Form MCSA-5875, Medical Examination Report Form

Form MCSA-5875 (Revised: 04/01/2013)

OMB No. 2126-0006

Expiration Date:

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 20 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
Safety Administration

(for Commercial Driver Medical Certification)

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) 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.
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 medical 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 Transportation (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 abovementioned statement.

MEDICAL RECORD #
(or sticker)

CMV Driver Signature:

Date:

SECTION 1. Driver Information (to be filled out by the driver)
PERSONAL INFORMATION
Last Name:

First Name:

Address:

City:

Driver License Number:

State of Issue:

Middle Initial:

Date of Birth:
State:

Age:

Zip Code:

Gender:

M

F

Phone:

Intrastate Only?
CDL*?

Yes
Yes

No
Driver ID Verified By**:
No

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

Yes

No

DRIVER HEALTH HISTORY
Do you have or have your ever had:

Yes No

Yes No

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 procedures

21. Bone, muscle, joint, or nerve problems

7. High blood pressure

22. Blood clots or bleeding problems

8. High cholesterol

23. Cancer

9. Chronic cough, shortness of breath, or other breathing problems

24. Chronic infection or other chronic diseases

10. Lung disease (e.g., asthma)

25. Problems staying awake, loud snoring

11. Kidney problems, kidney stones, or pain/problems with urination

26. Sleep apnea

12. Stomach, liver, or digestive problems

27. Have you ever had a sleep test (e.g., sleep apnea)?

13. Diabetes or blood sugar problems

28. Have you ever spent a night in the hospital?

14. Anxiety, depression, nervousness, other mental health problems

29. Have you ever been treated for mental health problems?

15. Fainting or passing out

30. Have you ever had a broken bone?

31. Have you ever had surgery? If "yes," please list and explain below.

32. Other health condition(s) not described above

33. Are you currently taking medications (prescription, over-thecounter, herbal, diet supplements)? If "yes," please describe below.

34. Did you answer "yes" to any of questions 1-30? If so, please
comment further on those health conditions below.

(Attach additional sheets if necessary)
*CDL Yes/No: Commercial driver's license (CDL) means a license issued to an individual by a State or other jurisdiction of domicile, in accordance with the
standards contained in 49 CFR part 383, which authorizes the individual to operate a class of a commercial motor vehicle. CDL includes a commercial
learner's permit (CLP). Check yes if the person is a CDL holder or is applying to become a CDL holder.

**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.

Form MCSA-5875 (Revised: 04/01/2013)

Last Name:

First Name:

Middle Initial:

Date:

Page 2

DRIVER LIFESTYLE QUESTIONS
Yes No

Yes No

35. Have you ever used or do you now use tobacco?

37. Have you used an illegal substance within the past 2 years?

36. Do you currently drink alcohol?

38. Have you ever failed a drug test or been dependent on an
illegal substance?

DRIVER SIGNATURE
A driver is expected to provide the medical examiner with an accurate and complete medical history, as indicated in this Form that is part of 49 CFR
391.43. A driver who provides fraudulent or intentionally false information is in violation of 49 CFR 390.35, and would be subject to the penalties under
49 CFR 390.37.
Driver's Signature:
Date:
SECTION 2. Examination Report (to be filled out by the medical examiner)
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)

TESTING
Last Name:

First Name:

Middle Initial:

Height:

feet

inches Weight:

pounds

Neck circumference (optional)*:

inches BMI (optional)*:
Pulse rate:
Pulse rhythm regular:
Yes
No
*(Please note that a neck circumference greater than 17" for men/16" for women OR a body mass index greater than 33 are both risk factors for sleep apnea.)

Blood Pressure

Systolic

Urinalysis

Diastolic

Sitting

Sp. Gr.

Protein

Blood

Sugar

Urinalysis is required.
Numerical readings
must be recorded.

Second reading
(optional)

Protein, blood, or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other testing if indicated (e.g., A1C, EKG; see FMCSA guidance)

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 corrective lenses should be noted on the Medical Examiner's Certificate.
Acuity
Uncorrected Corrected Horizontal Field of Vision
Right Eye:

20/

20/

Right Eye:

Left Eye:

20/

20/

Left Eye:

Both Eyes:

20/

20/

Applicant can recognize and distinguish among traffic control
signals and devices showing red, green, and amber colors

Hearing
Standard: Must first perceive whispered voice at greater than 5 feet (with or without
hearing aid OR average hearing loss in better ear at less than 40 dB.
Check if hearing aid used for test:
Right Ear
Left Ear
Neither
Right Ear Left Ear
Whisper Test Results

Record distance (in feet) from driver at which a forced
whispered voice can first be heard
degrees
OR
Yes No Audiometric Test Results
Right Ear
Left Ear
degrees

500 Hz

1000 Hz

2000 Hz

500 Hz

1000 Hz

Monocular vision
Referred to ophthalmologist or optometrist?
Received documentation from ophthalmologist or optometrist?

Average (right):

Average (left):

2000 Hz

Form MCSA-5875 (Revised: 04/01/2013)

Last Name:

First Name:

Middle Initial:

Date:

Page 3

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 if the body system is normal, or if there are any abnormalities. 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. If organic disease is present, note if it has been
compensated for.
Body System
1. General

Normal Abnormal

Body System
8. Abdomen

Normal Abnormal

2. Skin

9. Inguinal hernia (male only)

3. Eyes

10. Back

4. Ears

11. Extremities/joints

5. Mouth/throat

12. Spine

6. Heart

13. Neuro/reflexes

7. Lungs/chest

14. Gait

Impressions:

(Attach additional sheets if necessary)
MEDICAL EXAMINER DETERMINATION
Meets standards in 49 CFR 391.41; qualifies for 2-year certificate
Does not meet standards (explain why):
Meets standards, but periodic monitoring required (due to):
Driver qualified for:

3 months

Wearing corrective lenses
Accompanied by a

6 months

1 year

other:

Wearing hearing aid
waiver/exemption (Driver must present exemption certificate at time of certification)

Accompanied by a Skill Performance Evaluation (SPE) certificate
Driving within an exempt intracity zone (see 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64

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 Signature:
Address:

Medical Examiner Name:
City:

Medical Examiner's License or Certificate Number:

State:
MD

DO

Date:
Zip Code:
Physician Assistant

Advanced Practice Nurse

State issuing License or Certificate:

Phone:
Chiropractor

Other Practitioner

Medical Certificate Expiration Date:

National Registry Number:
Determination pending (specify reason):
Return to medical exam office for follow-up on (must be 45 days or less):
Comment on reasons for amendment:

(if amended) Medical Examiner Signature:

Date: