Form MCSA-5875 (Revised: 04/01/2013)
OMB No. 2126-0006
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 20 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 Examination Report Form
U.S. Department of Transportation
Federal Motor Carrier
(for Commercial Driver Medical Certification)
PRIVACY ACT STATEMENT This statement is provided pursuant to the Privacy Act of 1974,
5 USC §
AUTHORITY: Title 49, United States Code (USC),
49 USC 31133(a)(8)
MEDICAL RECORD #
PURPOSE: To record results of a driver's physical examination to determine qualification to operate a commercial motor vehicle (CMV) in interstate commerce according to the require-
391.41-49. Providing this information is mandatory. If this information is not provided, the medical examiner will not be able to determine qualification to operate a
CMV in interstate commerce according to the requirements in
Medical examiners are required to complete the Medical Examination Report Form for every driver physical examination performed in accordance with
391.41. Each original
(paper or electronic) completed Medical Examination Report Form must be retained on file at the office of the medical examiner for at least 3 years from the date of examination. The
medical examiner must make all records and information in these files available to an authorized representative of FMCSA or an authorized Federal, State, or local enforcement agency
representative, within 48 hours after the request is made
ROUTINE USES: The information is used for the purpose set forth above and may be forwarded to Federal, State, or local law enforcement agencies for their use. Medical Examination Report Forms collected by FMCSA will be
stored in FMCSA's automated National Registry of Certified Medical Examiners System and will be used to monitor the performance of medical examiners listed on the National Registry.
In addition to those disclosures permitted under
5 USC 552a(b)
of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transportation (DOT) Prefatory Statement of General
Routine Uses published in the Federal Register on December 29, 2010
82132), under "Prefatory Statement of General Routine Uses'' (available at ).
ACKNOWLEDGMENT: I understand the provisions of the Privacy Act of 1974 as related to me through the abovementioned statement.
CMV Driver Signature:
SECTION 1. Driver Information (to be filled out by the driver)
Date of Birth:
Driver License Number:
State of Issue:
Driver ID Verified By**:
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
DRIVER HEALTH HISTORY
Do you have or have your ever had:
1. Head/brain injuries or illnesses (e.g., concussion)
16. Dizziness, headaches, numbness, tingling, or memory loss
2. Seizures, epilepsy
17. Unexplained weight loss
3. Eye problems (except glasses or contacts)
18. Stroke, mini-stroke (TIA), paralysis, or weakness
4. Ear and/or hearing problems
19. Missing or limited use of arm, hand, finger, leg, foot, toe
5. Heart disease, heart attack, bypass, or other heart problems
20. Neck or back problems
6. Pacemaker, stents, implantable devices, or other heart procedures
21. Bone, muscle, joint, or nerve problems
7. High blood pressure
22. Blood clots or bleeding problems
8. High cholesterol
9. Chronic cough, shortness of breath, or other breathing problems
24. Chronic infection or other chronic diseases
10. Lung disease (e.g., asthma)
25. Problems staying awake, loud snoring
11. Kidney problems, kidney stones, or pain/problems with urination
26. Sleep apnea
12. Stomach, liver, or digestive problems
27. Have you ever had a sleep test (e.g., sleep apnea)?
13. Diabetes or blood sugar problems
28. Have you ever spent a night in the hospital?
14. Anxiety, depression, nervousness, other mental health problems
29. Have you ever been treated for mental health problems?
15. Fainting or passing out
30. Have you ever had a broken bone?
31. Have you ever had surgery? If "yes, " please list and explain below.
32. Other health condition(s) not described above
33. Are you currently taking medications (prescription, over-the-
34. Did you answer "yes" to any of questions 1-30? If so, please
counter, herbal, diet supplements)? If "yes," please describe below.
comment further on those health conditions below.
(Attach additional sheets if necessary)
*CDL Yes/No: Commercial driver's license (CDL) means a license issued to an individual by a State or other jurisdiction of domicile, in accordance with the
**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.
standards contained in
49 CFR part
383, which authorizes the individual to operate a class of a commercial motor vehicle. CDL includes a commercial
learner's permit (CLP). Check yes if the person is a CDL holder or is applying to become a CDL holder.