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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where you will enter your personal information. Fill in your last name, first name, middle initial, date of birth, age, and contact details including street address, city, state/province, and zip code.
Indicate your driver's license number and issuing state/province. Specify your gender and whether you are a CLP/CDL applicant/holder. If applicable, provide the type of photo ID used for identity verification.
In the Driver Health History section, answer questions regarding past surgeries and current medications. Be thorough in your responses to ensure accurate medical evaluation.
Continue through the health history questions (1-32), marking 'Yes', 'No', or 'Not Sure' as appropriate. Provide additional comments if you answered 'Yes' to any question.
Finally, sign and date the form in the CMV Driver's Signature section to certify that all information is complete and accurate.
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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?
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.
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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FMCSA Form MCSA-5875
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Have you ever had surgery? If yes, please list and explain below.
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