Form Mcsa 5875 PDF Details

The Form MCSA-5875, also known as the Medical Examination Report Form for Commercial Driver Medical Certification, plays a critical role in ensuring the safety and health standards of commercial vehicle operators in the United States. This comprehensive document, mandated by the Federal Motor Carrier Safety Administration (FMCSA), must be completed by certified medical examiners, highlighting its significance in the commercial driving sector. It encompasses detailed sections that cover personal and health history information provided by the driver and a thorough medical examination conducted by the examiner. Drivers are required to disclose previous medical conditions, surgeries, medication usage, and any history of substance abuse, making the form a key element in assessing a driver's ability to safely operate a commercial motor vehicle (CMV). The form's strict compliance guidelines, underscored by the Public Burden Statement, indicate that not responding or failing to comply can lead to penalties, emphasizing the seriousness of the document. The health history section seeks detailed information on a wide range of health conditions, from vision and hearing issues to mental health and chronic diseases, ensuring that each driver's physical and mental fitness is accurately evaluated. By necessitating drivers to sign off on the accuracy and completeness of the information provided, and through a rigorous examination process, Form MCSA-5875 serves as a vital tool in maintaining road safety standards by certifying only those who meet strict health criteria.

QuestionAnswer
Form NameForm Mcsa 5875
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesform mcsa 5875 revised 2021, dot physical form 2021, medical examination forms, medical exam form

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Form MCSA-5875

OMB No. 2126-0006 Expiration Date: 11/30/2021

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per 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.

U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Medical Examination Report Form

(for Commercial Driver Medical Certification)

SECTION 1. Driver Information (to be filled out by the driver)

MEDICAL RECORD #

(or sticker)

PERSONAL INFORMATION

 

Last Name:

 

First Name:

 

 

 

 

Middle Initial:

 

 

 

Date of Birth:

 

 

 

 

 

Age:

 

 

 

 

 

Street Address:

 

 

 

City:

 

 

 

 

 

State/Province:

 

 

Zip Code:

 

 

 

 

 

 

 

 

Driver's License Number:

 

 

 

 

 

Issuing State/Province:

 

 

 

Phone:

 

 

 

 

Gender:

 

M

F

 

E-mail (optional):

 

 

 

 

 

 

CLP/CDL Applicant/Holder*:

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver ID Verified By**:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

Yes

No

Not Sure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*CLP/CDL Applicant/Holder: See instructions for definitions.

 

 

 

 

 

**Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver's license, passport.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER HEALTH HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery? If "yes," please list and explain below.

 

 

 

 

 

 

 

 

 

 

 

Yes No

Not Sure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?

Yes No Not Sure

If "yes," please describe below.

 

 

 

 

 

(Attach additional sheets if necessary)

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

Page 1

Form MCSA-5875

 

 

 

OMB No. 2126-0006 Expiration Date: 11/30/2021

 

 

 

 

 

 

 

 

 

 

Last Name:

First Name:

 

DOB:

 

Exam Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVER HEALTH HISTORY (continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not

 

 

Not

Do you have or have you ever had:

 

Yes No Sure

 

 

Yes No Sure

1.Head/brain injuries or illnesses (e.g., concussion)

2.Seizures, epilepsy

3.Eye problems (except glasses or contacts)

4.Ear and/or hearing problems

5.Heart disease, heart attack, bypass, or other heart problems

6.Pacemaker, stents, implantable devices, or other heart procedures

7.High blood pressure

8.High cholesterol

9.Chronic (long-term) cough, shortness of breath, or other breathing problems

10.Lung disease (e.g., asthma)

11.Kidney problems, kidney stones, or pain/problems with urination

12.Stomach, liver, or digestive problems

13.Diabetes or blood sugar problems

Insulin used

14.Anxiety, depression, nervousness, other mental health problems

15.Fainting or passing out

16.Dizziness, headaches, numbness, tingling, or memory loss

17.Unexplained weight loss

18.Stroke, mini-stroke (TIA), paralysis, or weakness

19.Missing or limited use of arm, hand, finger, leg, foot, toe

20.Neck or back problems

21.Bone, muscle, joint, or nerve problems

22.Blood clots or bleeding problems

23.Cancer

24.Chronic (long-term) infection or other chronic diseases

25.Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

26.Have you ever had a sleep test (e.g., sleep apnea)?

27.Have you ever spent a night in the hospital?

28.Have you ever had a broken bone?

29.Have you ever used or do you now use tobacco?

30.Do you currently drink alcohol?

31.Have you used an illegal substance within the past two years?

32.Have you ever failed a drug test or been dependent on an illegal substance?

