Form WH-515 MSPA Doctor's Certificate

Doctor’s Certificate

U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division
OMB No. 1215-0036
Expires: XX/XX/XXXX

This is to certify that I have this day examined:

___________________________________________________________

(Name)

In accordance with Section 398.3(b) of the Motor Carrier Safety Regulations of the
Department of Transportation, and that I find the applicant:
_________________________

Qualified under said rules.

_________________________

Qualified only when wearing glasses.

I have kept on file a completed examination.

___________________
(Date)

__________________________________________
(Place)

(Signature of examining doctor)

(Address of doctor)

(Signature of driver)

(Address of driver)
Form WH-515
(Rev. 11/06)

Take this form to your doctor. Ask the doctor to read this section, examine you, and
fill in the certificate (located on the front of this form). After making a copy for your
employer and yourself, submit the original with your Farm Labor Contractor or Farm
Labor Contractor Employee application (WH-530).
You must carry your copy with you whenever you are driving workers subject to the
MSPA. Please make sure that this replaced text appears on the second page, not on
the bottom of the first as it is now.

To the Doctor:
Section 398.3(b) provides:
No person shall drive any vehicle carrying migrant workers without possessing the
following minimum qualifications:
No mental, nervous, organic, or functional disease likely to interfere with safe driving;
No loss of foot, leg, hand, arm;
No loss fingers, impairment of use of foot, leg, hand, fingers, arm or other structural
defects or limitation likely to interfere with safe driving.
Eyesight: visual acuity of at least 20/40 (Snellen) in each eye either without glasses or by
correction with glasses; form field of vision in the horizontal meridian shall not be less
than a total of 140 degrees, ability to distinguish colors, red, green, and yellow; drivers
requiring correction by glasses shall wear properly prescribed glasses at all times when
driving.
Hearing shall not be less than 10/20 in the better ear for conversational tones without a
hearing aid.
Shall not be addicted to the use of narcotics or habit-forming drugs, or to the excessive
use of alcoholic beverages or liquors.
________________________________________________________________________
Public Burden Statement
We estimate that it will take an average of 5 minutes to complete this collection of information, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. If you have any comments regarding this burden estimate or any other aspect of this collection information, including
suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, Department of Labor, Room S-3502,
200 Constitution Ave, N.W., Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.