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Fill Out Your Mcsa 5875 Form

The MCSA-5875 form is a crucial document used for medical certification in the commercial driving sector, specifically seeking to evaluate a driver's health and fitness to operate commercial motor vehicles. It collects personal information, medical history, and various health assessments to ensure safety on the roads. Completing this form accurately is essential for compliance with federal regulations that govern commercial driving.

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Article Structure

The MCSA-5875 form is a critical document for individuals seeking a medical examination for commercial driver certification. Designed by the Federal Motor Carrier Safety Administration, it ensures compliance with health standards necessary for safe driving. The form consists of various sections, beginning with detailed personal information about the driver, including name, contact details, and driver's license information. A comprehensive health history section follows, prompting drivers to disclose any past or present medical conditions, medications, and surgeries. Medical examiners utilize this information to assess the driver's fitness for operating a commercial motor vehicle. The form also includes detailed guidelines for conducting vision and hearing tests, as well as a thorough physical examination. After careful evaluation, medical professionals document their findings in the form, determining whether a driver meets the necessary health standards set forth in federal regulations. Proper completion and handling of the MCSA-5875 are paramount, as the information contained within is sensitive and intended for official use only.

Mcsa 5875 Example

Form MCSA-5875

OMB No. 2126-0006 Expiration Date: 11/30/2021

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.

U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Medical Examination Report Form

(for Commercial Driver Medical Certification)

SECTION 1. Driver Information (to be filled out by the driver)

MEDICAL RECORD #

(or sticker)

PERSONAL INFORMATION

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:

E-mail (optional):

CLP/CDL Applicant/Holder*:

Yes

Driver ID Verified By**:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

Yes

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)?	Yes No Not Sure
If "yes," please describe below.

(Attach additional sheets if necessary)

**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.**

Page 1

Form MCSA-5875				OMB No. 2126-0006 Expiration Date: 11/30/2021

Last Name:	First Name:		DOB:		Exam Date:


DRIVER HEALTH HISTORY (continued)

		Not				Not
Do you have or have you ever had:		Yes No Sure				Yes No 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

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

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

(Attach additional sheets if necessary)

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)

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Form MCSA-5875

OMB No. 2126-0006 Expiration Date: 11/30/2021

Last Name:

First Name:

DOB:

Exam Date:

TESTING

Pulse rate:

Pulse rhythm regular:

Yes

Height: feet

inches

Weight:

pounds

Blood Pressure

Systolic

Diastolic

Urinalysis

Sp. Gr.

Protein

Blood

Sugar

Sitting

Urinalysis is required.

Numerical readings

Second reading

must be recorded.

(optional)

Other testing if indicated

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.

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).

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?

Check if hearing aid used for test:

Right Ear

Left Ear

Neither

Whisper Test Results

Right Ear Left Ear

Record distance (in feet) from driver at which a forced

whispered voice can first be heard

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 Body System	Normal Abnormal
1. General	8. Abdomen
2. Skin	9. Genito-urinary system including hernias
3. Eyes	10. Back/Spine
4. Ears	11. Extremities/joints
5. Mouth/throat	12. Neurological system including reflexes
6. Cardiovascular	13. Gait
7. Lungs/chest	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 3

Medical Examiner's Certificate Expiration Date:

Form MCSA-5875			OMB No. 2126-0006 Expiration Date: 11/30/2021

Last Name:	First Name:	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:

Physician Assistant

Chiropractor

Advanced Practice Nurse

Other Practitioner (specify):

National Registry Number:

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Form MCSA-5875			OMB No. 2126-0006 Expiration Date: 11/30/2021

Last Name:	First Name:	DOB:		Exam Date:

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.

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:

Physician Assistant

Chiropractor

Advanced Practice Nurse

Other Practitioner (specify):

National Registry Number:

Medical Examiner's Certificate Expiration Date:

Page 5

Instructions MCSA-5875

Instructions for Completing the Medical Examination Report Form (MCSA-5875)

I.Step-By-Step Instructions Driver:

Section 1: Driver information

·Personal Information: Please complete this section using your name as written on your driver's license, your current address and phone number, your date of birth, age, gender, driver's license number and issuing state.