Other health condition(s) not described above:

Yes

No

Not Sure

Did you answer "yes" to any of questions 1-32? If so, please comment further on those health conditions below.

Yes No

Not Sure

 

 

 

 

 

 

(Attach additional sheets if necessary)

CMV DRIVER'S SIGNATURE

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

Driver's Signature:

 

Date:

SECTION 2. Examination Report (to be filled out by the medical examiner)

DRIVER HEALTH HISTORY REVIEW

Review and discuss pertinent driver answers and any available medical records. Comment on the driver's responses to the "health history" questions that may affect the driver's safe operation of a commercial motor vehicle (CMV).

(Attach additional sheets if necessary)

Page 2

Form MCSA-5875

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OMB No. 2126-0006 Expiration Date: 11/30/2021

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

 

 

 

DOB:

 

 

 

 

 

Exam Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TESTING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pulse rate:

 

Pulse rhythm regular:

 

Yes

No

 

 

Height: feet

inches

Weight:

 

 

pounds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood Pressure

Systolic

 

Diastolic

 

 

Urinalysis

 

Sp. Gr.

 

Protein

 

Blood

 

Sugar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sitting

 

 

 

 

 

 

Urinalysis is required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Numerical readings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Second reading

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

must be recorded.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other testing if indicated

 

 

 

 

 

Protein, blood, or sugar in the urine may be an indication for further testing to

 

 

 

 

 

 

 

 

 

rule out any underlying medical problem.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision

Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At least 70° field of vision in horizontal meridian measured in each eye. The use of cor- rective lenses should be noted on the Medical Examiner's Certificate.

Hearing

Standard: Must first perceive whispered voice at not less than 5 feet OR average hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).

Acuity

Uncorrected

Corrected

Horizontal Field of Vision

Right Eye:

20/

 

 

20/

 

Right Eye:

 

degrees

 

 

 

 

 

 

 

 

 

 

Left Eye:

20/

 

 

20/

 

Left Eye:

 

degrees

 

 

 

 

 

 

 

 

 

 

Both Eyes:

20/

 

 

20/

 

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors

Monocular vision

Referred to ophthalmologist or optometrist?

Received documentation from ophthalmologist or optometrist?

Check if hearing aid used for test:

Right Ear

Left Ear

Neither

Whisper Test Results

 

 

 

 

 

 

 

Right Ear Left Ear

Record distance (in feet) from driver at which a forced

 

 

 

 

 

 

whispered voice can first be heard

 

 

 

 

 

 

 

 

 

 

 

 

OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Audiometric Test Results

 

 

 

 

 

 

 

 

 

 

 

 

Right Ear

 

 

 

 

 

 

Left Ear

 

 

 

 

 

 

 

 

 

 

500 Hz

 

1000 Hz

 

2000 Hz

 

500 Hz

 

1000 Hz

 

 

2000 Hz

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Average (right):

 

 

 

 

Average (left):

 

 

 

 

 

 

 

PHYSICAL EXAMINATION

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or 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 steps to correct the condition as soon as possible, particularly if neglecting the condition could result in a more serious illness that might affect driving.

Check the body systems for abnormalities.

Body System

Normal Abnormal Body System

Normal Abnormal

1. General

8. Abdomen

 

2. Skin

9. Genito-urinary system including hernias

 

3. Eyes

10. Back/Spine

 

4. Ears

11. Extremities/joints

 

5. Mouth/throat

12. Neurological system including reflexes

 

6. Cardiovascular

13. Gait

 

7. Lungs/chest

14. Vascular system

 

Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CMV. Enter applicable item number before each comment.

(Attach additional sheets if necessary)

Page 3

Medical Examiner's Certificate Expiration Date:

Form MCSA-5875

 

 

 

OMB No. 2126-0006 Expiration Date: 11/30/2021

 

 

 

 

 

 

 

 

 

Last Name:

First Name:

 

DOB:

 

Exam Date:

 

 

 

 

 

 

 

 

 

 

 

Please complete only one of the following (Federal or State) Medical Examiner Determination sections:

MEDICAL EXAMINER DETERMINATION (Federal)

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):

Does not meet standards (specify reason):

 

 

 

 

 

 

Meets standards in 49 CFR 391.41; qualifies for 2-year certificate

 

 

 

 

Meets standards, but periodic monitoring required (specify reason):

 

 

 

 

Driver qualified for:

3 months

6 months

1 year

other (specify):

 

 

Wearing corrective lenses

Wearing hearing aid

Accompanied by a waiver/exemption (specify type):

 

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Qualified by operation of 49 CFR 391.64 (Federal)

Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal)

 

 

 

 

Determination pending (specify reason):

Return to medical exam office for follow-up on (must be 45 days or less):

Medical Examination Report amended (specify reason):

(if amended) Medical Examiner's Signature:

 

Date:

Incomplete examination (specify reason):

 

 

 

 

 

If the driver meets the standards outlined in 49 CFR 391.41, 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 reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge, I believe it to be true and correct.

