HomeMy WebLinkAbout16-259r IDENTIFICATION NO. _ �S
1 (Office UseOnly)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
C ITY OF I OWA C ITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(319) 3S6-5040
(319) 356-5497 FAX
First Middle Last
1. Name (REQUIRED) /L1 d�/�i/1/�� �s�jq�✓ �✓��i d�
2. Address (REQUIRED) 2 2 6//
3. Contact Information (REQUIRED) Email: Cell Phone: (31 11.7/"5v77
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) 08/23/ ZD/
b. Taxicab Business Name (REQUIRED) �Ie/% "1 45:0--/7
5. Prior experience in transportation of passengers: D r zl,,7 /'
c„f -<eY v;[e, Jrz ,'".0,t✓///- ///,C'tx.6.
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? i✓U
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
Where
�t io
When
What
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the,name(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CER lF.IED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
62 3 AN 4/5"2 3 issued on o9/T/4o/6 expiring on 4D8/z3/2v/P . I understand that if I
falsely answer any questions in this application, that this application may be denied. I agree that in making this application, I
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and
documents relating to this application, and 1 further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant �JnK�"`�/4fZ1 Date 11134116'
STATE OF IOWA )
COUNTY OF JOHNSON )
�h
Subscribed and sworn to before me by u o on this 3b day of
IyOVgr+.�ev auto
No ublic' and for the State of Iowa
I have reviewed this application, DCI report, and
there is no information which would indicate thjRf the
dents of the,)2i VofTokva City (Title 5, Chapter/2, City
of Pdhc:e Chief or designee
tified driving record of this applicant and have determined that
would be detrimental to the safety, health or welfare of resi-
2 s- /K
3a-/6
Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Sign re of City Clerk or designee
Date
1ef#1ef###yfe4##Iffff##}f1f1f#1f11TTT#F****###1r#felfe#fM1f##ff�##f1#Yf1111f#1H11*f1f*f*f111f*f*'M1#####1#'#++###++###+#H4
Office Use Only
ci
Approved application
DCI report
State certified driving record
Website update
perk/rAXIDRNBADGEAPPL92014am ded.DOC 07r2016
NOV. 10. LVID II;VOHm uiv 01 brlmindl 1nye5ttgdtlell nu. Vu I I . I/i
FrI...._— _. ._✓- _.., C(ort. _...__ ---- .,•. 11/23/2016 13:4- ..746 / 00 2
STATE GF )IOWA
Criminal History Reca.rtl Check
V, ,. ;I Request FarlIn
To: foga Division of Criminal htvestigation
Support Operations Bureau, P Floor
215 E. 7" Street
[fart Moines, Iowa 50319
(515) 725-6066-
(515) 725-6000
25-6066-(515)725-6000 Fax
1 4 nnnnd,.n e,. TI„\,9 l.iietnm Pornrel rhefl: niv
DC1 Account Number: (400-1—
—� (ifanfliceble)
Frorr: City of Iowa City ___
City Clerkrs Office
410 C. Washington Street ^�
Iowa City, IA 52240_, ,.
Phone; 319.356.5041 _
Fax: 319-356-5497
Last Name puandhiory)
First Name (mandatory)
Middle Nalne (wammcnded
17
Date of (nsndatory)
Gender (mandamry)
Social Security Number (rdcommwdcd)
Birth
D Fl 2 3 ( / Y4 -'o
(Male ❑T eena)e
-? / ? - ifO r/- O Z 3
Maiver 1'nformarion: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record inrormation, as allowed by low, always
obtain a waiver signature from the subject of the request. M
Waiver Release: I tureby give permission for slit above regorssingoffieial to conduct at Iowa efiminat history record chcek swish the Division of Criminal
Invesligatimt (DCI). Ally erimhtal history dais wncerning me tial is main(ained by the DCI may be released as allomil by law.
