Form MCSA-5870 "Insulin-Treated Diabetes Mellitus Assessment Form"

What Is Form MCSA-5870?

This is a legal form that was released by the U.S. Department of Transportation - Federal Motor Carrier Safety Administration and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

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Download Form MCSA-5870 "Insulin-Treated Diabetes Mellitus Assessment Form"

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MCSA-5870
OMB Control Number: 2126-0006
Expiration Date: 11/30/2021
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
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 8 minutes per response,
including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. 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.
INSULIN-TREATED DIABETES MELLITUS ASSESSMENT FORM
Name: _________________________________________________________________
DOB: ______________
Driver’s License Number (if applicable): ____________________________________
State: ______________
This individual is being evaluated either to determine whether he/she meets the physical qualification standards of the
Federal Motor Carrier Safety Administration (FMCSA) to operate a commercial motor vehicle or because the individual
has recently experienced a severe hypoglycemic episode. A treating clinician should complete this form to the best of his/her
ability based on his/her knowledge of the individual’s medical history. Completion of this form does not imply that a treating
clinician is making a medical certification decision to qualify the individual to drive a commercial motor vehicle. Any
determination as to whether the individual is physically qualified to drive a commercial motor vehicle will be made by a
certified medical examiner on FMCSA’s National Registry of Certified Medical Examiners.
FMCSA defines a treating clinician as a healthcare professional who manages, and prescribes insulin for, treatment of
the individual’s diabetes mellitus as authorized by the healthcare professional’s applicable State licensing authority.
Instructions to the Individual:
When you are being evaluated prior to a medical certification examination, the certified medical examiner must receive this
form and begin the examination no later than 45 calendar days after a treating clinician signs this form.
When you are being evaluated after a severe hypoglycemic episode, you must retain this form and give it to the certified
medical examiner at your next medical certification examination.
Insulin-Treated Diabetes Mellitus Diagnosis
1. Date insulin use began:
Blood Glucose Self-Monitoring Records
2. Has the individual maintained at least the preceding 3 months of ongoing blood glucose self-monitoring records while
being treated with insulin that are measured with an electronic glucometer that stores all readings, records the date and
time of readings, and from which data can be electronically downloaded?
_____Yes _____No
3. Has the individual provided at least the preceding 3 months of electronic self-monitoring records while being treated
with insulin from his/her glucometer to the treating clinician for review?
_____Yes _____No
1
**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. **
MCSA-5870
OMB Control Number: 2126-0006
Expiration Date: 11/30/2021
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
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 8 minutes per response,
including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. 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.
INSULIN-TREATED DIABETES MELLITUS ASSESSMENT FORM
Name: _________________________________________________________________
DOB: ______________
Driver’s License Number (if applicable): ____________________________________
State: ______________
This individual is being evaluated either to determine whether he/she meets the physical qualification standards of the
Federal Motor Carrier Safety Administration (FMCSA) to operate a commercial motor vehicle or because the individual
has recently experienced a severe hypoglycemic episode. A treating clinician should complete this form to the best of his/her
ability based on his/her knowledge of the individual’s medical history. Completion of this form does not imply that a treating
clinician is making a medical certification decision to qualify the individual to drive a commercial motor vehicle. Any
determination as to whether the individual is physically qualified to drive a commercial motor vehicle will be made by a
certified medical examiner on FMCSA’s National Registry of Certified Medical Examiners.
FMCSA defines a treating clinician as a healthcare professional who manages, and prescribes insulin for, treatment of
the individual’s diabetes mellitus as authorized by the healthcare professional’s applicable State licensing authority.
Instructions to the Individual:
When you are being evaluated prior to a medical certification examination, the certified medical examiner must receive this
form and begin the examination no later than 45 calendar days after a treating clinician signs this form.
When you are being evaluated after a severe hypoglycemic episode, you must retain this form and give it to the certified
medical examiner at your next medical certification examination.
Insulin-Treated Diabetes Mellitus Diagnosis
1. Date insulin use began:
Blood Glucose Self-Monitoring Records
2. Has the individual maintained at least the preceding 3 months of ongoing blood glucose self-monitoring records while
being treated with insulin that are measured with an electronic glucometer that stores all readings, records the date and
time of readings, and from which data can be electronically downloaded?
_____Yes _____No
3. Has the individual provided at least the preceding 3 months of electronic self-monitoring records while being treated
with insulin from his/her glucometer to the treating clinician for review?
_____Yes _____No
1
**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. **
MCSA-5870
OMB Control Number: 2126-0006
Expiration Date: 11/30/2021
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
