MSPA Doctor’s Certificate

DOCTOR’S CERTIFICATE                                 U.S. Department of Labor
                                                     Wage and Hour Division
                                                     OMB No. 1235-0016
                                                     Expires: 8/31/2027


                      This is to certify that I have this day examined:


                             (Name of Driver of Migrant Workers)


in accordance with Section 398.3(b) of the Federal Motor Carrier Safety Regulations of the
Federal Highway Administration and that I find him:

_______________________              Qualified under said rules.

_______________________              Qualified only when wearing glasses.

I have kept on file in my office a completed examination.



      (Date)

                                                         (Place)




(Name of examining doctor)                          (Signature of examining doctor)




                            (Address of doctor)




                           (Address of driver)




                           (Signature of driver)                     Form WH-515 (Rev. xx/15)


  FOR INTERNAL USE ONLY: Medical Certificate Expiration Date: ____________________
                                                GENERAL INSTRUCTIONS

Take this form to a licensed doctor of medicine or osteopathy. Ask the doctor to read the following 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 (Form WH-530).

You must carry your copy with you whenever you are driving workers subject to the Migrant and Seasonal Agricultural
Worker Protection Act (MSPA).

                                                      TO THE DOCTOR

Regulations 29 C.F.R. § 500.104(b)(1)(ii)(I) and 49 C.F.R. § 398.3(b) provide for the following minimum qualifications
for persons who drive any motor vehicle carrying migrant workers subject to the regulations:

(A) No loss of foot, leg, hand or arm.

(B) No mental, nervous, organic, or functional disease, likely to interfere with safe driving.

(C) No loss of fingers, impairment of use of foot, leg, fingers, hand or arm, or other structural defect or limitation, likely to
interfere with safe driving.

(D) 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.

(E) Hearing. Hearing shall not be less than 10/20 in the better ear, for conversational tones, without a hearing aid.

(F) Liquor, narcotics and drugs. Shall not be addicted to the use of narcotics or habit-forming drugs, or the excessive use
of alcoholic beverages or liquors.

                                                 INFORMATION AND USE

The MSPA and Federal Regulations require farm labor contractors and farm labor contractor employees to submit a
doctor’s certificate when they seek authorization to drive migrant/seasonal agricultural workers. Failure to submit this
statement may result in driving authorization not to be authorized. The Wage and Hour Division of the U.S. Department
of Labor uses this statement to verify that those who drive migrant/seasonal agricultural workers are physically fit to do
so.

The MSPA and regulations require–subject to certain limited exemptions–any farm labor contractor, agricultural
employer, or agricultural association (or their employees) providing transportation to migrant and seasonal agricultural
workers to have a legible doctor’s certificate (or copy thereof) on file at the principal place of business for every driver
employed or used. In addition, the regulations provide for each driver to have the certificate (or copy thereof) in his or her
possession while driving migrant or seasonal farm workers subject to the Act. Failure to carry the certificate, or a legible
copy thereof, results in the driver not being authorized to transport migrant and seasonal agricultural workers at that time
and may result in the assessment of a civil money penalty.

                                              PUBLIC BURDEN STATEMENT

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control
number. We estimate that it will take an average of 20 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, U.S. Department of Labor, Room S-3502, 200 Constitution AV, NW, Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE; RETURN IT TO THE PATIENT.