Reading category certification recertification 1401599099 stage 1 1 year rarely disqualifying alone one year if. Medical examination reports must meet the requirements of 391. Edit, fill, sign, download medical examination report for commercial driver fitness determination online on. Printable and fillable medical examination report for.
A medical evaluation summary completed only by either a board qualified or board. The commercial motor vehicle driver medical examination. Please mail the selfcertification form and medical certificate if. Driver medical evaluation ds 326 pdf back to main forms page. This medical examination report for commercial driver fitness determination is a pretty comprehensive template. The drivers license application will be used to update the voter registration record of currently registered voters in the state of hawaii, unless the applicant affirmatively declines on page 2 of this application national voter registration act of 1993. Printable and fillable medical examination report for commercial driver fitness determination university of virginia. In recording distance vision, use 20 feet as normal. This medical examination report must remain on file with the department. Justia medical examination report for commercial driver. Dot medical examination formscertificate download dot. Medical examination report for commercial driver fitness determination.
Driver s information driver s name last, first, middle social security no. Medical applications and forms medical examinations. Medical examination report mer form, mcsa5875 fmcsa. Medical examination report form entira family clinics. This is a indiana form and can be use in department of revenue statewide. List all medications including overthecounter medications used regularly or recently. Driver s name first, last, middle social security no. Update on commercial driver medical examination rules and.
Medical examination report for commercial driver fitness determination form. A medical examination form for commercial driver fitness determination will not be accepted or returned to you. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. Drivers information driver completes this section drivers name last, first, middle social security no. Based on the medical examination report for commercial driver fitness determination, published in the federal register, september 30, 2003, vol. Some of the main types of drivers include the following. A copy of your signed medical examiners certificate. Driver information driver complete this sectiondriver name last, first, middle social security no. Commercial drivers are required to certify using penndots selfcertification form dl11cdpdf.
Lung disease, emphysema, asthma, chronic bronchitis. Revised blood pressure guidelines for commercial drivers. Drivers information medical examination report 649f 6045 100709 for commercial driver fitness determination drwer completes this section. Drivers name first, last, middle social security no.
As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. As part of the physical, drivers are required to fill out the medical history portion of. Texas department of public safety courtesy, service. Health history driver completes this section, but medical examiner is encouraged to discuss with driver. Birthdate m d y age sex m f new certification recertification followup date of exam address city, state, zip code work tel. Drivers information drivers name last, first, middle social security no. Medical examination report for commercial driver fitness. Federal motor carrier safety administration fmcsa skill. Driver s information driver completes this section driver s name last, first, middle social security no. Medical examination report for commercial driver fitness determination 1.
Medical examination report for commercial fitness determination form. Alternatively, medical providers with access to the internet can print the dme, complete and sign it, and forward it to the driver. Birthdate age sex new certification date of exam m recertification m d y f follow up 2. 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. Justia medical examination report for commercial fitness. Fmcsa standards require states to issue commercial drivers licenses only after a driver. Get, create, make and sign mn medical examination report form. Driver s information driver completes this section date of exam m recertification m d y driver s name last, first, middle social security no. Having been examined and approved by a cardiologist for medical fitness. For additional information, please contact the ibt safety and health department, 25 louisiana avenue, nw, washington, dc 20001. Cdl holder must send all pages of the medical examination report for commercial driver fitness determination along with the medical examiners certificate. To obtain a cdl, the applicant must provide a valid medical examination report for commercial driver fitness determination and medical examiners certificate medical report and medical examiners certificate, pass applicable vision and knowledge tests, obtain a commercial drivers license learners permit clp and pass.
Applicants may be required to provide medical exam results, employment history, driving experience and motor vehicle records. To record results of a drivers physical examination, to determine qualification to operate a commercial motor vehicle cmv, and to promote driver. Printable and fillable medical examination report for commercial driver fitness determination. Medical examination report for commercial driver fitness determination 2. Form detail texas department of public safety courtesy, service. Indiana clpcdl holder must maintain on file a valid medal examinationmedical examiners certificate. Comment on the drivers responses to the health history questions that may affect the drivers safe operation of a commercial motor vehicle cmv. Medical examiners certificate expiration date medical examiners signature medical examiners telephone number date certificate signed medical examiners name please print or type md do. Medical examiners are responsible for evaluating commercial drivers fitness to drive and safely perform related nondriving tasks. Medical examination report for commercial fitness determination. Download free printonly pdf or purchase interactive pdf version of this form. The driver medical examination report dmer is the primary tool used by the superintendent to assess the severity, progression, treatment or effects of a medical condition, if any, in regards to a drivers fitness to drive.
Me determines if driver meets physical qualification standards in 391. A complete medical examination report form, mcsa5875, with any attachments embodies my findings completely and correctly, and is on file in my office. Edit, fill, sign, download medical examination report for commercial driver fitness determination university of virginia online on. When the medical examiners certificate expires, the medical status will change from. Walk out with a completed medical examination report for commercial driver fitness determination and a. This webpage contains information and instructions to. Do not send an official copy of the medical examination report for commercial. Download forms frequently asked medical examination report for commercial driver fitness determination if you have a cdl, go to a certified physician listed on the national registry of certified medical examiners.
Medical examination report for commercial driver fitness determination the drivers role responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Get the medical examination report for commercial driver fitness. Birthdate age sex date of exam address city, state, zip code work tel. Driver medical evaluation ds 326 california department of. Medical examination report for commercial driver fitness determination medical examiner should take at least two readings to confirm bp. 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. Download and create your own document with medical examination report for commercial driver fitness determination 32kb 8 pages for free. The federal motor service security administration requires that interstate business motorized vehicle drivers the affected person for whom youre finishing this report has submitted an utility to the division of state for licensure as a driver schooling teacher. Washington state commercial driver fitness determination form. Download medical examination report for commercial driver.
Selfcertification medical examiners certification pa. Medical examination report for commercial driver fitness determination 649f 6045 1. Concerning the medical examination report mer kind, mcsa5875. 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. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. To record results of a drivers physical examination, to determine qualification to operate a commercial motor vehicle cmv, and. Drivers medical examination report dmer province of.
If your physician chooses to use this process, be sure that you complete the form prior to returning it to the driver safety office. A cdl physical is the medical exam required to obtain your commercial drivers license. Health history for any yes answer, indicate onset date, diagnosis, treating physicians name and address, and any current limitation. Insulintreated diabetes mellitus assessment form, mcsa5870. The driver medical examination report dmer is the primary tool used by the superintendent to assess the severity, progression, treatment or effects of a medical condition, if. Drivers information driver completes this section date of exam m recertification m d y drivers name last, first, middle social security no. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. When performing a commercial motor vehicle driver medical examination, the examiner must consider the federal medical standards, plus related recommendations and guidance, to reach a certification. This report contains several sections, namely, drivers information, health history, vision, hearing, blood pressurepulse rate, laboratory and other test findings, and physical examination. A copy of the results of your medical examination report, pursuant to 49 cfr 391.
If the form is available in electronic format, click on name of the form to open. The form, mcsa5875, includes a medical examiners certificate mcsa5876 that is signed by a health care professional, when the driver meets the federal requirements. Texas department of public safety courtesy, service, protection. Drivers information driver must complete this section. Florida school bus operators medical examination report for. Driver fitness determination to your firstenergy recruiter.