Form Mcsa 5875 Printable Version

Form Mcsa 5875 Printable Version 1 The MEC Form MCSA 5876 can be reduced in size as long as all the content is readable 2 The MEC Form MCSA 5876 may be printed in black and white These are the only changes allowed

The medical examiner must make all records and information in these files available to an authorized representative of FMCSA or an authorized Federal State or local enforcement agency representative within 48 hours after the request is made 49 CFR 391 43 i FMCSA National Registry Transportation Login

Medical Examiner s Certificate Form MCSA 5876 pdf 96 01 KB About the Medical Examiner s Certificate MEC Form MCSA 5876 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

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Form Mcsa 5875 Printable Version

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Medical Examination Report Form Federal Motor Carrier

https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/2022-03/…
Form MCSA 5875 OMB No 2126 0006 Expiration Date 3 202 Page 1 U S Department of Transportation Federal Motor Carrier Safety Administration Rev 3 29 2022 Public Burden Statement

Medical Applications And Forms FMCSA

https://www.fmcsa.dot.gov//medical-applications-and-forms
Medical Examination Report MER Form MCSA 5875 Medical Examiner s Certificate MEC Form MCSA 5876 Vision Evaluation Report Form MCSA 5871 391 41 CMV Driver Medication Form MCSA 5895 optional Medical Exemptions Diabetes Package This package has been removed due to the update of the Diabetes Standard

Medical Examination Report Form Federal Motor Carrier Safety

https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/regu…
Form MCSA 5875 OMB No 2126 0006 Expiration Date 9 30 2019 Medical Examination Report Form for Commercial Driver Medical Certification U S Department of Transportation Federal Motor Carrier Safety Administration Public Burden Statement

Medical Examiner s Certificate Federal Motor Carrier Safety

https://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Med…
A complete Medical Examination Report Form MCSA 5875 with any attachments embodies my findings completely and correctly and is on file in my office Medical Examiner s Signature Medical Examiner s Name please print or type Medical Examiner s State License Certificate or Registration Number Medical Examiner s

Medical Examination Report Form Mhsystem

https://mhsystem.org//mohp/MedicalExaminationReportForm(…
Form MCSA 5875 OMB No 2126 0006 Expiration Date 11 30 2021 Last Name First Name DOB Exam Date DRIVER HEALTH HISTORY continued Do you have or have you ever had Yes No Not Sure 1 Head brain injuries or illnesses e g concussion 2 Seizures epilepsy 3 Eye problems except glasses or contacts 4 Ear and or hearing problems 5

PDF Versions of the forms are available at these links on the FMCSA website Medical Examination Report MER Form MCSA 5875 Medical Examiner s Certificate MEC Form MCSA 5876 The date found on the top right corner of the Medical Examination Report Form MCSA 5875 and Medical Examiner s Certificate MCSA 5876 Form MCSA 5875 OMB No 2126 0006 Expiration Date 03 3 202 5 Page 3 Last Name First Name DOB Exam Date TESTING PHYSICAL EXAMINATION Pulse Rate Pulse rhythm regular Yes No Height feet inches Weight pounds Blood Pressure Systolic Diastolic Sitting Second reading optional Urinalysis Sp Gr Protein Blood Sugar

The Form MCSA 5875 Medical Examination Report Form U S Department of Transportation form is 5 pages long and contains 4 signatures 30 check boxes 270 other fields Country of origin US File type PDF BROWSE U S DEPARTMENT OF TRANSPORTATION FORMS Related forms Form MCSA 5876 Medical Examiner s