MCSA-5876 Medical Examiner's Certificate Revised

Form MCSA-5876

OMB No. 2126-0006

Expiration Date: 8/31/2018

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)

I certify that I have examined Last Name:

First Name:

in accordance with (please check only one):

the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply) OR
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), and, with knowledge of the driving duties,
I find this person is qualified, and, if applicable, only when (check all that apply):
Wearing corrective lenses
Wearing hearing aid

Accompanied by a
waiver/exemption
Accompanied by a Skill Performance Evaluation (SPE) Certificate

Driving within an exempt intracity zone (49 CFR 391.62) (Federal)
Qualified by operation of 49 CFR 391.64 (Federal)
Grandfathered from State requirements (State)

The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form,
MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.

Medical Examiner's Signature

Medical Examiner's Telephone Number

Medical Examiner's Name (please print or type)

Medical Examiner's Certificate Expiration Date

Date Certificate Signed

MD

Physician Assistant

Advanced Practice Nurse

DO

Chiropractor

Other Practitioner (specify)

Medical Examiner's State License, Certificate, or Registration Number

Issuing State

National Registry Number

Driver's Signature

Driver's License Number

Issuing State/Province

CLP/CDL Applicant/Holder

Driver's Address
Street Address:

City:

State/Province:

Zip Code:

Yes

No

**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.**