The links below provide access to both electronic and printonly versions of the forms. Txdot is working to make electronic forms compatible with all browsers. Idot pdf forms can be opened directly when using internet explorer. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate mec, form. If any additional testing or exams are needed besides those noted above, additional authorization is needed this includes any additional testing to complete dot exam. Once your physical is complete, the medical examiner will give you a medical examiners certificate form mcsa5876. A medical examiners certificate, which is commonly known as a dot medical card, provides proof the driver has met the medical requirements to hold a cdl. Department of transportation federal motor carrier safety administration. Our physicians can prepare a completed medical examination report form. Fmcsa form mcsa5875 us department of transportation. Materials certification exception summary ms word document construction forms. To obtain a form by mail, call dmvs automated phone service 24 hours a day, 7 days a week at 180077703.
Cdl drivers dot physical exam form 5875 pdf medical card. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form. The date found on the top right corner of the medical. Release of information form 49 cfr part 40 drug and alcohol testing suggested format dot agency specific documents. To order printed forms complete dt1435 request for forms or contact maps and publications, wisconsin department of transportation, p. Medical examination report mer form, mcsa5875 federal. Certification of physical exemption 49 cfr part 3990 cdl10 these forms allow you to certify to one of the cdl categories listed below, which determines if a medical variance or a u. About the medical examination report mer form, mcsa5875the federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Medical examination report form for commercial driver medical certification u.
Pdf versions of the forms are available at these links on the fmcsa. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form. Page includes various formats of dot physical form for pdf, word and excel. Medical examiners certificate mec, form mcsa5876 this form is an example of what certified drivers can expect. The information i have provided regarding this physical examination is true and complete. Medical examiners certificate mec, form mcsa5876 fmcsa.
The dot 649 f form does not require any additional documents. About the medical examiners certificate mec, form mcsa5876. If you have problems with acrobat reader or our pdf form, select pdf troubleshooting. Medical examination report mer form, mcsa5875 this form is an example of what patients can expect. Personally identifiable information access request form. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Regulatory exam authorization form employers authorizing regulatory exams such as respirator clearance and medical surveillance should complete the attached and send it in with the employee. A complete medical examination report form, mcsa5875, with any attachments embodies my. The dot physical examination forms medical examination report mer and medical examiners certificate mec are available from the federal motor carrier safety. Medical certificates and selfcertification the governor has issued a proclamation allowing waivers and extensions to certain cdl and clp holders. Most of what we consider as physical capability has. Abdomen and viscera enlarged liver, enlarged spleen, masses, bruits, hernia, signi.
Division of personnel application for examination employment history supplemental form. A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a. Our physicians can prepare a completed medical examination report form for your certification. Dot physical medical forms are forms for those who need to take part in the medical exam of the dot physicals.
Dot physical authorization form authorization must be presented to receive services give to patient to hand carry or fax to location you plan on using see above for list of facilities and fax. An annual medical physical examination, or annual checkups as they are commonly dubbed, is the general process of having your body physically assessed by a healthcare worker, such as a. Section 1, the vision report, must be completed, signed, and dated by a licensed ophthalmologist, optometrist, or. Extremities limb be subject to spe certificate if otherwise qualified. Got all the way thru and when i hit the print forms. Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, cyanosis. It is mandated by federal guidelines that all commercial drivers pass the department of transportation physical. Medical examination report for commercial driver fitness. As a part of the medical certification process for insulin treated diabetes mellitus itdm individuals, the federal motor carrier safety administration requires that the insulin treated diabetes mellitus assessment form. Mcsa5876 form fmcsa us department of transportation. It is summarized to provide a quick reference source for questions that may arise while performing a dot physical. Mar 09, 2018 this entry was posted in news and tagged dot medical exam, dot medical guidelines diabetes, dot physical, dot physical form on march 9, 2018 by admin. Dot physical exam forms are the main forms used to guarantee that the person is able to take the exam.
Includes instructions to physician, minimum requirements and physical qualifications for commercial drivers. December 2014 department of the treasury internal revenue service request for taxpayer identification number and certification give form online w9 2017 form if you are providing form w9 to an ffi to document a joint account each holder of the account that is a u. Includes cdl nrcme medical card certificate on page 9. A physical form is a type of form that is used as a means of evaluating an individuals physical capabilities so as to determine whether they are allowed to compete, work or even perform a certain task. I, the undersigned, hereby certify that all the information furnished on this form is true and correct.
South dakota dot physical exam for cdl federal guidelines mandate that anyone applying for a cdl must pass the department of transportation physical exam. Driver history abstract request official government use only form do21b pdf, rev 0119 driver license application request official government use only form do11c pdf, rev 0119 federal medical examiner certificate. Vascular system abnormal pulse and amplitude, carotid or arterial bruits, varicose veins. Cdl drivers dot medical exam form 649f pdf 9 pages. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. As part of the motor carrier safety improvement act, the federal motor carrier safety administration fmcsa amended the federal motor carrier safety regulations fmcsrs to require commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiner. To avoid a downgrade or cancellation of your cdlclp, you must take this certificate to the dmv when you apply for your clpcdl, or faxemail it to the ny state dmv medical certification unit. These are to see if the person has any conditions that could prevent him or her from driving.
A physical form or physical examination forms are usually used by a nurse or a clinician when conducting a physical assessment. For large quantities, please read ordering dmv forms in large quantities. The purpose of this test is to check whether an applicant is fit enough to drive safely at the present time as well as in the foreseeable future. Obtain a commercial drivers license learners permit. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration fmcsa national registry. Florida dot physical form get the florida dot medical card form. If the medical examiner determines that the driver examined is physically qualified to drive a commercial motor vehicle in accordance with the physical qualification standards, the medical examiner will complete and provide the driver with a medical examiners certificate mec, form mcsa5876. Pass a dot physical examination and provide the bmv with an valid medical examination report mer and medical examiners certificate mec. Medical examination report of driver under article 19a.