Medical Examiner's Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner's Name (please print or type):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner's Address:

 

 

 

 

 

 

City:

 

 

State:

 

Zip Code:

 

Medical Examiner's Telephone Number:

 

 

 

 

 

 

Date Certificate Signed:

 

 

 

 

 

 

 

 

Medical Examiner's State License, Certificate, or Registration Number:

 

 

 

 

 

 

 

 

 

Issuing State:

 

MD

DO

Physician Assistant

Chiropractor

Advanced Practice Nurse

 

 

 

 

 

 

 

Other Practitioner (specify):

National Registry Number:

Page 4

Form MCSA-5875

 

 

 

OMB No. 2126-0006 Expiration Date: 11/30/2021

 

 

 

 

 

 

 

 

 

Last Name:

First Name:

 

DOB:

 

Exam Date:

 

 

 

 

 

 

 

 

 

 

 

MEDICAL EXAMINER DETERMINATION (State)

Use this section for examinations performed in accordance with 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):

Does not meet standards in 49 CFR 391.41 with any applicable State variances (specify reason):

Meets standards in 49 CFR 391.41 with any applicable State variances

Meets standards, but periodic monitoring required (specify reason):

Driver qualified for:

3 months

6 months

1 year

other (specify):

 

 

Wearing corrective lenses

Wearing hearing aid

Accompanied by a waiver/exemption (specify type):

 

 

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Grandfathered from State requirements (State)

 

If the driver meets the standards outlined in 49 CFR 391.41, with applicable State variances, then complete a Medical Examiner's Certificate, as appropriate.

I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that to the best of my knowledge, I believe it to be true and correct.

Medical Examiner's Signature:

Medical Examiner's Name (please print or type):

Medical Examiner's Address:

 

 

 

 

 

City:

 

 

State:

 

Zip Code:

 

Medical Examiner's Telephone Number:

 

 

 

 

Date Certificate Signed:

 

 

 

 

 

 

 

Medical Examiner's State License, Certificate, or Registration Number:

 

 

 

 

 

 

 

Issuing State:

 

MD

DO

Physician Assistant

Chiropractor

Advanced Practice Nurse

 

 

 

 

 

 

 

Other Practitioner (specify):

National Registry Number:

Medical Examiner's Certificate Expiration Date:

Page 5

How to Edit Form Mcsa 5875 Online for Free

We were building our PDF editor having the concept of making it as quick make use of as possible. For this reason the actual procedure of filling out the medical exam form is going to be smooth carry out the following steps:

Step 1: On this website page, choose the orange "Get form now" button.

Step 2: Now you are able to manage medical exam form. You've got lots of options thanks to our multifunctional toolbar - you'll be able to add, erase, or alter the information, highlight its specified elements, as well as carry out many other commands.

These segments are going to make up your PDF document:

cdl medical examination report form gaps to consider

Type in the appropriate information in the space Are you currently taking, Yes, No Not Sure, and This document contains sensitive.

step 2 to filling out cdl medical examination report form

The program will request you to insert certain vital data to automatically fill out the field Form MCSA, Last Name, First Name, DOB, Exam Date, OMB No, Expiration Date, DRIVER HEALTH HISTORY continued, Do you have or have you ever had, Yes No, Not Sure, Yes No, Not Sure, Headbrain injuries or illnesses, and Dizziness headaches numbness.

Entering details in cdl medical examination report form part 3

The Fainting or passing out, Have you ever failed a drug test, an illegal substance, Other health conditions not, Yes, Not Sure, Did you answer yes to any of, Yes, Not Sure, CMV DRIVERS SIGNATURE, I certify that the above, Drivers Signature, and Date box will be your place to put the rights and obligations of all parties.

cdl medical examination report form Fainting or passing out, Have you ever failed a drug test, an illegal substance, Other health conditions not, Yes, Not Sure, Did you answer yes to any of, Yes, Not Sure, CMV DRIVERS SIGNATURE, I certify that the above, Drivers Signature, and Date blanks to fill

Finish by looking at the following sections and filling them in as required: Review and discuss pertinent, and Page.

cdl medical examination report form Review and discuss pertinent, and Page fields to fill

Step 3: Choose the "Done" button. Now it's possible to export the PDF file to your device. Aside from that, it is possible to forward it via electronic mail.

Step 4: It is easier to have duplicates of the document. You can rest assured that we will not publish or check out your data.

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