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Click ‘Get Form’ to open the MCSA-5875 in the editor.
Begin with Section 1: Driver Information. Fill in your personal details including last name, first name, date of birth, and address. Ensure accuracy as this information is crucial for your medical certification.
Complete the Driver Health History section by answering questions about past surgeries and current medications. Be honest and thorough; any 'yes' answers will require further explanation.
Sign and date the CMV Driver's Signature section at the end of Section 1, certifying that all provided information is accurate.
If you are a medical examiner, proceed to Section 2: Examination Report. Review the driver’s health history and conduct necessary tests such as blood pressure and vision checks.
Finalize by completing either the Federal or State Medical Examiner Determination section based on your findings.
Start filling out your MCSA-5875 form online for free today!
As part of the physical, drivers are required to fill out the medical history portion of the Medical Examination Report (MER) Form, MCSA-5875.
Who fills out MCSA-5875?
DOT disqualifying medical conditions include those that may lead to loss of consciousness or involve inadequate hearing or vision, a compromised nervous system, or physical limitations that interfere with driving ability.
What is MCSA 5876?
As a part of the medical certification process for treated diabetes mellitus (ITDM) individuals, the Federal Motor Carrier Safety Administration requires that the Treated Diabetes Mellitus Assessment Form (ITDM), MCSA-5870, be completed by the ITDM individuals Treating Clinician attesting that the
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Form, MCSA-5875. The driver is required to obtain a new physical examination and a new Medical Examination Report Form, MCSA-5875, should be completed.
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