which affect neuro-motor functions.

6. COMMERCIAL DRIVERS: Drivers given a profile 5 may or may not be successful in passing a road test, but should have an opportunity to do so if their conditions are stable. The health care professional should check the driving skills test box at the bottom of the form.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY D: NEUROLOGIC

1. Or as recommended by health care professional, longer or shorter according to stability.

2. For example, as in recovery from strokes, head injuries, etc., where skill developed under supervision may be therapeutic.

CATEGORY E: EPILEPSY AND OTHER EPISODIC CONDITIONS

1. Epilepsy includes any recurrent loss of consciousness or conscious control arising from intermittent change in brain function. Because of the similarity of consequences, other disorders affecting consciousness or control such as syncope, cataplexy, narcolepsy, hypoglycemia, episodic vertigo interfering with function, etc., have been included in this section, to be considered in a similar fashion.

2. Since all forms of epilepsy (tonic-clonic or grand mal, partial complex or psychomotor, partial, with or without spread, and absence or petit mal) may interfere with safe driving, they will affect the level of driving recommended and will require initial and follow-up reports.

3. A non-commercial operator's license, with or without limitations, may be issued after a suitable interval in the following circumstances confirmed by a medical report:

A single seizure or cluster of seizures (profile 12 until evaluation completed).

Seizures occurring only in sleep over a period of three or more years.

Seizures so limited as not to interfere with control, if stable for a period of one year.

Seizures recurring when medication has been reduced on a health care professional's advice to change or continue medication and a corrective change has been made as recommended by the health care professional.

A seizure provoked by a clearly identified cause which is not likely to recur.

4. To qualify for a profile based upon freedom from seizures, a person should be free from side effects of medications which affect driving. Anyone taking medication is responsible to refrain from driving if it affects their alertness and coordination, until the health care professional approves resumption of driving and believes the patient can drive safely. Side effects such as skin or gum changes which do not affect driving may be disregarded. In individual cases where anticonvulsant medication effects cause a slowing of reaction time, consideration should be given to limitations on speed as suggested in Neurologic Category D.

5. Persons experiencing seizures may have associated problems which may affect driving safety and these should be reported under the appropriate profile.

6. Persons with past seizures may qualify for a higher risk responsibility level by making sure they faithfully take their prescribed medication and use other means of control. In time, they may qualify for an unrestricted license. Under these guidelines and standards it is possible for a person to resume driving after a seizure free interval of only three months. Each case should be considered carefully to balance possible risk against the person's need to get to and from work, etc.

7. COMMERCIAL DRIVERS: Federal DOT guidelines require any patient with a history of epileptic seizures (other than childhood febrile seizures or symptomatic seizures) to be disqualified for a commercial interstate license or medical certificate. An intrastate license or medical certificate may be granted under profiles 2, 3 and 4 depending upon the degree of seizure control.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY E: EPILEPSY AND OTHER EPISODIC CONDITIONS

1. Or shorter if recommended by health care professional, according to stability.
2. Or interval since last seizure or episode, up to renewal interval.
3. Or interval to qualify for higher profile.

CATEGORY F: LEARNING, MEMORY AND COMMUNICATION

1. Driving a motor vehicle is a complex operation which requires the ability to learn from experience, to remember facts related to driving situations, to communicate intentions by appropriate signals and to receive communications by interpretation of signs and in other ways. Greater demands for verbal communication are imposed when passengers are carried.

2. These functional profile levels are intended as guides for health care professionals in advising appropriate driving for their patients. In stable situations, such as retardation, a single medical confirmation will be sufficient, but in other circumstances, reconfirmation of the profile should be based upon medical judgement as to the likelihood of future changes. For example, a person who is improving after a head injury may be reviewed after an appropriate interval and receive increased privileges. Similarly, a person with increasing difficulties should be reviewed and greater limitations advised as may be appropriate. A health care professional should use available information to make the best judgement possible in the interest of their patient's safety. This should include information from their family, driving incidents, habits and other medically pertinent data. In general, AMA impairment percentages from 0 to 15% may be appropriate for driving private vehicles, while higher percentages will usually call for limitations.

