Form MCSA-5875 "Medical Examination Report Form (For Commercial Driver Medical Certification)"

What Is Form MCSA-5875?

Form MCSA-5875, Medical Examination Report Form (For Commercial Driver Medical Certification), is a document released for those individuals who work as commercial motor vehicle drivers and need to go through a medical examination. The purpose of the application is to gather information about a filer's medical history.

The document is used by commercial motor vehicle drivers all over the U.S. since they are required to pass a physical in order to start driving. The application is a part of the physical and contains a large amount of data about a driver's health.

MCSA-5875 was issued by the U.S. Department of Transportation, Federal Motor Carrier Safety Administration, and was last revised on . An MCSA-5875 printable form is available for download below.

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MCSA-5875 Instructions

The application is presented on five pages, which are accompanied by instructions on how to complete it. An MCSA-5875 Form consists of several parts which include the following:

  1. Driver's Information. This section is supposed to be filled out by a driver. The gaps here are organized in groups and are divided into several parts, such as:
    • Driver's personal information. In the first section, a filer must enter their full name, date of birth, age, address, driver's license number, email, etc.;
    • Driver's health history. Individuals use this part to report any surgeries they have had, any type of medication they are taking, injuries, diseases, and any other health problems that are listed there. For example, nerve problems, anxiety, high blood pressure, etc.;
    • Driver's signature. Filers must sign the form under the statement where they verify that the information they designated there is full and correct.
  2. Examination Report. The second part of the application must be filled in by a medical examiner. After reviewing the driver's information and discussing it with them, they must designate certain data about the driver's health, including:
    • Driver's health history review. In this part of the form, an examiner must comment on driver's health history answers, that may affect their ability to operate a commercial motor vehicle;
    • Testing information. After examining a driver, a physician must enter the data they received in the document. It must include the patient's blood pressure, pulse rate, height, weight, etc. A doctor must also test the driver's vision, hearing, urinalysis, and designate the results in the application as well;
    • Information about the driver's physical examination. Here an examiner must state any abnormalities a driver's body system has. After that, they should discuss it in the designated place in the document and indicate if it can affect a driver's safe operation of a commercial motor vehicle;
    • Medical examiner determination. Doctors use this part, to sum up the information throughout the document and enter their personal information, such as their full name, address, telephone number, etc. A doctor must also sign the document and state information about their license or certificate.

The last section of the application consists of two parts: State medical examiner determination, and Federal medical examiner determination, an examiner must fill in only one of them. If they performed their examinations following the Federal Motor Carrier Safety Regulations, they should complete the federal medical examiner determination.

If a doctor performed their examinations in accordance with the Federal Motor Carrier Safety Regulations with any applicable State variances, they should complete the state medical examiner determination.

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Download Form MCSA-5875 "Medical Examination Report Form (For Commercial Driver Medical Certification)"

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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.
Medical Examination Report Form
U.S. Department of Transportation
Federal Motor Carrier
(for Commercial Driver Medical Certification)
Safety Administration
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
Yes
No
CLP/CDL Applicant/Holder*:
E-mail (optional):
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
Yes
No
Not Sure
Have you ever had surgery? If "yes, " please list and explain below.
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
Not Sure
Yes
No
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
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.
Medical Examination Report Form
U.S. Department of Transportation
Federal Motor Carrier
(for Commercial Driver Medical Certification)
Safety Administration
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
Yes
No
CLP/CDL Applicant/Holder*:
E-mail (optional):
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
Yes
No
Not Sure
Have you ever had surgery? If "yes, " please list and explain below.
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
Not Sure
Yes
No
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:
DOB:
Exam Date:
First Name:
DRIVER HEALTH HISTORY (continued)
Not
Not
Do you have or have you ever had:
Yes No
Yes No
Sure
Sure
1. Head/brain injuries or illnesses (e.g., concussion)
16. Dizziness, headaches, numbness, tingling, or memory
loss
2. Seizures, epilepsy
17. Unexplained weight loss
3. Eye problems (except glasses or contacts)
18. Stroke, mini-stroke (TIA), paralysis, or weakness
4. Ear and/or hearing problems
19. Missing or limited use of arm, hand, finger, leg, foot, toe
5. Heart disease, heart attack, bypass, or other heart
problems
20. Neck or back problems
6. Pacemaker, stents, implantable devices, or other heart
21. Bone, muscle, joint, or nerve problems
procedures
22. Blood clots or bleeding problems
7. High blood pressure
23. Cancer
8. High cholesterol
24. Chronic (long-term) infection or other chronic diseases
9. Chronic (long-term) cough, shortness of breath, or other
25. Sleep disorders, pauses in breathing while asleep,
breathing problems
daytime sleepiness, loud snoring
10. Lung disease (e.g., asthma)
26. Have you ever had a sleep test (e.g., sleep apnea)?
11. Kidney problems, kidney stones, or pain/problems with
27. Have you ever spent a night in the hospital?
urination
28. Have you ever had a broken bone?
12. Stomach, liver, or digestive problems
29. Have you ever used or do you now use tobacco?
13. Diabetes or blood sugar problems
30. Do you currently drink alcohol?
Insulin used
31. Have you used an illegal substance within the past two
14. Anxiety, depression, nervousness, other mental health
years?
problems
32. Have you ever failed a drug test or been dependent on
15. Fainting or passing out
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:
Exam Date:
DOB:
TESTING
Pulse rate:
Pulse rhythm regular:
Height:
feet
inches Weight:
pounds
Yes
No
Blood Pressure
Urinalysis
Systolic
Diastolic
Sp. Gr.
Protein
Blood
Sugar
Sitting
Urinalysis is required.
Numerical readings
Second reading
must be recorded.
(optional)
Protein, blood, or sugar in the urine may be an indication for further testing to
Other testing if indicated
rule out any underlying medical problem.
Vision
Hearing
Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At
Standard: Must first perceive whispered voice at not less than 5 feet OR average
least 70° field of vision in horizontal meridian measured in each eye. The use of cor-
hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).
rective lenses should be noted on the Medical Examiner's Certificate.
Check if hearing aid used for test:
Right Ear
Left Ear
Neither
Acuity
Uncorrected
Corrected
Horizontal Field of Vision
Whisper Test Results
Right Ear Left Ear
Right Eye:
20/
20/
Right Eye:
degrees
Record distance (in feet) from driver at which a forced
Left Eye:
20/
20/
Left Eye:
degrees
whispered voice can first be heard
OR
Both Eyes:
20/
20/
Yes No
Applicant can recognize and distinguish among traffic control
Audiometric Test Results
signals and devices showing red, green, and amber colors
Right Ear
Left Ear
Monocular vision
500 Hz
1000 Hz
2000 Hz
500 Hz
1000 Hz
2000 Hz
Referred to ophthalmologist or optometrist?
Received documentation from ophthalmologist or optometrist?
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
Body System
Normal Abnormal
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
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):
Qualified by operation of
49 CFR 391.64 (Federal)
Accompanied by a Skill Performance Evaluation (SPE) Certificate
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):
Medical Examiner's Certificate Expiration Date:
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):
Medical Examiner's Certificate Expiration Date:
National Registry Number:
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