Mcsa 5876 Form PDF Details

The Form MCSA-5876, known as the Medical Examiner's Certificate, plays a critical role in ensuring the safety and fitness of commercial drivers across the United States. Issued by the Federal Motor Carrier Safety Administration (FMCSA), this form is a cornerstone of the regulatory framework designed to maintain high standards of health among those entrusted with the operation of commercial vehicles. It requires a thorough physical examination by a certified medical examiner who assesses a driver's health against the stipulations laid out in the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49), or any applicable state variances. The outcome of this assessment determines a driver's medical fitness for duty, including stipulations for corrective lenses, hearing aids, or the presence of any waivers or exemptions, such as a Skill Performance Evaluation (SPE) Certificate. The form, bearing an OMB Control Number, reflects compliance with the Paperwork Reduction Act, ensuring the necessity and validity of the information it gathers, all aimed at reducing public burden while collecting essential data required for the safety of all road users. Additionally, it embodies a pledge by the medical examiner to the accuracy and completeness of the medical examination, encapsulating critical information for the official use only, underlining the importance of meticulous handling to guard against inadvertent disclosure. The meticulous design of the form reflects a balance between the need for comprehensive health data and the protection of individual privacy, highlighting its significance in promoting road safety and protecting public welfare.

QuestionAnswer
Form NameMcsa 5876 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmcsa 5876 printable form 2021, medical examiner's certificate dmv, mcsa 5876 form, form mcsa 5876

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Form MCSA-5876

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 1 minute 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

MEDICAL EXAMINER'S CERTIFICATE

Federal Motor Carrier

(FOR COMMERCIAL DRIVER MEDICAL CERTIFICATION)

Safety Administration

I certify that I have examined Last Name:

 

First Name:

 

in accordance with (please check only one):

the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply) OR

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), and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply):

Wearing corrective lenses

Wearing hearing aid

Accompanied by a

 

waiver/exemption

Accompanied by a Skill Performance Evaluation (SPE) Certificate

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

Qualified by operation of 49 CFR 391.64 (Federal)

Grandfathered from State requirements (State)

Medical Examiner's Certificate Expiration Date

The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,

MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.

 

Medical Examiner's Signature

 

Medical Examiner's Telephone Number

 

 

Date Certificate Signed

 

 

 

 

 

 

 

 

 

 

 

 

Medical Examiner's Name (please print or type)

 

MD

Physician Assistant

Advanced Practice Nurse

 

 

 

 

 

 

 

 

DO

Chiropractor

Other Practitioner (specify)

 

 

 

 

 

 

 

 

 

 

 

 

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

 

Issuing State

 

 

 

National Registry Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver's Signature

 

 

 

Driver's License Number

 

 

 

Issuing State/Province

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver's Address

 

 

 

 

 

 

 

 

 

 

CLP/CDL Applicant/Holder

 

Street Address:

City:

 

 

State/Province:

 

Zip Code:

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**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.**

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