3. Intellectual function usually relates to age in younger individuals, but may be estimated for all ages in a common sense fashion. A person's ability to function may be affected by emotional factors or experience. A health care professional can often get a good indication of intelligence by learning how well a person handles school, work or activities of daily living. For example, a person who cannot figure change in making simple purchases may not be able to drive safely.

4. A very important component of any impairment of learning, memory, communication, or other intellectual functions is the element of emotional stability and maturity in social relations. A person with intellectual impairment who is impulsive or aggressive may be a dangerous driver. Hence, these factors must be considered in setting a profile level.

5. Most younger individuals with learning problems will have had testing done which may be used as a basis for recommendations. In other cases, estimates of abilities, including general intelligence, may be made using whatever resources are usually used by the health care professional. Since inappropriate driving may create risks for both the patient and the public, if there is uncertainty, psychometric testing or other referral should be considered. Individuals with I.Q.s below 70 are reported to have more accidents in emergency situations.

6. Ability may fluctuate in relation to effects of medications, alcohol, emotional stress or fatigue, etc. Hence, a person's age, habits, stability and related impairments as in head injuries, should be considered carefully. Recommendations should be conservative to take into account intervals when abilities may be less than usual.

7. Patients with closed head injury may have diffuse cognitive deficits, for example: impaired judgement, impulsiveness, distractibility, impaired attention, neglect, slowed reaction time or impaired cognitive endurance. If the patient has had a severe injury (defined as coma longer than 24 hours and/or post traumatic amnesia longer than 7 days) the patient should be required to be evaluated by a state driver license examiner.

8. Alzheimer's disease results in progressively impaired cognitive function and may require frequent review of driving abilities.

9. In special problems such as aphasia or inadequate language skills, the health care professional may indicate that a drive test should be given to make a careful final appraisal based upon special attention to learning and communication during the drive test. The health care professional should check the driving skills test box at the bottom of the form.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY F: LEARNING, MEMORY AND COMMUNICATION

1. Or shorter interval, as recommended by health care professional.
2. Initial medical confirmation only needed for static conditions. Otherwise intervals from three months up to renewal interval according to the health care professional's judgement regarding probability of change.

CATEGORY G: PSYCHIATRIC OR EMOTIONAL CONDITIONS

1. There is no certain way of predicting which person with psychiatric illness will have accidents, but many high risk drivers are such because of psychiatric conditions. Consistent application of the point system reflecting accident involvement and reckless driving with imposition of appropriate driving restrictions will help to identify and control many of the psychiatric population at risk.

2. The involuntary hospitalization or commitment law presently in effect in the State of Utah requires that the individual to be committed must have a major mental illness, lack insight into their condition, be untreatable in programs involving less restriction of personal freedom, be an imminent danger to themselves or others, or be incapable of self care. The coincidence of these four criteria adjudicated at a court hearing would be strong grounds for the withholding of the driving privilege during the duration of the commitment. Termination of committed status does not mean that the patient is necessarily mentally well but merely improved. Such individuals should be medically screened before resuming driving privileges.

3. There is a large population of individuals with psychotic illness who are being maintained on anti-psychotic medications in an ambulatory status in the community. All of these drugs, as well as the tricyclic anti-depressants, have varying degrees of sedative side effects and potentiate other CNS depressants. Most of these are individuals with a clinical diagnosis of "schizophrenia". The quality of the remission being maintained by medication varies widely. Some of the individuals continue to have significant mental disability. These persons should be screened in terms of severity of side effects incident to medication and the adequacy of the remission in terms of a reasonably stable, reality oriented, socially responsible and impulse controlled adjustive style.

4. Benzodiazepines have been implicated in automobile fatalities to a degree comparable with alcohol. Research shows the major period of risk is the first three weeks, after which tolerance generally develops to the sedation and dysfunctional effects on coordination.

5. There are a variety of behavioral conditions, extremes of mood and impairments in thinking associated with psychiatric disorders which may correlate with accident proneness or driver risk. These include:

1. Inattentiveness which may accompany even minor mental disturbances;
   
2. Impulsivity, explosive anger, and impaired social judgement characteristic of personality disorders, especially antisocial personality;
   
3. Suicidality, perceptual distortions, psychomotor retardation or frank irrationality in addition to the previously described symptoms which are common features of major psychiatric illnesses such as schizophrenia, major depressive disorder, bipolar (manic depressive) disorder and organic brain syndromes.