o CLP/CDL Applicant/Holder: Check "yes" if you are a commercial learner's permit (CLP) or com- mercial driver's license (CDL) holder, or are applying for a CLP or CDL. CDL means a license issued by a State or the District of Columbia which authorizes the individual to operate a class of a commercial motor vehicle (CMV). A CMV that requires a CDL is one that: (1) has a gross combina- tion weight rating or gross combination weight of 26,001 pounds or more inclusive of a towed unit with a gross vehicle weight rating (GVWR) or gross vehicle weight (GVW) of more than 10,000 pounds; or (2) has a GVWR or GVW of 26,001 pounds or more; or (3) is designed to transport 16 or more passengers, including the driver; or (4) is used to transport either hazardous materials requiring hazardous materials placards on the vehicle or any quantity of a select agent or toxin.

o Driver ID Verified By: The Medical Examiner/staff completes this item and notes the type of photo ID used to verify the driver's identity such as, commercial driver's license, driver's license, or passport, etc.

o Question: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years? Please check the correct box “yes” or “no” and if you aren't sure check the “not sure” box.

·Driver Health History:

o Have you ever had surgery: Please check “yes” if you have ever had surgery and provide a written explanation of the details (type of surgery, date of surgery, etc.)

o Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements): Please check “yes” if you are taking any diet supplements, herbal remedies, or prescription or over the counter medications. In the box below the question, indicate the name of the medication and the dosage.

o #1-32: Please complete this section by checking the “yes” box to indicate that you have, or have ever had, the health condition listed or the “No” box if you have not. Check the “not sure” box if you are unsure.

o Other Health Conditions not described above: If you have, or have had, any other health condi- tions not listed in the section above, check “Yes” and in the box provided and list those condition(s).

o Any yes answers to questions #1-32 above: If you have answered “yes” to any of the questions in the Driver Health History section above, please explain your answers further in the box below the question. For example, if you answered “yes” to question #5 regarding heart disease, heart attack, bypass, or other heart problem, indicate which type of heart condition. If you checked “yes” to ques- tion #23 regarding cancer, indicate the type of cancer. Please add any information that will be helpful to the Medical Examiner.

·CMV Driver Signature and Date: Please read the certification statement, sign and date it, indicating that the information you provided in Section 1 is accurate and complete.

Page 6

Instructions MCSA-5875

Medical Examiner:

Section 2: Examination Report

·Driver Health History Review: Review answers provided by the driver in the driver health history section 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 operating 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:

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

o Blood Pressure: record the blood pressure (systolic and diastolic) of the driver being examined. A second reading is optional and should be recorded if found to be necessary.

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

o 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.

o 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.

oDoes not meet standards: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41.

oMeets 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.

Page 7

Instructions MCSA-5875

oMeets standards, but periodic monitoring is required: Select this option when a driver is deter- mined to be qualified but needs periodic monitoring and provide an explanation of why periodic monitoring is required. Select the corresponding time frame that the driver is qualified and if select- ing other, specify the time frame.

·Determination that driver meets standards: Select all categories that apply to the driver's certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, driving within an exempt intracity zone, etc.).

oDetermination pending: Select this option when more information is needed to make a qualification decision and specify a date, on or before the 45 day expiration date, for the driver to return to the medical exam office for follow-up. This will allow for a delay of the qualification decision for as many as 45 days. If the disposition of the pending examination is not updated via the National Regis- try on or before the 45 day expiration date, FMCSA will notify the examining medical examiner and the driver in writing that the examination is no longer valid and that the driver is required to be re- examined.

·MER amended: A Medical Examination Report Form (MER), MCSA-5875, may only be amended while in determination pending status for situations where new information (e.g., test results, etc.) has been received or there has been a change in the driver's medical status since the initial examination, but prior to a final qualification determination. Select this option when a Medic- al Examination Report Form, MCSA-5875, is being amended; provide the reason for the amendm- ent, sign and date. In addition, initial and date any changes made on the Medical Examination Report Form, MCSA-5875. A Medical Examination Report Form, MCSA-5875, cannot be amended after an examination has been in determination pending status for more than 45 days or after a final qualification determination has been made. The driver is required to obtain a new phys- ical examination and a new Medical Examination Report Form, MCSA-5875, should be completed.

oIncomplete examination: Select this when the physical examination is not completed for any reason (e.g., driver decides they do not want to continue with the examination and leaves) other than situations outlined under determination pending.

oMedical Examiner information, signature and date: Provide your name, address, phone number, occupation, license, certificate, or registration number and issuing state, national registry number, signature and date.

oMedical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate (MEC) expires.

·Medical Examiner Determination (State): Use this section for examinations performed in accordance with the FMCSRs (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations). Complete the medical examiner determination section completely.

oDoes not meet standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be not qualified and provide an explanation of why the driver does not meet the standards in 49 CFR 391.41 with any applicable State variances.

oMeets standards in 49 CFR 391.41 with any applicable State variances: Select this option when a driver is determined to be qualified and will be issued a 2-year Medical Examiner's Certificate.

