Official US Government Icon

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

Secure Site Icon

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

The latest information on the Coronavirus Disease 2019 (COVID-19) is available on coronavirus.gov.

United States Department of Transportation United States Department of Transportation

Medical Release Form (Hearing) SAMPLE

About this document

This is a completed sample form which provides authorization to the Federal Motor Carrier Safety Administration to publish hearing exemption information in a public docket.

DOT is committed to ensuring that information is available in appropriate alternative formats to meet the requirements of persons who have a disability. If you require an alternative version of files provided on this page, please contact Christine.hydock@dot.gov.
Last updated: Thursday, April 26, 2018