6. The applicant's prior accident and violation records are more valid "predictors" of driver risk than psychiatric status. This record should be a major factor in placing restrictions upon driving. The combination of a bad driving record and mental disability could be a particularly lethal combination. If an applicant reports accidents or moving violations the health care professional should be alert to possible psychiatric problems. The health care professional may call 965-4437 for further information retained on the patient's driving record.

7. If a health care professional believes there may be a problem, but is not sufficiently familiar with the patient's psychiatric status to make a valid judgement, they should refrain from doing so until they gain access to current psychiatric information or records or makes an appropriate referral for evaluation.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY G: PSYCHIATRIC OR EMOTIONAL CONDITION

1. Or as recommended by health care professional, longer or shorter according to stability.
2. Or interval up to 1 year if recommended by health care professional.
3. Drivers with impulsivity, explosive anger, and impaired social judgement characteristic of personality disorders such as antisocial personality must have a recommendation from their health care professional as well as approval of the Medical Advisory Board.

CATEGORY H: ALCOHOL AND OTHER DRUGS

(Revised 4/98)

1. It is generally known that one-half or more of the highway accidents, injuries and fatalities are related to the use of alcohol. Chronic users of alcohol cause more fatal accidents than the combination of all other drivers with medical problems. Hence, an awareness of problems caused by alcohol is essential to the proper granting of driving privileges.

2. Use of other problem causing drugs can impair a person's driving ability. The nature of these substances is such that continued use creates problems which are recognizable and require special attention in licensing drivers.

3. Users of alcohol and other drugs are well known for their tendency to not report or under-report amounts used. There is a wide individual variation in the effects of such substances. Hence, about the only valid basis for evaluating an applicant's probable safety as a driver is careful appraisal of the person's history including, but not limited to, the past effect upon driving.

4. Adverse personal consequences of alcohol and drug use include (1) physical dependence or withdrawal symptoms, (2) medical or neurological findings associated with effects of alcohol or drug use upon the nervous system or other organs, (3) a history of alcohol or drug related behavioral change indicated by fighting, physical abuse or mood and personality instability, (4) history of alcohol or drug related vehicular accidents or trauma, and (5) convictions involving alcohol.

5. The interaction of psychoactive medications (antidepressants, benzodiazepines, neuroleptics, sedatives, hypnotics) taken in appropriate doses with alcohol or illicit drugs may hamper driving ability.

6. Users of mood altering and hallucinogenic drugs are next to users of alcohol in traffic violations. In addition, untoward drug-related experiences, such as flashbacks, or substance withdrawal seizures may be hazardous to driving. Not only "street" drugs (cannabis, amphetamines, LSD, cocaine, PCP, inhalants, ETC), but also inappropriately used prescription drugs (benzodiazepines, barbiturates, antihistamines, antipsychotics, antidepressants, sedative hypnotics, muscle relaxants, opiates, ETC) increase accident rates, especially when used in combination with alcohol.

7. There is increasing evidence that marijuana may affect driving by causing changes in depth perception, unpredictable alteration of reaction time, illusions of distance, impairment of accuracy of sensory perception, impairment of judgement and periodic lapses of attention, acutely as well as after chronic use. Marijuana may impair driving even several days after cessation of use.

8. Health care professionals should be alert to the fact that those with substance problems tend to visit them more often than the average. Patterns that suggest substance abuse include: gastrointestinal symptoms, often atypical; injuries or burns of vague causation; neurologic symptoms; general medical or flu-like symptoms, hypertension or skin problems; psychiatric symptoms, including depression; social maladjustment and interpersonal and work difficulties; and family health problems. Inquiry may lead to a clearer picture of the problem and temporary limiting of driving for the benefit of the public as well as the patient. Persons who have been stabilized by methadone treatment in a recognized clinic may qualify to drive a non-commercial vehicle as long as they remain under supervision.

9. Many young or inexperienced drivers are unaware of the high risks of driving associated with the use of alcohol, especially when mixed with other substances. Making factual information regarding drugs and alcohol and their effects on driving available to young drivers may help them to make safer choices. Health care professionals can effectively help in these educational efforts.

