Form Mcsa 5875 2018
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Expiration Date 8/31/2018 OMB No. 2126-0006 Form MCSA-5875 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 25 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 Medical Examination Report Form for Commercial Driver Medical Certification MEDICAL RECORD or sticker SECTION 1. Driver Information to be filled out by the driver PERSONAL INFORMATION Last Name Street Address First Name Middle Initial City Driver s License Number E-mail optional Age Date of Birth State/Province Zip Code Phone Issuing State/Province CLP/CDL Applicant/Holder Gender Yes M F No Driver ID Verified By Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years Not Sure DRIVER HEALTH HISTORY Have you ever had surgery If yes please list and explain below. Are you currently taking medications prescription over-the-counter herbal remedies diet supplements If yes please describe below. Attach additional sheets if necessary 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. Page 1 DOB Exam Date Do you have or have you ever had Not Yes No Sure 1. Head/brain injuries or illnesses e*g* concussion 2. Seizures epilepsy 16. Dizziness headaches numbness tingling or memory loss 3. Eye problems except glasses or contacts 17. Unexplained weight loss 4. Ear and/or hearing problems 18. Stroke mini-stroke TIA paralysis or weakness 5. Heart disease heart attack bypass or other heart problems 20. Neck or back problems 19. Missing or limited use of arm hand finger leg foot toe 6. Pacemaker stents implantable devices or other heart procedures 21. Bone muscle joint or nerve problems 7. High blood pressure 23. Cancer 8. High cholesterol 24. Chronic long-term infection or other chronic diseases breathing problems 25.
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What is the Form Mcsa 5875
The Form MCSA 5875, also known as the Medical Examination Report Form, is a crucial document used by commercial drivers in the United States. This form is required to assess the medical fitness of individuals applying for or renewing a Commercial Driver's License (CDL). It ensures that drivers meet the health standards set by the Federal Motor Carrier Safety Administration (FMCSA) to operate commercial vehicles safely.
The form includes sections for the driver's medical history, physical examination results, and the medical examiner's certification. It is essential for maintaining safety on the roads, as it helps to identify any medical conditions that could impair a driver's ability to operate a vehicle.
How to use the Form Mcsa 5875
Using the Form MCSA 5875 involves several key steps. First, the driver must complete the medical history section, providing accurate and comprehensive information about their health. This includes details about any previous medical conditions, medications, and treatments.
Next, the driver must visit a certified medical examiner who will conduct a physical examination. The examiner will review the medical history, perform a physical assessment, and determine if the driver meets the necessary health standards. After the examination, the medical examiner will complete the form, indicating whether the driver is medically qualified to hold a CDL.
Steps to complete the Form Mcsa 5875
Completing the Form MCSA 5875 requires careful attention to detail. Here are the steps to follow:
- Obtain the form from a reliable source, such as the FMCSA website or a certified medical examiner.
- Fill out the driver's medical history section thoroughly, ensuring all information is accurate.
- Schedule an appointment with a certified medical examiner who is authorized to conduct CDL medical examinations.
- During the examination, provide the medical examiner with the completed form and any additional medical records if necessary.
- After the examination, the medical examiner will complete the form, indicating the driver's medical status.
- Keep a copy of the completed form for personal records and submit it as required for CDL application or renewal.
Legal use of the Form Mcsa 5875
The legal use of the Form MCSA 5875 is governed by federal regulations set forth by the FMCSA. This form must be completed by a certified medical examiner and is a requirement for anyone seeking a CDL. The information provided on the form must be truthful and complete, as any discrepancies can lead to penalties or disqualification from obtaining a CDL.
Additionally, the form serves as a legal document that can be used in compliance checks by regulatory authorities. It is essential for drivers to understand that falsifying information on the form can result in serious legal consequences, including fines and loss of driving privileges.
Key elements of the Form Mcsa 5875
The Form MCSA 5875 contains several key elements that are critical for evaluating a driver's medical fitness. These elements include:
- Driver's Medical History: A comprehensive section that requires detailed information about the driver's past and present medical conditions.
- Physical Examination Results: The medical examiner's findings from the physical assessment, including vision, hearing, and overall health status.
- Certification Statement: A section where the medical examiner certifies whether the driver meets the medical standards for a CDL.
- Signature of the Medical Examiner: The form must be signed and dated by the medical examiner to validate the examination.
How to obtain the Form Mcsa 5875
Obtaining the Form MCSA 5875 is straightforward. The form can be accessed through various channels:
- FMCSA Website: The official FMCSA website provides downloadable versions of the form.
- Certified Medical Examiners: Many medical examiners have copies of the form available for their patients.
- State Licensing Agencies: Some state agencies may provide the form as part of the CDL application process.
It is important to ensure that you are using the most current version of the form to comply with federal regulations.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| DoT MCSA-5875 2025 | 4.5 Satisfied (50 Votes) | |
| DoT MCSA-5875 2022 | 4.8 Satisfied (749 Votes) | |
| DoT MCSA-5875 2021 | 4.8 Satisfied (2404 Votes) | |
| DoT MCSA-5875 2018 | 4.7 Satisfied (129040 Votes) | |
| DoT MCSA-5875 2015 | 4.7 Satisfied (1295 Votes) | |
| IRS W-9 2019 | 4.8 Satisfied (346 Votes) |
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Apr 1, 2025 — As part of the physical, drivers are required to fill out the medical history portion of the Medical Examination Report (MER) Form, MCSA-5875.Read more
**Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver's license, passport. (Attach additional ...Read more
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