B.06.05 Attachment 7 - MCSA Medical Examiner's Cert for Commerical Driver Medical Certification.pdf
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Form MCSA-5876 OMB No. 2126-0006 Expiration Date: 11/30/2021
Medical Examiner's Certificate (for Commercial Driver Medical Certification)
U.S. Department of Transportation Federal Motor Carrier Safety Administration
Public Burden Statement 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 collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 1 minute per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
I certify that I have examined Last Name: First Name: in accordance with (please check only one):
the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply) OR 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), and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply):
Wearing corrective lenses
Wearing hearing aid Accompanied by a waiver/exemption Accompanied by a Skill Performance Evaluation (SPE) Certificate
Driving within an exempt intracity zone (49 CFR 391.62) (Federal)
Qualified by operation of 49 CFR 391.64 (Federal)
Grandfathered from State requirements (State)
The information I have provided regarding this physical examination is true and complete. 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 Certificate Expiration Date
Medical Examiner's Signature Medical Examiner's Telephone Number Date Certificate Signed
Medical Examiner's Name (please print or type) MD
DO
Physician Assistant
Chiropractor
Advanced Practice Nurse
Other Practitioner (specify)
Medical Examiner's State License, Certificate, or Registration Number Issuing State National Registry Number
Driver's Signature Driver's License Number Issuing State/Province
CLP/CDL Applicant/Holder
Yes No
Driver's Address
Street Address: City: State/Province: Zip Code:
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.** https://www.fmcsa.dot.gov/regulations/title49/part/391 https://www.fmcsa.dot.gov/regulations/title49/part/391 http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=391.62 http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=391.64
Form MCSA-5876 OMB No. 2126-0006 Expiration Date: 11/30/2021 Medical Examiner's Certificate (for Commercial Driver Medical Certification) .\MCS-150C\US_DOT_logo.tif U.S. Department of Transportation logo U.S. Department of Transportation logo U.S. Department of Transportation Federal Motor Carrier Safety Administration Public Burden Statement 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 collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 1 minute per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
I certify that I have examined in accordance with (please check only one):
Select one of the following buttons. This is a required field.
I find this person is qualified, and, if applicable, only when (check all that apply):
The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form, MCSA-5875, with any attachments embodies my findings completely and correctly, and is on file in my office.
Select one button to describe Medical Examiner's practice. This is a required field.
CLP/CDL Applicant/Holder Indicate whether Medical Examiner has or has applied for a CLP/CDL.
Driver's Address **This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**
9.0.0.2.20101008.1.734229 Medical Examiner's Certificate Craig Federhen MCSA-5876 Form
| Enter the driver's last name. This is a required field.: |
| Enter the driver's first name. This is a required field.: |
| fedButton: |
| stateButton: |
| Check if driver wears corrective lenses.: 0 |
| Check if driver wears a hearing aid.: 0 |
| Check if driver has an exemption certificate.: 0 |
| Please enter the type of waiver or exemption here.: |
| Check if driver has a Skill Performance Evaluation certificate.: 0 |
| Check if driver is qualified for driving within an exempt intracity zone, as defined by 49 CFR 391.62.: 0 |
| Check if driver is qualified by operation of 49 CFR 391.64: 0 |
| Check if driver is grandfathered from State requirements.: 0 |
| Enter the date when the Medical Examiner's Certificate expires. This is a required field.: |
| Medical Examiner should sign here.: |
| Enter the Medical Examiner's phone number. Please use numerical characters only (e.g., enter (222) 333-4444 as 2223334444). This is a required field.: |
| Enter the date Medical Examiner signed this certificate. This is a required field.: |
| Please print or type the Medical Examiner's name. This is a required field.: |
| Check if medical examiner is a Doctor of Medicine.: |
| Check if medical examiner is a Doctor of Osteopathic Medicine.: |
| Check if medical examiner is a Physician Assistant.: |
| Check if medical examiner is a Chiropractor.: |
| Check if medical examiner is an Advanced Practice Nurse.: |
| Check if medical examiner is other than already listed.: |
| If the "Other Practitioner" button was clicked, then this field should be filled in to describe the medical examiner's area of expertise.: |
| Enter the Medical Examiner's license or certificate number here. This is a required field.: |
| Use the drop-down list to indicate where the medical examiner's license or certificate was issued. This is a required field.: |
| Enter the medical examiner's National Registry of Certified Medical Examiners number here. This is a required field.: |
| Driver should sign here.: |
| Enter the driver's license number here. This is a required field.: |
| Use the drop-down list to indicate where the driver's license was issued. This is a required field.: |
| If the driver has or has applied for a Commercial Driver's License, click the "Yes" box.: |
| If the driver does not have or has not applied for a Commercial Driver's License, click the "No" box.: |
| Enter the driver's street address. This is a required field.: |
| Enter the driver's city address. This is a required field.: |
| Use the drop-down menu to enter the driver's state address. This is a required field.: |
| Enter driver's zip code using 5 or 9 numbers (00000 or 00000-0000). This is a required field.: |
| designer__defaultHyphenation: |
File details come from the government source that posted it. Updated .