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This version of the form is not currently in use and is provided for reference only. Download this version of
Form MCSA-5875
for the current year.
Form MCSA-5875 Medical Examination Report Form (For Commercial Driver Medical Certification)
What Is Form MCSA-5875?
Form MCSA-5875, Medical Commercial Driver Medical Certification) , is a document released for those individuals who work as commercial motor vehicle drivers and need to go through a medical examination. The purpose of the application is to gather information about a filer's medical history.
The document is used by commercial motor vehicle drivers all over the U.S. since they are required to pass a physical in order to start driving. The application is a part of the physical and contains a large amount of data about a driver's health.
MCSA-5875 was issued by the U.S. Department of Transportation, Federal Motor Carrier Safety Administration , and was last revised on . An MCSA-5875 printable form is available for download below.
Form MCSA-5875 Instructions
The application is presented on five pages, which are accompanied by instructions on how to complete it. An MCSA-5875 Form consists of several parts which include the following:
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Driver's Information . This section is supposed to be filled out by a driver. The gaps here are organized in groups and are divided into several parts, such as:
- Driver's personal information . In the first section, a filer must enter their full name, date of birth, age, address, driver's license number, email, etc.;
- Driver's health history . Individuals use this part to report any surgeries they have had, any type of medication they are taking, injuries, diseases, and any other health problems that are listed there. For example, nerve problems, anxiety, high blood pressure, etc.;
- Driver's signature . Filers must sign the form under the statement where they verify that the information they designated there is full and correct.
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Examination Report . The second part of the application must be filled in by a medical examiner. After reviewing the driver's information and discussing it with them, they must designate certain data about the driver's health, including:
- Driver's health history review . In this part of the form, an examiner must comment on driver's health history answers, that may affect their ability to operate a commercial motor vehicle;
- Testing information . After examining a driver, a physician must enter the data they received in the document. It must include the patient's blood pressure, pulse rate, height, weight, etc. A doctor must also test the driver's vision, hearing, urinalysis, and designate the results in the application as well;
- Information about the driver's physical examination . Here an examiner must state any abnormalities a driver's body system has. After that, they should discuss it in the designated place in the document and indicate if it can affect a driver's safe operation of a commercial motor vehicle;
- Medical examiner determination . Doctors use this part, to sum up the information throughout the document and enter their personal information, such as their full name, address, telephone number, etc. A doctor must also sign the document and state information about their license or certificate.
The last section of the application consists of two parts: State medical examiner determination, and Federal medical examiner determination, an examiner must fill in only one of them. If they performed their examinations following the Federal Motor Carrier Safety Regulations, they should complete the federal medical examiner determination.
If a doctor performed their examinations in accordance with the Federal Motor Carrier Safety Regulations with any applicable State variances, they should complete the state medical examiner determination.
Download Form MCSA-5875 Medical Examination Report Form (For Commercial Driver Medical Certification)
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