If no, provide details:
___________________________________________________________________________________________
Note: The individual is not physically qualified to operate a commercial motor vehicle for up to the maximum 12-month
period until he/she provides a treating clinician with at least the preceding 3 months of electronic blood glucose self-
monitoring records while being treated with insulin. At the certified medical examiner’s discretion, the individual who
does not possess at least the preceding 3 months of electronic blood glucose self-monitoring records while being treated
qualify to operate a commercial motor vehicle for up to but not more than 3 months.
with insulin may
4. How many times per day is the individual testing his/her blood glucose? ____________________________________
5. Is the individual compliant with blood glucose self-monitoring based on his/her specific treatment plan?
_____Yes _____No
Comments (if necessary): ______________________________________________________________________
__________________________________________________________________________________________
Severe Hypoglycemic Episodes
6. Has the individual experienced any severe hypoglycemic episodes within the preceding 3 months? FMCSA defines a
severe hypoglycemic episode as one that requires the assistance of others, or results in loss of consciousness, seizure,
or coma.
_____Yes _____No
If yes, provide date(s) of occurrence, whether the cause has been addressed, and associated details (attach additional
pages as needed):
______________________________________________________________________________________________
______________________________________________________________________________________________
Hemoglobin A1C (HbA1C) Measurements
7. Has the individual had HbA1C measured intermittently over the last 12 months, with the most recent measure within
the preceding 3 months?
_____Yes _____No
If yes, attach the most recent result.
Diabetes Complications
8. Does the individual have signs of diabetic complications or target organ damage? This information will be used by
the certified medical examiner in determining whether the listed conditions would impair the individual’s ability to
safely operate a commercial motor vehicle.
a. Renal disease/renal insufficiency (e.g., diabetic nephropathy, proteinuria, nephrotic syndrome)?
_____Yes _____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:
2
**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. **
MCSA-5870
OMB Control Number: 2126-0006
Expiration Date: 11/30/2021
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
___________________________________________________________________________________________
b. Diabetic cardiovascular disease (e.g., coronary artery disease, hypertension, transient ischemic attack, stroke,
peripheral vascular disease)?
_____Yes _____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable: ___________
_____________________________________________________________________________________
_____________________________________________________________________________________
c. Neurological disease/autonomic neuropathy (e.g., cardiovascular, gastrointestinal, genitourinary)?
____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable: ___________
_____________________________________________________________________________________
_____________________________________________________________________________________
d. Peripheral neuropathy (e.g., sensory loss, decreased sensation, loss of vibratory sense, loss of position sense)?
____Yes ____No
If yes, provide the date of diagnosis, location, type of involvement, current treatment, and whether the condition is
stable:______________________________________________________________________________________
__________________________________________________________________________________________
e. Lower limb (e.g., foot ulcers, amputated toes/foot, infection, gangrene)?
____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:____________
_____________________________________________________________________________________
_____________________________________________________________________________________
f. Other? (specify condition)______________________________________________________________________
____Yes ____No
If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:
_____________________________________________________________________________________
Progressive Eye Diseases
9. Date of last comprehensive eye examination:_____________________________
10. Has the individual been diagnosed with either severe non-proliferative diabetic retinopathy or proliferative diabetic
retinopathy?
___Yes ____No
If yes, provide date of diagnosis: ___________________________________________
3
**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. **
MCSA-5870
OMB Control Number: 2126-0006
Expiration Date: 11/30/2021
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Individual’s Name: __________________________
11. Has the individual been diagnosed with any other progressive eye disease(s) (e.g., macular edema, cataracts,
glaucoma)?
____Yes ____No
If yes, specify the disease(s), provide the dates of diagnoses, current treatment, and whether the condition is stable:
_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. Additional Comments (attach additional pages as needed)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
I attest that I am a treating clinician (as defined above), that this individual maintains a stable insulin regimen and proper
control of his/her insulin-treated diabetes mellitus, and that the information provided is true and correct to the best of my
knowledge.
Date
_______________________________________
Printed Name and Medical Credential
Signature
_______________________________________
Professional License Number and State
_______________________________________
Phone Number
Email
_______________________________________
Street Address
City, State, Zip Code
4
**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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