If you are a taxpayer who owes money to the IRS, you may be wondering what your options are for paying off that debt. One option is to submit Form Mcsa 5875, which is known as an Offer In Compromise. This form can help you negotiate a payment plan with the IRS that is more affordable for you. Keep in mind that there are specific eligibility requirements that must be met in order to qualify for an Offer In Compromise, so be sure to review those before submitting your application. Additionally, the IRS will take into consideration various factors when determining whether or not to accept your offer, so it is important to have a reasonable plan in place.
The following are some specifics about form mcsa 5875. You can find out its length, the typical time necessary to prepare the form, the fields you'll need to fill in, and so on.
Question | Answer |
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Form Name | Form Mcsa 5875 |
Form Length | 9 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min 15 sec |
Other names | mcsa 5875, dot form mcsa 5875, dot forms 2021, dot physical form 2021 |
Form |
OMB No. |
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
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
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Last Name: |
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First Name: |
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Middle Initial: |
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Date of Birth: |
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Age: |
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Street Address: |
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City: |
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Zip Code: |
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Driver's License Number: |
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Issuing State/Province: |
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Phone: |
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Gender: |
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CLP/CDL Applicant/Holder*: |
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No |
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Driver ID Verified By**: |
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Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? |
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Not Sure |
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*CLP/CDL Applicant/Holder: See instructions for definitions. |
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**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. |
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DRIVER HEALTH HISTORY |
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Have you ever had surgery? If "yes," please list and explain below. |
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Yes No |
Not Sure |
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Are you currently taking medications (prescription, |
Yes No |
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If "yes," please describe below. |
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**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 |
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OMB No. |
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Last Name: |
First Name: |
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DOB: |
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Exam Date: |
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DRIVER HEALTH HISTORY (continued) |
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Do you have or have you ever had: |
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Yes No Sure |
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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
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,
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
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: |
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No |
Not Sure |
Did you answer "yes" to any of questions |
Yes No |
Not Sure |
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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: |
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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).
Page 2
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OMB No. |
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Last Name: |
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First Name: |
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DOB: |
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Exam Date: |
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TESTING |
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Pulse rate: |
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Pulse rhythm regular: |
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No |
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Height: feet |
inches |
Weight: |
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pounds |
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Blood Pressure |
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Diastolic |
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Urinalysis |
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Sp. Gr. |
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Protein |
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Blood |
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Sugar |
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Sitting |
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Urinalysis is required. |
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Numerical readings |
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Second reading |
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must be recorded. |
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(optional) |
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Other testing if indicated |
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Protein, blood, or sugar in the urine may be an indication for further testing to |
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rule out any underlying medical problem. |
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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 |
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Right Eye: |
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Right Eye: |
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Left Eye: |
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Left Eye: |
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Both Eyes: |
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20/ |
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Yes No |
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Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors
Monocular vision
Referred to ophthalmologist or optometrist?
Check if hearing aid used for test: |
Right Ear |
Left Ear |
Neither |
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Whisper Test Results |
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Right Ear Left Ear |
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Record distance (in feet) from driver at which a forced |
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whispered voice can first be heard |
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OR |
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Audiometric Test Results |
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Right Ear |
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Left Ear |
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500 Hz |
1000 Hz |
2000 Hz |
500 Hz |
1000 Hz |
2000 Hz |
Received documentation from ophthalmologist or optometrist? |
Average (left): |
Average (right): |
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 |
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2. Skin |
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3. Eyes |
10. Back/Spine |
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4. Ears |
11. Extremities/joints |
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5. Mouth/throat |
12. Neurological system including reflexes |
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6. Cardiovascular |
13. Gait |
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7. Lungs/chest |
14. Vascular system |
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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.
Page 3
Form |
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OMB No. |
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Last Name: |
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DOB: |
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Exam Date: |
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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
Does not meet standards (specify reason): |
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Meets standards in 49 CFR 391.41; qualifies for |
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Meets standards, but periodic monitoring required (specify reason): |
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Driver qualified for: |
3 months |
6 months |
1 year |
other (specify): |
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Wearing corrective lenses |
Wearing hearing aid |
Accompanied by a waiver/exemption (specify type): |
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Accompanied by a Skill Performance Evaluation (SPE) Certificate |
Qualified by operation of 49 CFR 391.64 (Federal) |
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Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal) |
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Determination pending (specify reason):
Return to medical exam office for
Medical Examination Report amended (specify reason):
(if amended) Medical Examiner's Signature: |
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Date: |
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Incomplete examination (specify reason): |
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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: |
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Medical Examiner's Name (please print or type): |
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Medical Examiner's Address: |
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City: |
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State: |
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Zip Code: |
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Medical Examiner's Telephone Number: |
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Date Certificate Signed: |
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Medical Examiner's State License, Certificate, or Registration Number: |
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Issuing State: |
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MD DO Physician Assistant
Other Practitioner (specify):
Chiropractor
Advanced Practice Nurse
National Registry Number:
Medical Examiner's Certificate Expiration Date:
Page 4
Form |
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OMB No. |
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Last Name: |
First Name: |
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DOB: |
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Exam Date: |
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MEDICAL EXAMINER DETERMINATION (State)
Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR
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): |
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Wearing corrective lenses |
Wearing hearing aid |
Accompanied by a waiver/exemption (specify type): |
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Accompanied by a Skill Performance Evaluation (SPE) Certificate |
Grandfathered from State requirements (State) |
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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: |
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Medical Examiner's Name (please print or type): |
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Medical Examiner's Address: |
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City: |
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State: |
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Zip Code: |
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Medical Examiner's Telephone Number: |
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Date Certificate Signed: |
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Medical Examiner's State License, Certificate, or Registration Number: |
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Issuing State: |
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MD DO Physician Assistant
Other Practitioner (specify):
Chiropractor
Advanced Practice Nurse
National Registry Number:
Medical Examiner's Certificate Expiration Date:
Page 5
Instructions
Instructions for Completing the Medical Examination Report Form
I.