·Determination that driver meets standards: Select all categories that apply to the driver's certification (e.g., wearing corrective lenses, accompanied by a waiver/exemption, etc.).

Page 8

Instructions MCSA-5875

oMedical Examiner's Certificate Expiration Date: Enter the date the driver's Medical Examiner's Certificate (MEC) expires.

II.If updating an existing exam, you must resubmit the new exam results, via the Medical Examination Results Form, MCSA-5850, to the National Registry, and the most recent dated exam will take precedence.

III.To obtain additional information regarding this form go to the Medical Program's page on the Federal Motor Carrier Safety Administration's website at http://www.fmcsa.dot.gov/regulations/medical.

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Get Mcsa 5875 PDF Form

Form Characteristics

Fact Name	Details
OMB Control Number	The MCSA-5875 form has the OMB Control Number 2126-0006.
Expiration Date	This form expired on November 30, 2021.
Public Burden Statement	Responding to this information collection is mandatory. The estimated time for completion is approximately 25 minutes.
Medical Examination Purpose	The form is used for medical examination reports required for commercial driver medical certification.
Federal Regulations	It operates under the Federal Motor Carrier Safety Regulations found in 49 CFR 391.41-391.49.

Guidelines on Utilizing Mcsa 5875

Filling out the MCSA 5875 form accurately is essential for commercial driver medical certification. Make sure all sections are completed entirely before submitting to avoid delays in processing. Below are the steps to guide you through filling out the form.

Start with Section 1: Driver Information. Fill in your medical record number or sticker number if applicable.
Provide your personal information: last name, first name, middle initial, date of birth, age, street address, city, state, zip code, driver's license number, issuing state, and phone number. Include your gender and email address if desired.
Indicate whether you are a CLP/CDL applicant or holder by selecting "Yes" or "No."
Verify your identity and record the type of ID used.
Answer the question regarding a past USDOT/FMCSA medical certificate. Mark appropriately.
Proceed to the Driver Health History section. Answer questions about surgeries, current medications, and any specific health conditions. Use "Yes," "No," or "Not Sure" for your responses.
Respond to the detailed health history questions (questions 1-32) regarding various medical conditions like heart problems, vision, hearing, or mental health issues. Attach additional sheets if necessary.
Sign and date the CMV Driver's Signature section certifying the accuracy of your answers.
Once you have completed Section 1, hand the form to your medical examiner for Section 2.
Ensure the medical examiner reviews and completes their part, which includes the examination report and medical determination.

Once you have completed these steps and submitted the form, the medical examiner will review your information and perform the necessary examinations. It’s crucial to retain copies of everything for your records. This will help keep you informed about your health status as it pertains to your ability to drive commercially.

What You Should Know About This Form

What is the MCSA 5875 form used for?

The MCSA 5875 form is a Medical Examination Report that is required for commercial drivers in the United States. It is used to assess the medical fitness of individuals applying for or holding a commercial driver’s license (CDL). This examination evaluates various health factors to ensure that drivers can operate commercial motor vehicles (CMVs) safely.

Who is required to complete the MCSA 5875 form?

Any individual applying for a commercial driver's license (CDL) or a Commercial Learner's Permit (CLP) must complete the MCSA 5875 form. It is essential for drivers to disclose their medical history to demonstrate their ability to safely operate a CMV.

What information is included in the MCSA 5875 form?

The form includes sections where drivers provide personal information, a detailed health history, and answers to specific medical questions. Health areas covered range from past surgeries to conditions like diabetes or heart problems. The form also includes sections for medical examiners to record their findings and determine whether the driver meets the necessary medical standards.

How long does it take to complete the MCSA 5875 form?

On average, drivers can expect to spend about 25 minutes filling out the MCSA 5875 form. This estimate includes time spent reviewing instructions, gathering necessary information, and completing the form.

What happens if a driver answers "yes" to any medical question on the form?

If a driver answers "yes" to any of the medical questions, they may need to provide additional information or documentation. This is crucial so that the medical examiner can accurately assess the driver’s condition and determine their fitness to operate a CMV. Sometimes, further testing or consultation may be required to evaluate the driver’s health status.

What is the role of the medical examiner in the MCSA 5875 process?

The medical examiner is responsible for reviewing the completed form, conducting a physical examination, and determining whether the driver meets the medical standards outlined in federal regulations. They must also sign and date the form upon completion, certifying that they have reviewed all relevant information.

