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Form MCSA-5875
(Revised: 10/02/2015)
OMB No. 2126-0006
Expiration Date: 8/31/2018
Medical Examination Report Form
(for Commercial Driver Medical Certification)
U.S. Department of Transportation
Federal Motor Carrier
Safety Administration
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.
PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a.
AUTHORITY: Title 49, United States Code (USC), 49 USC 31133(a)(8) and 31149(c)(1)(E)
.
PURPOSE: To record results of a driver's physical examination, to determine qualification to operate a commercial motor vehicle (CMV), and
to promote driver health in interstate commerce according to the requirements in 49 CFR 391.41-49
. Providing this information is mandatory.
If this information is not provided, the medical examiner will not be able to determine qualification to operate a CMV in interstate commerce
according to the requirements in 49 CFR 391.41-49. To record results of a driver's physical examination and to determine qualification to operate
a CMV in intrastate commerce when the driver is required by a State to be examined by a medical examiner listed on the National Registry of Certified Medical Examiners in accordance
with the provisions of 49 CFR 391.41-49 and any variances from the physical qualification standards adopted by such State.
Medical examiners are required to complete the Medical Examination Report Form for every driver physical examination performed in accordance with 49 CFR 391.41
. Each original
(paper or electronic) completed Medical Examination Report Form must be retained on file at the office of the medical examiner for at least 3 years from the date of examination. The
medical examiner must make all records and information in these files available to an authorized representative of FMCSA or an authorized Federal, State, or local enforcement agency
representative, within 48 hours after the request is made [49 CFR 391.43(i)].
ROUTINE USES: The information is used for the purpose set forth above and may be forwarded to Federal, State, or local law enforcement agencies for their use. Medical Examination
Report Forms collected by FMCSA will be stored in FMCSA's automated National Registry of Certified Medical Examiners System and will be used to monitor the performance of medi-
cal examiners listed on the National Registry.
In addition to those disclosures permitted under 5 USC 552a(b)
of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transporta-
tion (DOT) Prefatory Statement of General Routine Uses published in the Federal Register on December 29, 2010 (75 FR 82132), under "Prefatory Statement of General Routine
Uses'' (available at http://www.dot.gov/privacy/privacyactnotices).
ACKNOWLEDGMENT: I understand the provisions of the Privacy Act of 1974 as related to me through the above-mentioned statement.
Driver's Signature:
Date:
MEDICAL RECORD #
(or sticker)
SECTION 1. Driver Information (to be filled out by the driver)
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 Applicant* CLP Holder* CDL Applicant* CDL Holder*
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.
Ye s No Not Sure
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
If "yes," please describe below.
Ye s No Not Sure
(Attach additional sheets if necessary)