Form MCSA-5850 CMV Driver Medical Examination Results Form

FORM MCSA-5850 

OMB No.: 2126-0006  Expiration: 11/30/2021

Please note, the expiration date as stated on this form relates to the process for renewing the Information Collection Request for this
form with the Office of Management and Budget. This requirement to collect information as requested on this form does not expire.
For questions, please contact the Office of Registration and Safety Information, Registration, Licensing, and Insurance Division.
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 two 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.

United States Department of Transportation
Federal Motor Carrier Safety Administration

FMCSA Office of Registration and Safety Information
CMV Driver Medical Examination Results Form

FORM MCSA-5850

CMV DRIVER’S NAME AND ADDRESS

(use Legal Name as listed on Government-Issued Identification)

LAST NAME

FIRST NAME

MIDDLE INITIAL E-MAIL ADDRESS (optional)

STREET ADDRESS

CITY

STATE/PROVINCE

ZIP CODE

CMV DRIVER’S LICENSE INFORMATION
DRIVER’S LICENSE NUMBER

American
Alberta
Alaska
Alabama
British
Arkansas
Arizona
District
Delaware
Connecticut
Colorado
California
Marshall
Manitoba
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
Newfoundland
North
Northern
Northwest
Nova
Prince
Pennsylvania
Palau
Oregon
Ontario
Oklahoma
Ohio
Nunavut
Puerto
Rhode
Quebec
Saskatchewan
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Yukon
Wyoming
Wisconsin
Brunswick
Hampshire
Jersey
Mexico
York
Virginia
Scotia
Carolina
Dakota
Carolina
Dakota
Edward
Island
Islands
Columbia
Rico
of
Islands
Marianas
Samoa
Columbia
Territories
Island
and LabradorDATE OF BIRTH
ISSUING
STATE/PROVINCE

EXAMINATION INFORMATION

CLP/CDL Applicant/Holder:

Yes

No

(please complete only one of the Examination Information sections below)

Use Section 1 for examinations performed in accordance with the
Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):

OR

Use Section 2 for examinations performed in accordance with the Federal Motor
Carrier Safety Regulations (49 CFR 391.41-391.49), with any applicable State variances:

SECTION 1

SECTION 2

Examination Result:

Date of Examination:

Medically Qualified
(date MEC signed/issued):
Medically Unqualified
(date of examination):
Determination Pending
(date of examination):

Examination Result:

Medically Qualified
Medically Unqualified

Medical Examiner’s Certificate Expiration Date
(applicable when “Medically Qualified” is selected above):

Incomplete Examination
(date of examination):
Medical Examiner’s Certificate Expiration Date
(applicable when “Medically
Qualified” is selected above):

(continued on next page)
FORM MCSA-5850 • Page 1 of 2

Rev 01/08/21

FORM MCSA-5850 

RESTRICTIONS AND VARIANCES

OMB No.: 2126-0006  Expiration: 11/30/2021

(check all that apply)

Wearing corrective lenses

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Wearing hearing aid

Driving within an exempt intracity zone (49 CFR 391.62) (Federal)

Accompanied by a waiver/exemption (specify type):

Qualified by operation of 49 CFR 391.64 (Federal)
Grandfathered from State requirements (State)

FORM MCSA-5850 • Page 2 of 2