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Click ‘Get Form’ to open the MCSA-5875 form in the editor.
Begin by filling out Section 1, Driver Information. Enter your personal details such as Last Name, First Name, Address, and Date of Birth. Ensure all fields are completed accurately.
Proceed to the Driver Health History section. Answer each health-related question honestly by selecting 'Yes' or 'No'. If you answer 'Yes' to any questions, provide additional comments as needed.
Complete the Driver Lifestyle Questions by indicating your current habits regarding tobacco and alcohol use.
Sign and date the form at the bottom of Section 1 to confirm that all information provided is accurate.
If you are a medical examiner, fill out Section 2 with examination results and ensure all necessary tests are recorded.
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You may submit your documents by either: Submitting a Ticket to the FMCSA Contact Center (complete the required fields and upload your documents). Faxing the form and supporting documents to 202-366-3477.
Who fills out MCSA 5875?
This form provides authorization to the Federal Motor Carrier Safety Administration to publish hearing or seizure exemption information in a public docket. FMCSA. Federal Motor Carrier Safety Administration. .fmcsa.dot.gov. AUTHORIZATION FOR RELEASE OF INFORMATION.
How to submit forms to FMCSA?
Before 2014, any doctor could complete a DOT exam, but now the doctor must have completed specific training, passed an exam, and be registered with the FMCSA. This means that you cannot go to your local doctors office for your DOT physical unless they have a staff member who is qualified to give the examination.
Can my regular Dr. do a dot physical?
What Do I Need to Bring to a DOT Physical Exam? Current drivers license. Full medical history. List of current medications. FMCSA medical examination report form (optional)
What is a MCSA 5875?
As part of the physical, drivers are required to fill out the medical history portion of the Medical Examination Report (MER) Form, MCSA-5875.
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Form MCSA-5875. OMB No.: 2126-0006 Expiration Date: 03/31/2025. Page 2. Last Name: First Name: DOB: Exam Date: DRIVER HEALTH HISTORY (continued). CMV DRIVERS
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