How often must the MCSA 5875 form be completed?

The MCSA 5875 form must typically be completed every two years. However, if a driver has specific medical conditions or if state regulations require more frequent evaluations, the medical certification may need to be updated sooner.

What happens if a driver is deemed as not meeting the medical standards?

If a driver does not meet the medical standards outlined in the MCSA 5875, they may be disqualified from operating a CMV. They could also receive a temporary certification that requires follow-up evaluations. In some cases, drivers might need to treat or manage their health condition before they can be recertified.

Is the information on the MCSA 5875 form confidential?

Yes, the information provided on the MCSA 5875 form is considered sensitive and is for official use only. It should be handled with care to avoid unauthorized disclosure. Only authorized personnel should have access to these documents, and appropriate measures should be taken for disposal once they are no longer needed.

Where can drivers send comments regarding the MCSA 5875 form or suggestions for improvement?

Drivers can send comments or suggestions about the MCSA 5875 form to the Information Collection Clearance Officer at the Federal Motor Carrier Safety Administration (FMCSA). The address is 1200 New Jersey Avenue, SE, Washington, D.C. 20590. This feedback can help improve the process and reduce the burden on those completing the form.

Common mistakes

Filling out Form MCSA-5875 can often feel overwhelming, and mistakes can lead to delays or complications in the medical certification process. One common mistake occurs when individuals fail to accurately provide their personal information. This includes not just the basics like name and address, but also important details such as the driver's license number and issuing state. Even small errors can cause confusion. It's essential to double-check this section before submitting the form.

Another frequent error is failing to fully disclose medical history. The health history section has numerous questions about past and current health issues. Many people may assume that certain conditions or medications are minor and don’t require mentioning. Omitting these details can have serious consequences. Remember, honesty is crucial, as any incorrect information might invalidate the medical examination.

Many applicants neglect to thoroughly review the health history questions. Each question is designed to determine a driver's ability to safely operate a commercial vehicle. It’s easy to overlook answering “yes, no, or not sure” accurately for all items listed. A missed question or an unclear response could lead to additional scrutiny or a failed certification. Take your time to read through this section carefully.

Finally, individuals often forget to sign the form. While it may seem minor, a missing signature can completely halt the process. The driver's signature not only confirms that the information provided is accurate but also acknowledges the potential consequences of submitting false or misleading details. Be sure to give the form a final review and ensure that all required signatures are included before submission.

Documents used along the form

The MCSA-5875 form is a critical document used in the process of obtaining a medical certification for commercial drivers. It captures key health information about the individual and is essential for ensuring that drivers meet federal safety standards. Alongside this form, there are several other documents that are commonly utilized. Together, they create a comprehensive medical profile that aids in the assessment of a driver's fitness to operate commercial motor vehicles.

Medical Examiner's Certificate: This document is issued by the medical examiner after reviewing the driver's health history and conducting a thorough examination. It certifies whether the driver meets the health standards required for operating a commercial vehicle. This certificate typically indicates the duration until which the driver is certified, which can vary based on their health status.
Medical History Questionnaire: Often completed before the medical examination, this form gathers detailed health information from the driver. It asks about previous surgeries, medications, chronic conditions, and other health-related questions that might impact driving ability. This questionnaire serves as a preliminary assessment of the driver's health.
Vision and Hearing Test Results: These are separate records indicating the results of vision and hearing tests, which are vital for ensuring that drivers can respond appropriately to traffic signals and sounds. These tests help determine if corrective measures, such as glasses or hearing aids, are necessary.
Drug and Alcohol Testing Results: Documentation relating to any drug and alcohol tests performed on the driver is essential. This ensures compliance with federal and state regulations regarding substance use. These test results may be required to confirm the driver’s eligibility.
Driver Qualification Files: Employers are required to maintain a driver qualification file that contains all necessary documentation. This includes the MCSA-5875 form, Medical Examiner’s Certificate, and other records proving that the driver is qualified. These files are crucial for audits and compliance checks by regulatory agencies.
State-specific Medical Forms: Depending on the state, additional forms may be required to align with local regulations. These can add further details or requirements for state-operated programs, reflecting the variance in laws that might apply.

Each of these documents plays a significant role in the broader evaluation process. Together, they ensure that drivers are medically fit to operate commercial vehicles, prioritizing safety for everyone on the road. Accurate and thorough documentation is vital in maintaining compliance with federal regulations, ultimately protecting public safety.