Incomplete examination once you begin the exam process by providing the medical history portion of the exam form mcsa5875 to our staff, the medical examiner must report the. Insulintreated diabetes mellitus assessment form, mcsa5870. Dot physical forms and others to fill out before your visit. Indiana dot physical exam for cdl federal guidelines mandate that anyone applying for a cdl must pass the dot health exam. Dot physical application forms are the kind of forms. Post navigation form for every driver physical examination performed in accordance with 49 cfr 391. This physical can be conducted by either your primary car physician or at a occupational health center. Includes instructions to physician, minimum requirements, physical qualifications and cdl medical certificate for commercial drivers. Dot physical form download free documents for pdf, word and. Pdf versions of the forms are available at these links on the fmcsa website.
As part of the motor carrier safety improvement act, the federal motor carrier safety administration fmcsa amended the federal motor carrier safety regulations fmcsrs to require commercial drivers license cdl holders, subject to the physical qualification requirements of the fmcsrs, to provide a current copy of their medical examiners. After december 12, 2015, mcs150 and opseries forms can only be used to update company records or apply for additional. Its like having the answers before you take the test. Discussion in ups discussions started by brownmonster, may 14, 2012. Dot medical examination formscertificate download dot. Dec 18, 2019 medical applications and forms medical examinations. I hereby authorize the social security administration to release to the department of transportation. Minnesota rail service improvement program loan application pdf 102 kb, pp labor compliance. Welcome to the forms resource page for the division of driver licensing. If additional space is required for further comments and information, use form ds874c, and attach it to this form. Commercial driver examination course given february 20th, 2009. Commercial driver license cdl medical certification requirement. The dot physical exam looks for certain preexisting medical conditions that might impair a drivers ability to safely operate a commercial motor vehicle.
Marshall island physical exam formguidance on medical exams and. New dot medical certification forms mcsa dot physical doctors. Electronic forms only work with microsoft internet explorer. Record what type of photo id was used to verify the identity of the driver, e.
Any charges or fees for the medical or vision examinations and the preparation or completion of this form. Nov 26, 2018 the federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. The department of transportation dot requires commercial motor vehicle cmv operators to have the dot physical exam to maintain their driver certification. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Medical applications and forms medical examinations. The following is a complete list of forms for the selected alphabet letter. Pass a skills test in a vehicle class you intend to operate. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. I authorize the examining physician to disclose to the client organization all information learned and findings made by him in the course of the examination or stated on this form. Cdl drivers dot medical exam form 649f pdf1 updated 1162015. Documents and forms us department of transportation. Some of these tests may require an additional fee, such as an audio booth hearing examination andor an ecg. Refer to the faq for workarounds in other web browsers.
New cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. Each original paper or electronic completed medical examination report form must be retained on file at the office of the medical examiner for at least 3 years from the date of. To find help on which form you need, or if you cannot find the form you are looking for, please visit the wisdot contacts page or the division of motor vehicles dmv contacts. What is a dot medical exam it is an exam that indicates an individual is physically qualified to operate a commercial motor vehicle in accordance with 49 cfr 391. The pennsylvania department of transportation penndot offers many driver and vehicle forms online, though some are only available in person as indicated. As you may or may not know, all cdl drivers and anyone who operates vehicles that require a hoisting license must possess a dot medical card. Cdl drivers dot physical exam form 649f pdf medical card. Starting may 21, 2014, all commercial motor vehicle drivers must have a physical performed by a medical examiner listed on the national registry of certified medical examiners. The forms are grouped by officebureau and sorted by form number. Medical examiners certificate mec, form mcsa5876 this form. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration.
About the insulin treated diabetes mellitus itdm assessment form, mcsa5870. Adobe reader is required for all pdf files and microsoft excel and word or open office for all excel and word documents. Department of transportation dot medical examiners certificate is required to be on file with the department. Drivers vehicle inspection report check any defective item and give details under remarks. Dot physical form fill online, printable, fillable, blank pdffiller. The purpose of this exam is to check whether an applicant is fit enough to drive safely now and in the foreseeable future.
Sections 1 and 2 must be signed and dated not more than 90 days before the date this form is submitted to the nevada dmv. After december 12, 2015, mcs150 and opseries forms can only be used to update company records or apply for additional authorities, not for initial registration with fmcsa. Submit only the medical doctor or osteopathic physician evaluation page, located at the end of this form, to employer for drivers 70 years of age and older authority. Fees for these services are available upon request. Medical examination report mer form, mcsa5875 fmcsa. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. A cdl skills exam must be taken at one of the authorized cdl driving skills exam. For your convenience, many dmv pdf forms can be filled in online and then printed.
Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. There are various types of these kinds of dot physical assessment forms that allow any company or person to see if theyre ready to operate any kind of commercial vehicle for any purpose. A physical exam or a physical assessment is an important means of preventive medicine for everyone regardless of race, age, sex, or level of activity. Forms library tc 94 kytc kentucky transportation cabinet. Insulintreated diabetes mellitus assessment form, mcsa. The mer will be completed online at the center and does not need to be printed and completed beforehand. The secretary of the department of transportation is, by statute, responsible for the decision of drivers licensing. Dot medical exam and commercial motor vehicle certification about the exam. Dot medical guidelines diabetes certified dot physical. Dot physical authorization form cornell university. Cdl dot medical department of revenue motor vehicle.
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