MCSA-5850 CMV Driver Medical Examination Results Form

Form MCSA-5850

OMB No.: 2126-0006  Expiration Date: 03/31/2025

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 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.

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

CMV Driver Medical Examination Results Form

CMV Driver’s Name and Address (use Legal Name as listed on Government-Issued Identification)
First Name:

Last Name:

Middle Initial:
(enter ‘NMN’ if driver does not have a middle name)

City:

Street Address:

State/Province:

Zip Code:

Email:
(optional)

CMV Driver’s License Information
Issuing State/Province:

Driver’s License Number:
CLP/CDL Applicant/Holder:

Yes

Date of Birth:
(use mm/dd/yyyy format)

No

Examination Information (please complete only one of the Examination Information sections below)
Use this section for examinations performed in accordance with the
Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):
Examination Result:

Medically Qualified
(Date MEC signed/issued):

OR

Use this section for examinations performed in accordance with the Federal
Motor Carrier Safety Regulations (49 CFR 391.41-391.49), with any applicable
State variances:
Date of Examination:
(use mm/dd/yyyy format)

(use mm/dd/yyyy format)

Medically Unqualified
(Date of examination/determination):
(use mm/dd/yyyy format)

Determination Pending
(Date of examination):

Examination Result:

Medically Qualified
Medically Unqualified

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

(use mm/dd/yyyy format)

(use mm/dd/yyyy format)

Incomplete Examination
(Date of examination):
(use mm/dd/yyyy format)

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

(use mm/dd/yyyy format)

Restrictions and Variances (check all that apply)
Wearing hearing aid

Accompanied by a Skill Performance Evaluation (SPE) Certificate

Wearing corrective lenses

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

Accompanied by a waiver/exemption (specify type):

Grandfathered from State requirements (State)

**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.**
Rev 2/27/2023