Waiver Signaffn e:
Iowa Criminal History Record Check Results
As of _J11, a search of tho provided name and date of birth revealed:-,
I� No Iowa Criminal History Record found with DCI V
y
® Iowa Criminal History Record attached, DCI # _ c
DO initials__
DC1-77 (08/25110)
Received Time Nov. 23. 2016 12:30PM No. 8772
lowa Department of Transportation
ofilice of Unvff sewm (Toll Free) NO -532-1121
PO sox 9204, Des Manes, IA 50306-9204 515-244-4124
i 0 FAC 515 139.1 ail
Certified Abstract of Driving Record
Inquiry Date:
11/8/2016
DL/ID #:
623AH4523 (IA)
Customer #:
5946835
Name:
Nugod, Mohamed
Class:
B
ID Status:
None
Medical Examiner Jurisdiction
Osman
Medical Examiner Phone
319 356-3335
Medical Examiner Type
Medical Doctor
Address:
2264 11TH ST
Audit #:
1302726
DL Status:
VAL
Date Added to Coils Driving Record
08/18/2016
Issue Date:
09/15/2016
CDL Status:
VAL
City/State:
CORALVILLE, IA
Expiration Date:
08/23/2018
CDL Cert Status:
Non -Excepted
522411367
Interstate
Endorsements:
PS
CDL Med Status:
Certified
Mailing Address:
2264 11TH ST
Restrictions:
Corrective Lenses,
Restriction
None
No Class A
Supplement:
Passenger Vehicle
Date of Birth:
8/23/1940
Mailing
CORALVILLE, IA
Sex:
M
City/State:
522411367
CDL Medical Examiner's Certificate
Certificate Specifics
Explanations
Medical Examiner First Name
Claudia
Medical Examiner Middle Name
Lynn
Medical Examiner Last Name
Corwin
Medical Examiner License Number
29261
Medical Examiner National Registry Number
8795856463
Medical Examiner Jurisdiction
IA
Medical Examiner Phone
319 356-3335
Medical Examiner Type
Medical Doctor
Medical Certificate Restriction 1
Wearing corrective lenses
Medical Certificate Issued Date
03/23/2016
Medical Certificate Expiration Date
03/23/2017
Date Added to Coils Driving Record
08/18/2016
History Information
Convictions
Citation Date
I Conviction Date
ACD
Explanation
1county
)UR
101/19/2013
101/25/2013
IS92
Seed
I Iowa
11A
05/26/2015
07/10/2015
592
5 eed
Johnson
IA
11/25/2015
12/17/2015
S92
Speed (30 mph
Johnson
IA
under in 35-55 mph
zone
Name: Nugod, Mohamed Osman DL/ID: 623AH4523
pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of
an official record currently In the custody of said Office, and that I have been authorized by the Director of the Iowa Department
of Transportation to so certify.
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
` IF Nr 11/8/2016
`y� '>j{',�[ I�D1NA �II��
It,
',NS.� Office of Driver Services
i
Iowa Department of Transporation
Name: Nugod, Mohamed Osman DL/ID: 623AH4523
Form MCSA-5876 (Revised: 12/D6/2015)
OMB No. 21260006 &piration Date: 8/31/2018
IPublic Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to "Ford to, nor shall a person be subject to penalty for failure to comply with a collection of information subject Wthe requirements ofthe Paperwork Reductio Actunless
that collection of information displays a current valid OMB Control Number.The OMB Control Number for this information collection is 21260006. Public reporting for this collection of information is estimated to be approximately 1 minute pe(response,
. including the time for reviewing instructions, gathering the data needed,and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any
other aspect of this collection of information, Including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC -RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590,
I certify that I have examined Last Name:
Nugod
Medical Examiner's Certificate
(for Commercial Driver Medical Certification)
First Name: Mohamed in accordance with (please check only one):
0 the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.491 and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply) OR
0 the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations), and, with knowledge of the driving duties,
find this person is qualified, and, if applicable, only when (check all that apply):
❑x Wearing corrective lenses ❑ Accompanied by a waiver/exemption ❑ Driving within an exempt intracity zone (49 CFR 391.62) (Federal)
❑ Wearing hearing aid ❑ Accompanied by a Skill Performance Evaluation (SPE) Certificate ❑ Qualified by operation of 49 CFR 391.64 (Federal)
❑ Grandfathered from State requirements (State)
Medical Examiner's Certificate Expiration Date
The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,
MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office. 11/15/2017
Name (please print
Tracie L Abbott
Madical Examiner's State License, Certificate, or Registration Number
A091593
Medical Examiner's Telephone Number Date Certificate Signed
319-356-3335 11/15/2016
OMD 0 Physician Assistant 0 Advanced Practice Nurse
0 DO 0 Chiropractor 0 Other Practitioner (specify)
Issuing state
IA
National Registry Number
6826553121
Driver's Signature Driver's License Number Issuing State/Province
10:d x--eG�'j o� 623AH4523 IA
9, r
Driver's Address -. Yr.± QL wit,� / u CLP/CDL Applicant/Holder
Street Address: 2264 11th St City. Coralville State/Province: IA Zip Code: 52241 Qct Yes ON.
