Medical Examination Report Form (Page 7 of 9) in pdf

Instructions MCSA-5875 (Revised: 12/09/2015)

Medical Examiner:

Section 2: Examination Report

• Driver Health History Review: Review answers provided by the driver in the driver health history sec-

tion and discuss any “yes” and “not sure” responses. In addition, be sure to compare the medication list

to the health history responses ensuring that the medication list matches the medical conditions noted.

Explore with the driver any answers that seem unclear. Record any information that the driver omitted.

As the Medical Examiner conducting the driver's physical examination you are required to complete the

entire medical examination even if you detect a medical condition that you consider disqualifying, such

as deafness. Medical Examiners are expected to determine the driver's physical qualification for operat-

ing a commercial vehicle safely. Thus, if you find a disqualifying condition for which a driver may

receive a Federal Motor Carrier Safety Administration medical exemption, please record that on the

driver's Medical Examiner's Certificate, Form MCSA-5876, as well as on the Medical Examination

Report Form, MCSA-5875.

• Testing:

Pulse rate and rhythm, height, and weight: record these as indicated on the form.

Blood Pressure: record the blood pressure (systolic and diastolic) of the driver being examined.

second reading is optional and should be recorded if found to be necessary.

Urinalysis: record the numerical readings for the specific gravity, protein, blood and sugar.

Vision: The current vision standard is provided on the form. When other than the Snellen chart is

used, give test results in Snellen-comparable values. When recording distance vision, use 20 feet as

normal. Record the vision acuity results and indicate if the driver can recognize and distinguish

among traffic control signals and devices showing red, green, and amber colors; has monocular

vision; has been referred to an ophthalmologist or optometrist; and if documentation has been

received from an ophthalmologist or optometrist.

Hearing: The current hearing standard is provided on the form. Hearing can be tested using either a

whisper test or audiometric test. Record the test results in the corresponding section for the test used.

• Physical Examination: Check the body systems for abnormalities and indicate normal or abnormal for

each body system listed. Discuss any abnormal answers in detail in the space provided and indicate

whether it would affect the driver's ability to safely operate a commercial motor vehicle.

In this next section, you will be completing either the Federal or State determination, not both.

• Medical Examiner Determination (Federal): Use this section for examinations performed in

accordance with the FMCSRs

(49 CFR

391.41-391.49). Complete the medical examiner determination

section completely. When determining a driver's physical qualification, please note that English language

proficiency

(49 CFR part

391.11: General qualifications of drivers) is not factored into that determination.

Does not meet standards: Select this option when a driver is determined to be not qualified and pro-

vide an explanation of why the driver does not meet the standards in 49 CFR 391.41.

Meets standards in 49 CFR 391.41; qualifies for 2-year certification: Select this option when a

driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.

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Medical Examination Report Form Page 7