Form MCSA-5875: DOT Medical Examination Report Form

Personal Information: Complete this section using your name as written on your driver's license, your current address and phone number, your date of birth, age, driver's license number and issuing state.

CLP/CDL Applicant/Holder: Check yes if you are a commercial learner's permit (CLP) or commercial driver's license (CDL) holder, or are applying for a CLP or CDL.

CDL means a license issued by a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicle (CMV).

A CMV that requires a CDL is one that: (1) has a gross combination weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000 pounds. Or (2) has a GVWR or GVW of 26,001 pounds or more. Or (3) is designed to transport 16 or more passengers, including the driver. Or (4) is used to transport either hazardous materials requiring hazardous materials placards on the vehicle or any quantity of a select agent or toxin.

Check the correct box, yes or no, and if you aren't sure check the not sure box.

Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the driver's identity, such as commercial driver's license, driver's license, or passport.

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years? Check yes, no or not sure.

Have you ever had surgery: Check yes if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc.).

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements): Check yes if you are taking any diet supplements, herbal remedies, or prescription or over the counter medications. In the box for the medications question, indicate the name of the medication and the dosage.

Questions 1-32: Check the yes box to indicate that you have, or have ever had, the health condition listed or the No box if you have not. Check the not sure box if you are unsure.

If you have, or have had, any other health conditions not described in the Driver Health History section, check Yes and in the Other Health Conditions box provided list those condition(s).

If you have answered yes to any of questions 1-32 in the Driver Health History section, explain your answers further in the box for the Any yes answers question.

For example, if you answered yes to question #5 regarding heart disease, heart attack, bypass, or other heart problem, indicate which type of heart condition. If you checked yes to question #23 regarding cancer, indicate the type of cancer. Add any information that will be helpful to the Medical Examiner.

CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section 1 is accurate and complete.

Inaccurate, false or missing information may invalidate the examination and the Medical Examiner's Certificate. Submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35. Submission of fraudulent or intentionally false information may subject you to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

Common mistake: Complete either the Federal or the State determination, not both.

Medical Examiner Determination (Federal): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49). Complete the medical examiner determination section completely.

In the Federal determination, when determining a driver's physical qualification, English language proficiency (49 CFR part 391.11: General qualifications of drivers) is not factored into that determination. Does not meet standards: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41. Meets standards in 49 CFR 391.41; qualifies for 2-year certification: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.

In the Federal determination on Form MCSA-5875, select Meets standards, but periodic monitoring is required when a driver is determined to be qualified but needs periodic monitoring, and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified for, and if selecting other specify the time frame. Determination that driver meets standards: Select all categories that apply to the driver's certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, driving within an exempt intracity zone, etc.).

Medical Examiner Determination (State): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations). Select Does not meet standards in 49 CFR 391.41 with any applicable State variances when a driver is determined to be not qualified and provide an explanation of why the driver does not meet those standards. Select Meets standards in 49 CFR 391.41 with any applicable State variances when a driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.

If updating an existing exam, the medical examiner must resubmit the new exam results, via the Medical Examination Results Form, MCSA-5850, to the National Registry, and the most recent dated exam will take precedence.

In the Federal determination, Determination pending: Select this option when more information is needed to make a qualification decision and specify a date, on or before the 45 day expiration date, for the driver to return to the medical exam office for follow-up. This will allow for a delay of the qualification decision for as many as 45 days.