Form MCSA-5875 (R2viseo. 1010212015)
OMB No. 21260006 Expiration Da:e: 8/31/2018
PdMbeordanstetermmt
A federal egerxymry, rut conduct or sponsor, antl aperson k notreadrad to remora to, na shall .person besublect to a Wahyfor failure to cdnply with a Mlerion ofm(Dtmati l wtseet I D the ienurtementsd
[IX PapPtworkl4ducdon A[t un e35 [IIDt eGtP-'TWri Of QIfClTatipl dhOri Sir ONtPnvald ofm Cix voINUTbn.The 0AM Crnr,.I Nurnix,fd thlS lnfIXmation nolfan. r, 21 M-0mr1 PubI. Ievonmg fix thircdlettldl
d mfornmatn rsestimated to beappmxtnete4y25minutespnlesppn5e,indudmgth tore for rwirv4ngmmuctians, gedlnnp the data neeret,andianpktmgand IeNewmg mecdleclion vfinformason. Aa
responsn totho collect'im nfinfa111YMM are mandatory.SN,d cwnmmtsregmtlmgthtsbulden estimate a airy other nRct dthis cdlec[ionofm(amation,irclrldirg suggestions kn redudrg this lindento:
Information Cogent. Oearence CMacec federal Moto Canter Safety admehoanon, W4VK ra.q New Jemey Pvmue, Si Weshingtpn,OL.20590.
U.S. Department of Transportation
Federal Motor Cartier
Safety Administration
Medical Examination Report Form
(fax Commercial Driver Medical Certification)
PRIVACY ACT STATEAW .This statement is providedpursuantto the Privacy Act of 7974SUSC4 S,5ZI
AUTHORRY:TitIe49, United States Code(USC),49 USC31133(aNRl and 11142LcRIM
PURPOSE: To record results of a driver's physical examination, to determine qualification to operate a commercial motur vehicle (CMV), and
to promote driver health in interstate commerce according to the requirements in 49 CFR 391.41_499. Providing this information is mandatory.
if this information is not provided, I he medical examiner will not be able to determine qualification to operate a CMV in interstatecommerce(or St;Cker)
according to the requirements in /•9 CFR 391.E A9.To record results of a driver's physical examination and to determine qualificaliun 10 operate
a CMV in intrastate commerce when the driver is required by a State to he examined by a medical examiner listed on the National Registry of Certified Medical Examiners in accordance
with the provisions of 49 CFR 391.41-49 and any variancestrom the physial qualification standards adopted by such State.
Medical examiners are required to complete the Medical Examination Report Form for every dr1w physical examination performed in accodance with 49CFR 9_1.<i: Each original
(paper or electronic) completed Medical Examination Report Form must be retained on file at the office of the medical examinerfor at least 3 years from the time of examination. The
medical examiner must make all records and information in these files available to an authorized representative of FMCSA wan authorized Federa, State, or local enforcement agency
representative, within 48 hours after The request is made LCIFE 32LI)1.
ROUTINE USES:The information is used for the purpose set forth above and may be forwarded to Federal, State, or local law enforcement agencies for their use. Me.diul Examination
Report Foots collected by FMC5A will be stored in FMCSA's automated National Registry of Cerr i ied Medical Examiners System and will be used to monitor the performance of matin
cal examiners listed on the National Registry.
In addition tothose disclosures permitted under 5 USC 552a(b) ofthe Privacy Act of 1974, additional disclosures may be made in accordancewith the U.S. Department of Transporta-
tion (DOT) Prefatory Statement of Geneal Routine Uses published in the Federal Register on December 29, 2010 (75 FR.8_2132, under "Prefatory Statement of General Routine
User' (available at mtQ;{(wwwdot.gw/oriv n a5yaRnoticm
ACKNOWLEDGMENT. f understand the provisions of the Privacy Act of 7974 as related tome through the above-mentioned statement.
