Certified medical examiners use this report to record an interstate commercial motor vehicle driver's DOT physical against the qualification standards in 49 CFR 391.41. The driver fills in Section 1 with personal details and a 32-question health history, and the examiner records the review, testing, physical exam and a federal or state determination. A qualified driver receives the Medical Examiner's Certificate (MCSA-5876), while the report stays in the examiner's files.
The driver completes Section 1, Driver Information and Driver Health History, and signs it; the examiner's staff records the photo ID used to verify identity. A medical examiner certified on FMCSA's National Registry completes Section 2: the health history review, testing, physical examination and either the Federal or the State determination.
The driver enters their name as written on the driver's license, current address, phone, date of birth, age, license number and issuing state, and checks whether they hold or are applying for a commercial learner's permit or CDL; the instructions define which vehicles require a CDL. The examiner or staff completes Driver ID Verified By with the type of photo ID used, such as a CDL, driver's license or passport. The driver also answers whether a medical certificate was ever denied or issued for less than two years.
The driver answers yes, no or not sure to prior surgery, current medications (including over-the-counter drugs, herbal remedies and supplements, with names and doses) and questions 1 to 32, which run from head injuries, seizures and heart disease to diabetes with insulin use, sleep disorders, alcohol and drug use. Any other conditions are listed, and every yes answer is explained in the comment box. The driver then signs a certification that the answers are accurate and complete, acknowledging that false information may invalidate the exam and certificate.
The examiner reviews the driver's answers, discusses every yes and not sure response, and compares the medication list with the reported conditions to make sure they match. Record anything the driver omitted and comment on responses that may affect safe CMV operation, drawing on available medical records. The examiner must finish the entire examination even after finding a condition considered disqualifying, and a disqualifying condition for which FMCSA has granted an exemption is recorded on both this report and the MCSA-5876.
Record pulse rate and whether the rhythm is regular, height and weight. Record a sitting blood pressure, systolic and diastolic, and a second reading when needed. Urinalysis is required and the form asks for numerical readings for specific gravity, protein, blood and sugar. The form notes that protein, blood or sugar in the urine may be an indication for further testing to rule out an underlying problem, and there is space for other testing if indicated.
The vision standard is at least 20/40 Snellen acuity in each eye with or without correction and at least 70 degrees of horizontal field in each eye. Record uncorrected and corrected acuity, using Snellen-comparable values if another chart is used, and fields; note color signal recognition, monocular vision, any referral to an eye specialist and documentation received. For hearing, record a forced whisper first heard at 5 feet or more, or audiometric results at 500, 1000 and 2000 Hz with an average loss of 40 dB or less in the better ear, and whether a hearing aid was used.
Mark each of 14 body systems normal or abnormal, from general appearance, skin, eyes and ears through cardiovascular, lungs, abdomen, genito-urinary system including hernias, back, extremities, neurological system including reflexes, gait and vascular system. Discuss every abnormal finding in detail, entering the item number before each comment, and state whether it would affect the driver's ability to operate a CMV safely. The form reminds examiners that a controlled condition may not be disqualifying and that temporary deferral is an option.
Complete this section, not the State one, for exams under 49 CFR 391.41-391.49. Choose does not meet standards with the reason, meets standards with a 2-year certificate, or meets standards with periodic monitoring for 3 months, 6 months, 1 year or another period with the reason. Check every condition that applies: corrective lenses, hearing aid, waiver or exemption, Skill Performance Evaluation certificate, or exempt intracity zone. English language proficiency is not part of this determination. Then add the examiner's details, National Registry number, signature, date and the certificate expiration date.
Choose determination pending when more information is needed, and give a return date no more than 45 days away. The report may be amended only while pending, when new results arrive or the driver's status changes; give the reason, sign and date, and initial and date each change. Choose incomplete examination when the exam is not finished for another reason, such as the driver leaving. If the pending exam is not resolved in the National Registry by the 45-day date, it is no longer valid.
Use this section instead of the Federal one for exams under 49 CFR 391.41-391.49 with any applicable State variances, which are valid only for intrastate operations. The options are does not meet standards with State variances, meets standards (a 2-year certificate), or meets standards with periodic monitoring and a set period. Conditions include corrective lenses, hearing aid, waiver or exemption, SPE certificate and grandfathered from State requirements. The examiner completes the same identity, license, National Registry number, signature and expiration date fields.
Download the current version from the source each time; forms change without notice.
Medical Examination Report Form (for Commercial Driver Medical Certification)
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Sources for this guide
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Only a medical examiner listed on FMCSA's National Registry of Certified Medical Examiners. Eligible professions include MDs, DOs, physician assistants, advanced practice nurses, chiropractors and other licensed practitioners, and each must complete National Registry training and pass the certification test. The examiner checks the matching credential box beside the signature in the determination section.
At least 3 years. The completed report, with any attachments, stays in the examiner's records, while a qualified driver leaves with the separate MCSA-5876 certificate. The examiner must also report the results of every exam to the National Registry by midnight local time of the next calendar day.
Up to 24 months. Meets standards in 49 CFR 391.41 qualifies the driver for a 2-year certificate. When a condition needs periodic monitoring, the examiner checks 3 months, 6 months, 1 year or another period and explains why, and enters the matching expiration date for the Medical Examiner's Certificate.
Only while the exam is in determination pending status, when new information such as test results arrives or the driver's medical status changes before a final decision. The examiner gives the reason, signs and dates, and initials and dates each change. After 45 days pending or after a final determination, the driver needs a new exam and a new report.