Medical Examination Report Form Page 4
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9Form MCSA-5875 (Revised: 12/09/2015)
OMB No. 2126-0006
Expiration Date: 8/31/2018
Last Name:
First Name:
Middle Initial:
DOB:
Exam Date:
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:
Page 4
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