Section 1: Driver information
·Personal Information: Please complete this section using your name as written on your driver's license, your current address and phone number, your date of birth, age, gender, driver's license number and issuing state.
O CLP/CDLApplicant/Holder: Check "yes" if you are a commercial learner's permit (CLP) or com- mercial 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 combina- tion 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.
O 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, etc.
O Question: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years? Please check the correct box “yes” or “no” and if you aren't sure check the “not sure” box.
·Driver Health History:
O Have you ever had surgery: Please check “yes” if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc.)
O Are you currently taking medications (prescription,
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O Other Health Conditions not described above: If you have, or have had, any other health condi- tions not listed in the section above, check “Yes” and in the box provided and list those condition(s).
O Any yes answers to questions
·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.
Page 6
Instructions
Medical Examiner:
Section 2: Examination Report
·Driver Health History Review: Review answers provided by the driver in the driver health history section and discuss any “yes” and “not sure” responses. In addition, be sure to compare the medication list to the health history responses ensuring that the medication list matches the medical conditions noted. Explore with the driver any answers that seem unclear. Record any information that the driver omitted. As the Medical Examiner conducting the driver's physical examination you are required to complete the entire medical examination even if you detect a medical condition that you consider disqualifying, such as deafness. Medical Examiners are expected to determine the driver's physical qualification for operating a commercial vehicle safely. Thus, if you find a disqualifying condition for which a driver may receive a Federal Motor Carrier Safety Administration medical exemption, please record that on the driver's Medical Examiner's Certificate, Form
·Testing:
O Pulse rate and rhythm, height, and weight: record these as indicated on the form.
O Blood Pressure: record the blood pressure (systolic and diastolic) of the driver being examined. A second reading is optional and should be recorded if found to be necessary.
O Urinalysis: record the numerical readings for the specific gravity, protein, blood and sugar.
O Vision: The current vision standard is provided on the form. When other than the Snellen chart is used, give test results in
O Hearing: The current hearing standard is provided on the form. Hearing can be tested using either a whisper test or audiometric test. Record the test results in the corresponding section for the test used.
·Physical Examination: Check the body systems for abnormalities and indicate normal or abnormal for each body system listed. Discuss any abnormal answers in detail in the space provided and indicate whether it would affect the driver's ability to safely operate a commercial motor vehicle.
In this next section, you will be completing either the Federal or State determination, not both.
·Medical Examiner Determination (Federal): Use this section for examinations performed in accordance with the FMCSRs (49 CFR
ODoes 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.
OMeets standards in 49 CFR 391.41; qualifies for
Page 7
Instructions
OMeets standards, but periodic monitoring is required: Select this option when a driver is deter- mined 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 and if select- ing 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.).
ODetermination 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
·MER amended: A Medical Examination Report Form (MER),
OIncomplete examination: Select this when the physical examination is not completed for any reason (e.g., driver decides they do not want to continue with the examination and leaves) other than situations outlined under determination pending.
OMedical Examiner information, signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date.
OMedical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate (MEC) expires.
·Medical Examiner Determination (State): Use this section for examinations performed in accordance with the FMCSRs (49 CFR
ODoes not meet standards in 49 CFR 391.41 with any applicable State variances: 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 with any applicable State variances.
OMeets standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be qualified and will be issued a
OMeets standards, but periodic monitoring is required: Select this option when a driver is deter- mined 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 and if select- ing 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, etc.).
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Instructions
OMedical Examiner information, signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date.
OMedical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate (MEC) expires.
II.If updating an existing exam, you must resubmit the new exam results, via the Medical Examination Results Form,
III.To obtain additional information regarding this form go to the Medical Program's page on the Federal Motor Carrier Safety Administration's website at http://www.fmcsa.dot.gov/regulations/medical.
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