Form MCSA-5876, Medical Examiner's Certificate

Form MCSA-5876 (Revised: 03/11/2013)

OMB No. 2126-0006

Expiration Date: 07/31/2015

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.

Medical Examiner's Certificate

U.S. Department of Transportation
Federal Motor Carrier
Safety Administration

(for Commercial Driver Medical Certification)

First Name:
in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and,
I certify that I have examined Last Name:
with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply):
Driving within an exempt intracity zone (49 CFR 391.62)

Wearing corrective lenses
Wearing hearing aid

Accompanied by a Skill Performance Evaluation (SPE) certificate

Accompanied by a

waiver/exemption

Qualified by operation of 49 CFR 391.64

The information I have provided regarding this physical examination is true and complete.
A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office.
Medical Certificate Expiration Date

Signature of Medical Examiner

Medical Examiner's Telephone Number

Medical Examiner Name (please print or type)

Date Certificate Signed

MD

Physician Assistant

Advanced Practice Nurse

DO

Chiropractor

Other Practitioner (specify)

Medical Examiner's License or Certificate Number

License/Certificate Issued By (State)

Signature of Driver

Driver's License Number

National Registry Number

License Issued By (State)

Intrastate Only
Yes

Address of Driver
Street:

City:

State:

Zip Code:

No

CDL
Yes

No