Drivers Signature:_?(Rrr..e.d.C/ Date: r7 /75' /76
SECTION 1. Driver Information (to be filled out by the driver)
Last Name: Nugod
First Name: Mohamed
Middlelnitial: O Date of Birth: 08/23/1940 Age: 76
StleetAddress: 94i City: Coralville State/Province. IA Zip Code: 52241
Driver's License Number, Issuing State/Province: _ Phone: 319-471-5077 Gender: @ M OF
E-mail(eptionai%: fy�6w2/S®,` n>3+� ��f^ OCLPApplicant' OCLPHoldera OCDLApplicant' OCDLHolderD
Driver IDVeraled By":
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? ®Yes ONO O Nc t Sure
KLPfta PpoemltMPldm Stt in4nxeans farddi�ioom. *'Dnaer IBVed6edty: Aeald wharryR of phuo IDwazuxdtovenlyth idmtay o1Me dnveceq. (Dl, dw<r s Iilense. Vassnnl.
Have you ever had surgery? If "yes." please list and explain below.
Yes No O Not Sure
ste4s X13
AreyGu currently taking medications (prescription. awr-the-counterherbalfeinedies, diet supplements)?
If "yes," please describe below.
®Yes ONo ONotSure
2%lLf�armii7,yoo/Aim/L%Gf'a/7✓./>/-<ev�'�$�'a1//�SoS nub:c%l�Jani.�mrnf/.gsr/iayczt/azti:ayo.r+'y I
,%7�a LnP�m�ri2:•vmPj LrrS/:7 ��Yv/ `Zo.r.�/ ,��J, fin 8/w,�y faw�.fiF�{'rT'i�J /co.7a�r r/,' -Fc con .r3-6 coon',
(Atrach addRional sheets i(neremary)
Page 1
Fmm MCSA-5875 (IT.W.d:10/022015)
OMBNo.21260006 t tlilaj Dn Dntr:8/318018
ILAtName: Nugod First Name: Mohamed Middle Initial: O DOB: 08/23/1940 Exam Date: 11/15/2016
DRIVER
Not
Not;
Do you have or have your ever had:
Yes
No
Sure
Yes
No
Sure
1. Head/brain injuries or illnesses (e.g., corxussion)
0
W
0
16. Dizziness, headaches, numbness, tingling, or memory
0
0
0
2. Seizures, epilepsy
0
®
0
loss
3. Eye problems (exreptglosses orconrocts)
0
0
0
17. Unexplained weight loss
0
0
0
4. Ear and/or hearing problems
o
0
o
18. Stroke, mini -stroke (TIA), paralysis, or weakness
0
0
0
S. Heart disease, heart attack, bypass, or other heart
*
0
0
19. Missing or limited use of arm, hand, finger, leg, foot, toe
0
0
0
problems
20. Neck or back problems
0
0
0
6. Pacemaker,stents, implantable devices, or other heart
W
0
0
21. Bone, muscle, joint, or nerve problems
0
0
0
procedures
22. Blood clots or bleeding problems
0
0
0
7. High blood pressure
0
0
0
23.Cancer
0
0
0
8. High cholesterol
0
0
0
24, Chronic (long-term) infection or other chronic diseases
0
0
0
9. Chronic (long-term) cough, shortness of breath, or other
0
0
0
25. Sleep disorders, pauses in breathing while asleep,
0
0
Q
breathing problems
daytime sleepiness, loud snoring
10. Lung disease (e.g.. asthma)
0
0
0
26. Have you ever had a sleep test ie.g., sleep apnea;?
0
0
0
11. Kidney problems, kidney stones, or pain/problems with
0
0
()
27, Have you ever spent a night in the hospital?
0
0
0
urination
12. Stomach, liver, or digestive problems
0
a
0
28• Have you ever had a broken bone?
0
0
0
13. Diabetes or blood sugar problems
0
0
0
29. Have you ever used or do you now usetobacco?
0
0
0
Insulin used
0
®
0
30. Do you currently drink alcohol?
0
0
0
14. Anxiety, depression, nervousness, other mental health
Q
®
31. Have you used an illegal substance within the past two
0
0
0 j
problems
years?
15. Fainting or passing out
Q
d
O
32• Have you ever failed a drug tester been dependent on
0
0
0
an illegal substance?
i
Other health condition(s) not described above:
QYes ONO 0 Not Sure
Did you answer "yes" to any of questions 1-32? If so, please comment further on those health conditions below. it Yes 0 No 0 Not Sure
ewe /icr-.r /- dGse r -s -c r Yaf q -�ctx� r%1 .'fa._WV, 4er,,e rfj a =2 C4;wx,fr S
(Atto<h aJditionai =iih'r if netessory)
I certify that the above information is accurate and complete I understand that inaccurate, false or missing information may inv�late the examination
and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR,31A5, and that submission
of fraudulent or in tIo ally false information may subject me to civil or criminal penalties under 49CFR 390.37and 49CFR 388pendicesAandB.
Driver's Signature:' -
co
SECTION 2. Examination Report (to be filled out by the medicol examiner)
'S7
IReview onddiscuss pertinent driver muwersondonyavoilabiemedicoirecords.Commentonthe drivers respoms to the"heolthhisrorv'gija x+nsrharmaya(;ectrhe
drivers safe operation of commedol motor vehicle (0141/).
+fV,0V b vvt, I r -I i%V, -1 L , IN a L"s s), -e X3114n1 to hrl- ,\V -
(Attach additional shot: it necessary)
Page 2
Form MM,S875 IBedsed:10/02/2015)
OMBNo.2126-0006 F.•puallon Date: 8/31/2018
6stName: Nugod First Marne: Mohamed Middle Initial: O DOB: 08/23/1940 Exam Date: 11/15/2016
Pulse rate: SA Pulse rhythm regular:)oYes O No Height: feet I.(JJnches Weight,
Blood Pressure Systolic USC) Diastolic ,o
Urinalysis Sp. Gr. Protein Blood Sugar
Sitting
Urinalysis is required.
Numerical readings • �� Nig 1 ��Q ' �L-v1 j
Second reading
(optional)
mustberecorded.
Other testing ifindicated
Protein, blood, or sugar in the urine. may be an indication for further testing to
rule out any underlying medical problem.
m)au Nee: is R�� 5.0
Vision
Hearing
Standard is atleastl06Vocuity(Snellen) in each eye with or without correction. At
Standard., Must first perceive whispered voice of not less than 5 feet OR average
least 70'field of vision in horizon tol meridian mea5utedin each eye. The use of car-
hearing ioss than of equal to 40 d$ in better Pat (with or without hearing aia),!
relive lenses should be noted on the Medical Examiner. Certificate
'..
Acuity Uncorrected Corrected Horizontal Field of Vision
rD
Check ifhearing aid used fortesY..0Rig htEar 0Left Eartsp��.�','1either
Rig
WhisperTest Results Right Ear Left EarRight
Eye: 20% 20/yRight EyedegreesRecord
Eye: 20% 20/� Left Eye: tclegreei
romLeft
whispered voice can first be heard
Both Eyes: 20/_ 20/A5 Yes No
OR
Applicant can recognize and distinguish among traffic control (0 O
AudiometricTest Results
signals and devices showing red, green, and amber colors
Right Ear Left Ear
sr-/
Monocular vision O y
co
500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz
Referred to ophthalmologist or optometrist? O
Received documentation from ophthalmologist or optometrist? 00
Average (right): Average (left):
PHYSICAL EXAMINATION
The presence of certain condition may not necessarily disqualify a driver, particularly ifthecondition is controlled adequately, is not Iikelyto worsen, or i
is readily amenable to treatment Even if a condition does not disqualify a driver,
the Medical Examiner may consider deferring the driver temporarily.
Also, the driver should be advised to take the necessary stepsto correct the condition as soon as possible, particularly if neglecting the condition could
result in a more serious illness that might affect driving.
C heck the body systems for abnormalities.
Body System Normal Abnormal
Body System Normal Abnormal'.
1. General O
B. Abdomen O
2. Skin O
9. Genito-urinary system including hernias O
3. Eyes ® O
10. Back/Spires { O
4. Ears 0) O
11. Extremities/joints Q O
5. Mouth/throat 0 O
12. Neurological system Including reflexes a O
6. Cardiovascular ® O
13, Gait 421) O
7. Lungs/chest W O
14. Vascular system Q. O
Discuss anyabnormol onswers in detail in the space below and indicate whetherit
would nBea the driver's ability to operate a CMV.
£iter applicable item numberbelore each comment.
Is.
