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Completing Form MCSA-5875 and Certificate Form MCSA-5876

Forms

The following is a statement from the FMCSA:

FMCSA has been informed that some Medical Examiners (MEs) are not using the current approved versions of the required driver examination forms and others are not completing all the fields on the forms. As a result of the Medical Examiner’s Certification Integration final rule, use of the Medical Examination Report Form, MCSA-5875 and Medical Examiner’s Certificate, Form MCSA-5876 are required and results of examinations must be recorded on these specific forms. These forms have been approved by the Office of Management and Budget and are published in 49 CFR 391.43(f)(2) and (h)(2), and therefore, must be used “as is.” Both forms must be filled out completely to be considered valid. If a driver provides a Medical Examiner’s Certificate, Form MCSA-5876 to the State Driver’s Licensing Agency (SDLA) that has missing information (e.g., ME’s phone number, occupation, license information, etc.), it is considered not valid and may not be accepted by the SDLA. Please ensure that you are using the current approved versions of the forms and that you are filling out each form completely. The current approved forms can be found on the FMCSA website at https://www.fmcsa.dot.gov/medical/driver-medical-requirements/medical-applications-and-forms.

If you have questions, please contact National Registry Technical Support at 617-494-3003 or FMCtechsup@dot.gov.



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