10. Since many persons rely on their automobiles for transportation to and from work, pressure may be brought to bear to make exceptions. Since the guidelines provide for limitations on speed, areas, time of day, etc., these should be used as appropriate to facilitate driving to and from work until the person has demonstrated sustained responsibility for unlimited privileges. 21

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Exammination forms.

CATEGORY H: ALCOHOL AND OTHER DRUGS

1. Or as recommended by health care professional, shorter or longer up to 1 year.
2. See narrative for examples of adverse consequences
3. Drug Abuse means any use of illicit drugs or inappropriate use of prescription or non-prescription drugs.
4. Random blood alcohol, random urine or hair drug analysis, or documented compliance with requirements of an approved treatment program at time of profiling.

CATEGORY I: VISUAL ACUITY

1. Visual acuity and peripheral vision guidelines for functional ability profiles are as shown.

2. Correction of vision may be either with regular glasses or with contact lenses, provided they are used at all times when driving. With spectacles, the correction must be less than 10 diopters to qualify for profile level 1. Profiles based upon use of a visual correction should be identified by the suffix "C".

3. Some of the eye conditions requiring special consideration, but which have no set standards, are listed below. Persons with these conditions may drive if they meet the criteria for acuity and fields.

4. COLOR VISION: People who are completely color blind usually suffer from poor visual acuity and possible associated visual field loss. Red-green color discrimination is not important because of traffic light standardization, except in the case of commercial drivers, who must be able to recognize standard colors of red, green and amber.

5. DARK ADAPTATION: Dark adaptation and glare tolerance are important for safe twilight and night driving, but methods of measurement and standards are not well established. However, individuals with cataracts, retinal abnormalities, chronic pupillary constriction, or other known causes of glare intolerance or poor dark adaptation should be carefully evaluated before being recommended for unrestricted licensure. Under certain conditions, a profile for daytime driving only may be recommended.

6. HETEROPHORIA can occasionally be a cause of driver fatigue. In more severe conditions, it may lead to blurred vision, diplopia or suppression of vision in one eye. A strabismic person, if diplopia (double vision) is not present, may be regarded as a one-eyed driver. A person with persisting diplopia may be licensed only on the basis of specific medical recommendations.

7. STEREOPSIS is only important in distances up to 75 feet and therefore relates more to parking, backing and following closely in city traffic. The best method for testing depth perception on the highway is the driver license examiner's road test.

8. MONOCULAR VISION: A person with vision with one eye or correctable vision in one eye to 20/40 may drive non-commercial vehicles. Side mirrors are not required because they are not considered adequate compensatory devices. In certain circumstances a driver with monocular vision may be approved by the Medical Advisory Board for a commercial intrastate license or medical certificate.

9. REFRACTIVE STATES: Myopia (near-sightedness), hyperopia (far-sightedness) and astigmatism (distorted, but constant for all viewing distances) can usually be compensated and need not be considered as problems. Likewise, presbyopia (inability to focus clearly at near) is natural to aging and is not of licensing concern if compensated.

10. TELESCOPIC LENS: When a person puts on a telescopic lens, the visual field is decreased to an extent that the wearer is not qualified to drive.

11. CHRONIC AND RECURRENT DISEASE, including nystagmus, glaucoma, cataracts, ptosis, corneal disorders, pupillary action, retinal changes and aphakia, are significant in that they usually produce changes in the visual acuity or visual fields.

12. VISUAL FIELDS: Recent research demonstrates that intact peripheral vision is important for safe driving. An adequate visual field for passenger vehicles is defined as 120 degrees on the horizontal meridian and 20 degrees on the vertical meridian both above and below fixation. If the patient has pathology that may affect the visual fields, such as glaucoma, retinitis pigmentosa, post panretinal photocoagulation, or cataracts, formal visual field testing using a Goldmann III-4-e object or its equivalent for automated perimetry may be helpful in determining the extent of visual field impairment. A person with a homonymous hemianopia is at increased risk for accidents and should be reviewed by the Medical Advisory Board.

Please refer to Profile Level Charts when completing Functional Ability Evaluation and Certificate of Visual Examination forms.

CATEGORY I: VISUAL ACUITY