4'J
(Attachaddittomtlat sheen i,''necessarv)
r -
Page 3
Fwm MCSR-5875 (Revised:10,'022015) 01RAanu.2126-0006 Expiration Date: 8/372018
Last Name: Nugod First Name: Mohamed Middle Initial: O DOB: 08/23/1940 Exam Date: 11/15/2016
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:
Jse this section for examinationsperformed in accordance with the federal Motor Carrier Safety Regulations (496FR 39},4 t-397.49)'
0 Does not meet standards (specify reason);
0 Meets standards in 49 CFR391 C-; qualifies for 2 -year certificate
® Meets standards, but periodic monitoring required (specifyreosol):
Driver qualified for. 03months 06months aIyear 0 other(Wecify):
Wearing corrective lenses ❑ Wearing hearing aid ❑Accompanledbyawaiver/exemption (specify type):
Accompanied by a Skill Performance Evaluation (SPE) Certificate ❑ Qualified by operation of 49 CFR 399.64 (Federal)
❑ Driving within an exempt intracity zone (see 49 ff_R_9!, 02) (FMerab
0 Determination pending (specify reason):
❑ Return to medical exam office for follow-up on (must tx 45 days orless):
❑ Medical Examination Report amended (spe.'Wreason):
(if amended) Medical Examiner's Signature: Date:
0 Incomplete examination (specifyreosony.
If the driver meets the standards outlined in 49 CFR 391 Al then complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h) as appropriate.
I have performed this evaluation for certification. I have personally revi a II available records and recorded information pertaining to this evaluation,
and attest that to the best of myknowlei--,�betrue ar�t.�
Examinees Name (please Itirarrwp . Trade Abbott, ARNP �.
3 tbn3 Dr, Minh
1A 523 17
Examiners Address: 519-356-3335 rCity: State:_ Zip Code:
dical Examiners Telephone Number: hh Date Certificate Signed: tCJ
dical Examiners State License, Certificate, or Registration Number: Y-4 �� Issuing Stater
MD ❑ DO ❑ Physician Assistant ❑ Chiropractor 0!�clvanced Practice Nurse
Other Practitioner (specify):
National Registry Number: G ird I Medical Examiners Certificate Expiration Date:
Page 4
Patient Employer
UI Health Works, LLC Nugod, Mohamed Fax
3 Lions Drive 317-80-4023
North Liberty, IA 52317 08/23/1940, 76
319-356-3335 991 22nd Ave
800-327-5605 Toll Free Coralville, IA 52241 `
319-467-7181 Fax 319-471-5077 HEALTH CARE.
DOS 1 1 /1 512 01 6
Report of Physical Examination
The above individual has been examined and is:
[ ] Fit to wear a respirator
1 Fit to work without restrictions - pending drug screen results (if applicable).
[ ] Fit to work with the following restrictions:
[ J No lifting over pounds.
[ ] No repetitive bending, stooping or lifting.
[ ] Repetitive use of R L Both hand(s) limited to hours per day, hours at a time.
[ ] No / limited climbing, stair, and / or ladder use.
[ ] May not work in unprotected elevations, around moving machinery or drive company
vehicles.
[ ] May not operate motor vehicles commercially.
[ ] Must wear hearing protection in areas greater than 85 dB A, 8 hour TWA.
[ ] Precluded from jobs requiring good visual acuity for:
near far color peripheral depth
[ ] Other:
[ ] Negative Drug Screen [ J Negative EBT
[ ] Positive Drug Screen [ ] Positive EBT Disposition per company policy
[ J Negative TB Test [ ] Positive TB Test Disposition per company policy
[ ) The requirements of the job exceed the estimated abilities of this individual,
Reasonable Accommodation(s) may be indicated. Please contact us to discuss.
[ ) At increased risk for development of:
( ) Cervical Spine problems ( ) Shoulder problems ( ) Elbow problems
( ) Carpal Tunnel Syndrome ( ) Wrist / Hand problems ( ) Low Back problems
( ) Knee problems ( ) Ankle problems o
( ) Other:
[ ] The requirements of the job may exceed the estimated abilities of this �dividual,
Reasonable Accommodation(s) may be indicated. Please contact us to disAebss.
0
[ ] May not be qualified for position; poses a Direct Threat to the health -and safety of
him/herself and/or others. ._._
Condition:
[ ] Other:
( J Final results of the physical exam and/or conditions needing treatment have been
discussed with this individual.
[]Brenda S. Buikema,MD []Patrick G. Hartley,MD []Claudia L. Corwin,MD—Vracie L. Abbott,ARNP
Cvroke"