Medical Examination Report (MER) Form MCSA 5875 DOT FORM MOD 02.26.2016
Form Mcsa 5875. 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. Department of transportation federal motor carrier safety administration.
Driver health history (continued) cmv driver’s signature driver health history review do you have or have you ever had: Medical examiner information medical examiner’s signaturemedical examiner’s telephone number medical examiner’s name (please print or type) Medical examination report form (for commercial driver medical certification) u.s. Pdf versions of the forms are available at these links on the fmcsa website: Medical examination report form (u.s. Head/brain injuries or illnesses (e.g., concussion) 16. /3 /202 page 2 last name: New expiration date on the forms is 12/31/2024. Medical examiner's certificate expiration date medical examiner's signaturemedical examiner's telephone number medical examiner's name (please print or type) 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.
Medical examiner's certificate expiration date medical examiner's signaturemedical examiner's telephone number medical examiner's name (please print or type) /3 /202 page 2 last name: Department of transportation) form is 5 pages long and contains: 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. Medical examiner information medical examiner’s signaturemedical examiner’s telephone number medical examiner’s name (please print or type) Yes no yes no not sure not sure. Pdf versions of the forms are available at these links on the fmcsa website: Driver health history (continued) cmv driver’s signature driver health history review do you have or have you ever had: Medical examination report form (for commercial driver medical certification) u.s. Medical examination report form (u.s. New expiration date on the forms is 12/31/2024.
