Public Burden StatementA 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
Middle Initial:
Age:
*
Phone:
Zip Code:
*
Gender:MF
Gender:MF
E-mail (optional):
example@example.com
CLP/CDL Applicant/Holder*:
*
Yes
No
Driver ID Verified By**:
Yes
*
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?YesNo
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?YesNo
Not Sure
**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.
*
YesNo
YesNo
YesNo
YesNo
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.
*
YesNoNot Sure
YesNoNot Sure
YesNoNot Sure
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.
**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.
2.Seizures, epilepsy3.Eye problems (except glasses or contacts)
*
4.Ear and/or hearing problems5.Heart disease, heart attack, bypass, or other heartproblems
4.Ear and/or hearing problems5.Heart disease, heart attack, bypass, or other heartproblems
Not Yes No Sure
4.Ear and/or hearing problems5.Heart disease, heart attack, bypass, or other heartproblems
2.Seizures, epilepsy3.Eye problems (except glasses or contacts)
*
4.Ear and/or hearing problems5.Heart disease, heart attack, bypass, or other heartproblems
4.Ear and/or hearing problems5.Heart disease, heart attack, bypass, or other heartproblems
Not Yes No Sure
Do you have or have you ever had:1.Head/brain injuries or illnesses (e.g., concussion)
*
Not Yes No Sure
Not Yes No Sure
Not Yes No Sure
Do you have or have you ever had:1.Head/brain injuries or illnesses (e.g., concussion)
*
Not Yes No Sure
Not Yes No Sure
Not Yes No Sure
Do you have or have you ever had:1.Head/brain injuries or illnesses (e.g., concussion)
*
Not Yes No Sure
Not Yes No Sure
Not Yes No Sure
Not Yes No Sure
*
16.Dizziness, headaches, numbness, tingling, or memoryloss
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
uled_to_be_in_Ori
Not Yes No Sure
*
uled_to_be_in_Ori
uled_to_be_in_Ori
uled_to_be_in_Ori
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
Not Yes No Sure
*
uled_to_be_in_Ori
uled_to_be_in_Ori
uled_to_be_in_Ori
Not Yes No Sure
*
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
Not Yes No Sure
*
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
Not Yes No Sure
*
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
Not Yes No Sure
*
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
23.Cancer24.Chronic (long-term) infection or other chronic diseases
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
Not Yes No Sure
*
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
Not Yes No Sure
*
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
19.Missing or limited use of arm, hand, finger, leg, foot, toe20.Neck or back problems
Not Yes No Sure
*
6.Pacemaker, stents, implantable devices, or other heartprocedures
6.Pacemaker, stents, implantable devices, or other heartprocedures
6.Pacemaker, stents, implantable devices, or other heartprocedures
Not Yes No Sure
*
6.Pacemaker, stents, implantable devices, or other heartprocedures
6.Pacemaker, stents, implantable devices, or other heartprocedures
6.Pacemaker, stents, implantable devices, or other heartprocedures
Not Yes No Sure
*
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
Not Yes No Sure
*
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
Not Yes No Sure
*
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
9.Chronic (long-term) cough, shortness of breath, or otherbreathing problems10.Lung disease (e.g., asthma)
Not Yes No Sure
*
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
23.Cancer24.Chronic (long-term) infection or other chronic diseases
Not Yes No Sure
*
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
Not Yes No Sure
*
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
Not Yes No Sure
*
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
11.Kidney problems, kidney stones, or pain/problems with urination12.Stomach, liver, or digestive problems
Not Yes No Sure
*
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
23.Cancer24.Chronic (long-term) infection or other chronic diseases
Not Yes No Sure
*
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
Not Yes No Sure
*
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
26.Have you ever had a sleep test (e.g., sleep apnea)?27.Have you ever spent a night in the hospital?
Not Yes No Sure
*
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
Not Yes No Sure
*
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
Not Yes No Sure
*
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
Not Yes No Sure
*
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 twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
Not Yes No Sure
*
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
Not Yes No Sure
*
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.
30.Do you currently drink alcohol?31.Have you used an illegal substance within the past twoyears?
*
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
Not Yes No Sure
*
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
14.Anxiety, depression, nervousness, other mental health problems15.Fainting or passing out
28.Have you ever had a broken bone?29.Have you ever used or do you now use tobacco?
*
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
32.Have you ever failed a drug test or been dependent on an illegal substance?
Last name___________________________ First name______________________ Middle initial _____ DOB: _____________ Exam Date:_____What_date_are
*
/
Month
/
Day
Year
Date
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:
*
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:
*
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:
*
uled_to_be_in_Ori
*
Form MCSA-5875
*
Form MCSA-5875
Form MCSA-5875
Form MCSA-5875
Form MCSA-5875
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 1 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.
*
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 1 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.
U.S. Department of Transportation Federal Motor Carrier Safety Administration
Medical Examiner's Certificate (for Commercial Driver Medical Certification)
*
Advanced Practice NurseOther Practitioner (specify)
*
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.
*
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
*
I certify that I have examined Last Name:
*
Medical Examiner's Telephone Number
*
Medical Examiner's State License, Certificate, or Registration Number
*
First Name:
*
Medical Examiner's Telephone Number
*
MDDO
Physician AssistantChiropractor
Physician AssistantChiropractor
MDDO
Physician AssistantChiropractor
OMB No. 2126-0006Expiration Date: 9/30/2019
*
/
Month
/
Day
Year
Date
Physician AssistantChiropractor
*
in accordance with (please check only one):
*
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):
*
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
*
CLP/CDL Applicant/Holder
*
Ye s
No
Print name:
*
Print name:
*
Print name:
*
/
Month
/
Day
Year
Date
AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION AND NOTICE OF PRIVACY PRACTICES
2740 N Mayfair Ave Springfield, MO 65803 Office (417)521-3925 Fax (417)521-6860
3.I understand the copies of the records indicated above will be communicated to:New Prime Inc. dba PRIME INC 2740 N Mayfair Ave Springfield, MO 65803 P (417) 866-0001 4. I understand that to the extent of any recipient of the information, as identified above, may not be a“covered entity” under federal law, the information may no longer be protected by Federal Privacy Lawonce it is disclosed to the recipient and, there, may be subject to re-disclosure by the recipient.5. I understand that the purpose(s) of the requested use and disclosure is (are): Employment and PrimeDriver Health and Fitness Program.6. I understand that I may revoke the authorization in writing at any time except to the extent that eitherparty named above has already relied on this authorization. I understand that I may revoke thisauthorization by sending or faxing written notice stating my intent to revoke the authorization to:Trinity Healthcare C/O Angie Abraham
2740 N Mayfair Ave Springfield MO 65803 P (417) 521-3925 F (417) 521-6860 7. Unless otherwise revoked, I understand that the specific date or event upon which this authorizationexpires is: _____/_____/______ (one year of less from date of service).8. I understand that my treatment may not be conditioned on my completion of this authorization formexcept when the provision of care is solely for the purpose of creating protected health information fordisclosure to a third party.9. I acknowledge the organization has published a Notice of Privacy Practices and this is available uponrequest.
Review
Should be Empty: