Medical Examination Report Form

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)
Personal Information

SECTION 1. Driver Information (to be filled out by the driver)
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State/Province
Zip Code
Driver’s License Number
Issuing State/Province
Phone
E-Mail (optional)
example@example.com
CLP/CDL Applicant/Holder*:

YesNo
Driver ID Verified By**
Driver ID Verified By**:

Yes Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?NoNot Sure
*CLP/CDL Applicant/Holder: See instructions for definitions.

**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.
DRIVER HEALTH HISTORY
Have you ever had surgery?

YesNoNot Sure
If "yes," please list and explain below.
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?

YesNoNot Sure
If "yes," please describe below.

Do you have or have you ever had:

	Yes	No	Not Sure
1. Head/brain injuries or illnesses (ex: concussion)
2. Seizures/epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart problems
6. Pacemaker, stents, implantable devices, or other heart procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
10. Lung disease (ex: asthma)
11. Kidney problems, kidney stones, or pain/problems with urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems
Insulin used
14. Anxiety, depression, nervousness, other mental health problems
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
26. Have you ever had a sleep test (ex: sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?
32. Have you ever failed a drug test or been dependent on an illegal substance?

Other health condition(s) not described above?

YesNoNot Sure
If "yes," please describe and explain below:
Did you answer "yes" to any of questions 1-32? If so, please comment further below.

YesNoNot Sure
If so answered "yes" to any questions 1-32, please comment further on those health conditions below:
Driver’s Signature

Clear
Driver’s Signature

MonthDayYear
Date
**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.**
Instructions MCSA-5875

Step-By-Step Instructions
Section 1: Driver Information •
Driver Health History:
Have you ever had surgery: Please check “yes” if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet

supplements): Please check “yes” if you are taking any diet supplements, herbal remedies, or prescription or over the counter medications. In the box below the question, indicate the name of the medication and the dosage. #1-32: Please complete this section by checking the “yes” box to indicate that you have, or have ever had, the health condition listed or the “No” box if you have not. Check the “not sure” box if you are unsure. Other Health Conditions not described above: If you have, or have had, any other health condi- tions not listed in the section above, check “Yes” and in the box provided and list those condition(s Any yes answers to questions #1-32 above: If you have answered “yes” to any of the questions in the Driver Health History section above, please explain your answers further in the box below the question. For example, if you answered “yes” to question #5 regarding heart disease, heart attack, bypass, or other heart problem, indicate which type of heart condition. If you checked “yes” to question #23 regarding cancer, indicate the type of cancer. Please add any information that will be helpful to the Medical Examiner. CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section 1 is accurate and complete.
Personal Information: Please complete this section using your name as written on your driver’s license, your current address and phone number, your date of birth, age, driver’s license number and issuing state. ◦CLP/CDL Applicant/Holder: Check “yes” if you are a commercial learner’s permit (CLP) or commercial driver’s license (CDL) holder, or are applying for a CLP or CDL. CDL means a license issued by a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicle (CMV A CMV that requires a CDL is one that: (1) has a gross combination weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000 pounds; or (2) has a GVWR or GVW of 26,001 pounds or more; or (3) is designed to transport 16 or more passengers, including the driver; or (4) is used to transport either hazardous materials requiring hazardous materials placards on the vehicle or any quantity of a select agent or toxin. Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the driver’s identity such as, commercial driver’s license, driver’s license, or passport, etc.

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years?

Please check the correct box “yes” or “no” and if you aren’t sure check the “not sure” box.
Other health condition(s) not described above
CMV DRIVER’S SIGNATURE
Does not meet standards (specify reason)
Meets standards, but periodic monitoring required (specify reason)
Accompanied by a waiver/exemption (specify type)
Determination pending (specify reason)
Return to medical exam office for follow-up on (must be 45 days or less)
Medical Examination Report amended (specify reason)
(if amended) Medical Examiner’s Signature

Clear
Date

MonthDayYear
Date
Incomplete examination (specify reason)
Does not meet standards in 49 CFR 391.41 with any applicable State variances (specify reason)
Meets standards, but periodic monitoring required (specify reason)
Accompanied by a waiver/exemption (specify type)
Should be Empty:

Form MCSA-5875

Public Burden Statement

Medical Examination Report Form

Personal Information

DRIVER HEALTH HISTORY

Instructions MCSA-5875

Section 1: Driver Information •

Driver Health History: