Fillable Form MCSA-5875: Medical Examination Report Form

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Form MCSA-5875: Medical Examination Report Form

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Page 1
Form MCSA-5875
OMB No. 2126-0006
Expiration Date: 11/30/2021
Medical Examination Report Form
(for Commercial Driver Medical Certification)
U.S. Department of Transportation
Federal Motor Carrier
Safety Administration
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.
MEDICAL RECORD #
(or sticker)
SECTION 1. Driver Information (to be filled out by the driver)
Last Name: First Name: Middle Initial:
Date of Birth:
Age:
Street Address: City: State/Province: Zip Code:
Driver's License Number: Issuing State/Province:
Phone:
Gender:
M F
E-mail (optional):
CLP/CDL Applicant/Holder*:
Yes No
Driver ID Verified By**:
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
Yes No Not 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? If "yes," please list and explain below.
Yes No Not Sure
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
If "yes," please describe below.
Yes No
Not Sure
PERSONAL INFORMATION
**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.**
(Attach additional sheets if necessary)
Page 2
Form MCSA-5875
OMB No. 2126-0006
Expiration Date: 11/30/2021
Last Name:
First Name:
DOB: Exam Date:
DRIVER HEALTH HISTORY (continued)
Do you have or have you ever had: Yes No
Not
Sure
1. Head/brain injuries or illnesses (e.g., 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 (e.g., 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
Yes No
Not
Sure
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 (e.g., 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:
Yes No Not Sure
Did you answer "yes" to any of questions 1-32? If so, please comment further on those health conditions below.
Yes No Not Sure
CMV DRIVER'S SIGNATURE
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.
Driver's Signature:
Date:
SECTION 2. Examination Report (to be filled out by the medical examiner)
DRIVER HEALTH HISTORY REVIEW
Review and discuss pertinent driver answers and any available medical records. Comment on the driver's responses to the "health history" questions that may affect the
driver's safe operation of a commercial motor vehicle (CMV).
(Attach additional sheets if necessary)
(Attach additional sheets if necessary)
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Page 3
Form MCSA-5875
OMB No. 2126-0006
Expiration Date: 11/30/2021
Last Name: First Name: Exam Date:
DOB:
TESTING
Pulse rate:
Pulse rhythm regular:
Yes No
Height:
feet inches Weight: pounds
Blood Pressure Systolic Diastolic
Sitting
Second reading
(optional)
Other testing if indicated
Urinalysis Sp. Gr. Protein Blood Sugar
Urinalysis is required.
Numerical readings
must be recorded.
Protein, blood, or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Vision
Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At
least 70° field of vision in horizontal meridian measured in each eye. The use of cor-
rective lenses should be noted on the Medical Examiner's Certificate.
Acuity Uncorrected Corrected Horizontal Field of Vision
Right Eye:
20/ 20/ Right Eye: degrees
Left Eye:
20/ 20/ Left Eye: degrees
Both Eyes:
20/ 20/
Yes No
Applicant can recognize and distinguish among traffic control
signals and devices showing red, green, and amber colors
Monocular vision
Referred to ophthalmologist or optometrist?
Received documentation from ophthalmologist or optometrist?
Hearing
Standard: Must first perceive whispered voice at not less than 5 feet OR average
hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).
Check if hearing aid used for test:
Right Ear Left Ear Neither
Whisper Test Results
Record distance (in feet) from driver at which a forced
whispered voice can first be heard
Right Ear Left Ear
OR
Audiometric Test Results
Right Ear Left Ear
500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz
Average (right): Average (left):
PHYSICAL EXAMINATION
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or
is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily.
Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could
result in a more serious illness that might affect driving.
Check the body systems for abnormalities.
Body System Normal Abnormal
1. General
2. Skin
3. Eyes
4. Ears
5. Mouth/throat
6. Cardiovascular
7. Lungs/chest
Body System Normal Abnormal
8. Abdomen
9. Genito-urinary system including hernias
10. Back/Spine
11. Extremities/joints
12. Neurological system including reflexes
13. Gait
14. Vascular system
Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CMV.
Enter applicable item number before each comment.
(Attach additional sheets if necessary)
Page 4
Form MCSA-5875
OMB No. 2126-0006
Expiration Date: 11/30/2021
Last Name: First Name: Exam Date:
DOB:
Please complete only one of the following (Federal or State) Medical Examiner Determination sections:
MEDICAL EXAMINER DETERMINATION (Federal)
Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49
):
Does not meet standards (specify reason):
Meets standards in 49 CFR 391.41; qualifies for 2-year certificate
Meets standards, but periodic monitoring required (specify reason):
Driver qualified for: 3 months 6 months 1 year other (specify):
Wearing corrective lenses Wearing hearing aid
Accompanied by a waiver/exemption (specify type):
Accompanied by a Skill Performance Evaluation (SPE) Certificate
Qualified by operation of 49 CFR 391.64 (Federal)
Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal)
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:
Date:
Incomplete examination (specify reason):
If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h), as appropriate.
I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation,
and attest that to the best of my knowledge, I believe it to be true and correct.
Medical Examiner's Signature:
Medical Examiner's Name (please print or type):
Medical Examiner's Address: City: State: Zip Code:
Medical Examiner's Telephone Number:
Date Certificate Signed:
Medical Examiner's State License, Certificate, or Registration Number: Issuing State:
MD DO Physician Assistant Chiropractor Advanced Practice Nurse
Other Practitioner (specify):
National Registry Number:
Medical Examiner's Certificate Expiration Date:
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Page 5
Form MCSA-5875
OMB No. 2126-0006
Expiration Date: 11/30/2021
Last Name: First Name: Exam Date:
DOB:
MEDICAL EXAMINER DETERMINATION (State)
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 (which will only be valid for intrastate operations):
Does not meet standards in 49 CFR 391.41 with any applicable State variances (specify reason):
Meets standards in 49 CFR 391.41 with any applicable State variances
Meets standards, but periodic monitoring required (specify reason):
Driver qualified for: 3 months 6 months 1 year other (specify):
Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption (specify type):
Accompanied by a Skill Performance Evaluation (SPE) Certificate Grandfathered from State requirements (State)
If the driver meets the standards outlined in 49 CFR 391.41, with applicable State variances, then complete a Medical Examiner's Certificate, as appropriate.
I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation,
and attest that to the best of my knowledge, I believe it to be true and correct.
Medical Examiner's Signature:
Medical Examiner's Name (please print or type):
Date Certificate Signed:
Medical Examiner's Address: City: State: Zip Code:
Medical Examiner's Telephone Number:
Medical Examiner's State License, Certificate, or Registration Number: Issuing State:
MD DO Physician Assistant Chiropractor Advanced Practice Nurse
Other Practitioner (specify):
National Registry Number:
Medical Examiner's Certificate Expiration Date:
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Completed 5 December 2021

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