(for Commercial Driver Medical Certification)
SECTION 1. Driver Information (to be filled out by the driver)
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.
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?If “yes,” please describe below.
Other health condition(s) not described above:
Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below:
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.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
SECTION 2. Examination Report (to be filled out by the medical examiner)
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).
TESTING
Blood Pressure
Sitting
Second reading(optional)
Urinalysis is required.Numerical readings must be recorded.
Protein, blood, or sugar in the urine may be an indication for further testing torule 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 corrective lenses should be noted on the Medical Examiner’s Certificate
Acuity
Right Eye:
Left Eye:
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).
Whisper Test Results
Record distance (in feet) from driver at which a forced whispered voice can first be heard
OR Audiometric Test Results
Right Ear:
Left Ear:
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
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.
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):
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 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):
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.
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.DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I. Step-By-Step Instructions
Driver:
Section 1: Driver Information
Medical Examiner:
Section 2: Examination Report
In this next section, you will be completing either the Federal or State determination, not both.
II. If updating an existing exam, you must resubmit the new exam results, via the Medical ExaminationResults 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 FederalMotor Carrier Safety Administration’s website at http://www.fmcsa.dot.gov/regulations/medical.
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