Similar forms

Medical Examiner's Certificate: Similar to the MCSA-5875, this document certifies a driver's medical fitness to operate a commercial vehicle. It provides essential details about the medical examination and validities the driver's health status.
DOT Medical Examination Report (Form MCSA-5876): This form also assesses a driver's medical history and physical condition. It includes sections for health evaluations and ensures compliance with federal safety regulations.
DOT Drug and Alcohol Testing Form: Like the MCSA-5875, this document is vital for safety in commercial driving. It records results from mandatory drug and alcohol tests for drivers, ensuring that they meet required standards for safe operation.
Commercial Driver's License Application: This application captures essential personal details and qualifications, much like the driver information section in the MCSA-5875 form. It helps assess eligibility to obtain a commercial driver's license.
Driver Qualification File: A compilation of documents related to a driver’s qualifications. It includes medical examination reports and driving records, similar in purpose to the MCSA-5875, ensuring driver safety on the road.
Health History Questionnaire: A form that gathers extensive health information about a driver, akin to the health history section in the MCSA-5875. It helps identify any medical issues that might affect a driver's ability to drive safely.
Pre-Employment Screening Report: This document serves as a background check for potential drivers, including medical evaluations, much like the MCSA-5875, ensuring that only qualified individuals are driving commercial vehicles.
Driver Incident Report: Used to document any incidents involving a commercial driver, this report shares similarities with the MCSA-5875 in that both aim to improve road safety. It provides insights into any medical issues that may have contributed to an incident.

Dos and Don'ts

When filling out the MCSA 5875 form, follow these guidelines to ensure accuracy and completeness.

Double-check all personal information, including your name, date of birth, and address.
Provide a valid driver's license number and the issuing state, as this information is essential.
If you have had any surgeries, medications, or medical conditions, be honest and thorough in your disclosures.
Seek assistance if you are unsure about any questions, especially those related to your health history.
Sign and date the form, confirming the accuracy of the information provided.

Conversely, avoid these common pitfalls while completing the form.

Do not leave any sections blank; this can lead to delays in processing.
Avoid providing incomplete or vague answers, as they may raise concerns about your qualifications.
Never attempt to falsify information; doing so can have serious legal consequences.
Do not forget to review the entire form after completion to catch any potential errors.

Misconceptions

Misconception 1: The MCSA 5875 form is optional.

This form is mandatory for commercial drivers seeking medical certification. Completing it is required to ensure that drivers meet health standards necessary for safe operation of commercial vehicles.

Misconception 2: Only drivers with health issues need to complete the MCSA 5875 form.

All drivers, regardless of their health, must fill out the MCSA 5875 form. It captures necessary health history, which is vital for assessing fitness to drive.

Misconception 3: The medical examiner only looks at my most recent health issues.

The medical examiner reviews the entire health history provided on the form. This inclusive approach helps in identifying potential risks that may not be immediately apparent.

Misconception 4: I can skip questions I think are irrelevant.

It's essential to answer all questions truthfully and completely. Skipping questions can lead to disqualification from obtaining a medical certificate.

Misconception 5: My medical history is private and won't be shared.

While personal information is protected, it is shared with relevant authorities as required for the certification process. Proper handling and compliance with confidentiality regulations are crucial.

Misconception 6: The MCSA 5875 form is only for drivers with a commercial driver's license (CDL).

It also applies to those seeking a commercial learner's permit (CLP). Anyone aiming to operate commercial motor vehicles must complete the form regardless of their current licensing status.

Misconception 7: A driver can only be certified for two years.

While many drivers do receive a two-year certification, some may be eligible for shorter durations or even longer ones depending on their health status and the medical examiner's evaluation.

Key takeaways

Filling out and using the MCSA 5875 form effectively is crucial for commercial drivers seeking medical certification. Here are some key takeaways:

Accurate Information is Essential: Drivers must provide truthful and complete answers on their medical history. Inaccuracies may invalidate the medical examination and the certification.
Health History Review: Both the driver and the medical examiner should thoroughly discuss any pertinent health issues that could impact safe vehicle operation. This review is an integral part of the evaluation process.
Time Commitment: Expect to spend approximately 25 minutes completing the form. This includes reviewing instructions, gathering necessary information, and filling out the details required.
Mandatory Response: All information requested on the MCSA 5875 form is required. Failure to complete it properly may lead to penalties under federal regulations.

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Qualification Certificate,Professional Certification Document,Authority Verification Form,Certification Record,Standards Compliance Certificate,Qualification Verification Form,Credentialing Document,Certification of Expertise,Professional Validation - Form number is DD Form 1902, revised in May 1991.