Medical Examiner'S Certificate Template
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1Form MCSA-5876
OMB No. 2126-0006
Expiration Date: 8/31/2018
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.
Medical Examiner's Certificate
U.S. Department of Transportation
Federal Motor Carrier
(for Commercial Driver Medical Certification)
Safety Administration
I certify that I have examined Last Name:
First Name:
in accordance with (please check only one):
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
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):
Wearing corrective lenses
Driving within an exempt intracity zone
(49 CFR
391.62) (Federal)
Accompanied by a
waiver/exemption
Wearing hearing aid
Accompanied by a Skill Performance Evaluation (SPE) Certificate
Qualified by operation of
49 CFR 391.64
(Federal)
Grandfathered from State requirements (State)
Medical Examiner's Certificate Expiration Date
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.
Medical Examiner's Signature
Medical Examiner's Telephone Number
Date Certificate Signed
Medical Examiner's Name (please print or type)
MD
Physician Assistant
Advanced Practice Nurse
DO
Chiropractor
Other Practitioner (specify)
Medical Examiner's State License, Certificate, or Registration Number
Issuing State
National Registry Number
Driver's Signature
Driver's License Number
Issuing State/Province
CLP/CDL Applicant/Holder
Driver's Address
State/Province:
Street Address:
City:
Zip Code:
Yes
No
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Parent category: Business