MCSA-5876 Medical Examiner's Certificate Revised

Form MCSA-5876

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

Please note, the expiration date on this form relates to the process for renewing the Information Collection Request that includes this form with the Office of Management and Budget. This requirement to collect information as
requested on this form does not expire.
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 one 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)

CMV DRIVER 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

Accompanied by a waiver/exemption (specify type):

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

Wearing hearing aid

Accompanied by a Skill Performance Evaluation (SPE) Certificate

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 Certificate Expiration Date

MEDICAL EXAMINER INFORMATION
Medical Examiner’s Signature

Medical Examiner’s Telephone Number

Medical Examiner’s Name (please print or type)

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

Date Certificate Signed

MD

Physician Assistant

Advanced Practice Nurse

DO

Chiropractor

Other Practitioner (specify)

Issuing State

National Registry Number

American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Marshall
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
North
Northern
Puerto
Pennsylvania
Palau
Oregon
Oklahoma
Ohio
Rhode
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Wyoming
Wisconsin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Island
Islands
Rico
ofIslands
Marianas
Samoa
Columbia

CMV DRIVER INFORMATION
Driver’s Signature

Driver’s License Number

Issuing State/Province

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
ofIslands
Marianas
Samoa
Columbia
Territories
Island
and Labrador

Driver’s Address
Street Address:

CLP/CDL Applicant/Holder

City:

State/Province:

Canada
WY
WV
WI
WA
VT
VI
VA
UT
TX
TN
SD
SC
RI
PW
PR
PA
OR
OK
OH
NY
NV
NM
NJ
NH
NE
ND
NC
MT
MS
MP
MO
MN
MI
MH
ME
MD
MA
LA
KY
KS
IN
IL
ID
IA
HI
GU
GA
FM
FL
DE
DC
CT
CO
CA
AZ
AS
AR
AL
AK

Zip Code:

Yes

No

Rev 02/27/21