Medical examiner report for commercial driver fitness determination

The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners. Medical examiner report for commercial driver fitness determination 1. The medical examination report form for commercial driver fitness determination contains all the information required by 49 cfr 391. You will need to carry a copy of this certificate with. A medical examination form for commercial driver fitness determination will not be accepted or returned to you. Driver s information driver completes this section driver s name last, first. We perform the dmv eye examination and dot required urine test onsite takes 2 minutes. This report contains several sections, namely, drivers information, health history, vision, hearing, blood pressurepulse rate, laboratory and other test findings, and physical examination. Medical examination report for commercial driver fitness determination. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiner s certificate mec, form mcsa5876 to drive. Dot medical examination formscertificate download dot.

This report contains several sections, namely, driver s information, health history, vision, hearing, blood pressurepulse rate, laboratory and other test findings, and physical examination. A final update regarding posting and use of driver examination forms was published in the federal register allowing mes to use both the current and newly revised versions of the medical examination report form and medical examiners certificate from december 22, 2015 until april. Form popularity medical examination report for commercial driver fitness determination form. Drivers of class a, b, and c commercial vehicles must meet medical requirements established by the federal government and the department. Edit, fill, sign, download medical examination report for commercial driver fitness determination university of virginia online on. Dot physical form fill online, printable, fillable, blank pdffiller. If you pass the dot physical, your dot physical provider will fill out the medical examiners certificate and give you a copy. Collection of most popular forms in a given sphere. Florida school bus operators medical examination report for. Drivers information driver completes this section drivers name last. Drivers seeking information about the commercial drivers license cdl program medical requirements should start by visiting the fmcsas commercial drivers license program website and the cdl medical overview and medical programs pages. Driver completes this section, but medical examiner is encouraged to discuss with driver. Medical examination report for commercial driver fitness determination ra4 this is a new jersey form that can be used for motor vehicle commission within statewide. Medical examiner report fife for commercial driver fitness.

Trusted commercial driver fitness determination specialist serving somerset, nj. Each original paper or electronic completed medical examination report form must be retained on file at the office of the medical examiner for at least 3 years from the date of. The examiner will then fill out the medical examination report for commercial driver fitness determination form, along with all supporting documents, and. If you pass the dot physical, your dot physical provider will fill out the medical examiner s certificate and give you a copy. Nov 26, 2018 the federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiner s certificate mec, form mcsa5876 to drive. Birthdate age sex date of exam address city, state, zip code work tel. Schedule a dot physical to get your medical examiners certificate. Me determines if driver meets physical qualification standards in 391. The driver must file a medical report, renewable every two years.

Alternatively, medical providers with access to the internet can print the dme, complete and sign it, and forward it to the driver. Drivers information driver completes this section date of exam m recertification m d y drivers name last, first, middle social security no. Health history for any yes answer, indicate onset date, diagnosis, treating physicians name and address, and any current limitation. We will then perform a medical examination report for commercial driver fitness determination which follows strict guidelines mandated by the federal motor. Drivers information driver completes this section date of exam. Also, the driver should be advised to take the necessary steps to correct. Health history driver completes this section, but medical examiner is encouraged to discuss with driver. As of september 30, 2004, the fmcsa requires the use of the new form, medical examiner report for commercial driver fitness determination, which reflects the revised blood pressure guidelines. Canvas medical examination report for commercial driver. Our dot physical is the quickest and most convenient dot medical exam on all of long island nassau, suffolk, queens.

Medical examination report for commercial driver fitness determination 2. If meets standards, complete a medical examiners certificate according to 49 cfr 391. Your medical examination report for commercial driver fitness determination will be send electronically to the commercial drivers license information system cdlis, along with your dot physical forms. Medical examination report for commercial driver fitness.

Medical examination report for commercial driver fitness determination 649f 6045 1. A certified medical examiner will issue you a dot health card after you meet the dot. Driver fitness determination exam dot product documentation. Driver s name last, first, middle social security no.

Drivers information drivers name last, first, middle social security. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Physicians do have some latitude regarding drivers and blood pressure, for example to rule out. Driver s information driver completes this section. Commercial driver license medical eligibility california. This medical examination report for commercial driver fitness determination is a pretty comprehensive template. Download medical examination report for commercial driver. Comment on the drivers responses to the health history questions that may affect the drivers safe operation of a commercial motor vehicle cmv. Report, and a urine test for commercial driver fitness determination. Department of transportation federal motor carrier safety administration. Contact us at 7326596650 or visit us at 1527 route 27, suite 2100, somerset, nj 08873. Please submit only copies of your medical examiner s certificate and keep originals for your records. For guidance see instructions to the medical examiner.

Incomplete or illegible certificates will be returned and must be resubmitted. To obtain a cdl, the applicant must provide a valid medical examination report for commercial driver fitness determination and medical examiner s certificate medical report and medical examiner s certificate, pass applicable vision and knowledge tests, obtain a commercial drivers license learners permit clp and pass. Florida school bus operators medical examination report. It will remain valid in the system for two years from the date of issuance, unless you have a medical condition that requires more frequent examination. Contact us at 7326596650 or visit us at 1527 route 27, suite 2100, somerset, nj. Birthdate age sex new certification date of exam m.

Printable and fillable medical examination report for commercial driver fitness determination university of virginia. If your physician chooses to use this process, be sure that you complete the form prior to returning it to the driver safety office. Fillable medical examination report for commercial driver fitness determination. It is a comprehensive assessment of the drivers health history, vision, hearing, blood pressure, lab results, physical examination and more. Medical certification requirements as part of the cdl. Birthdate age sex m f new certification recertification follow up date of exam address city, state, zip code work phone. If meets standards, complete a medical examiner s certificate according to 49 cfr 391. Headbrain injuries, disorders or illnesses seizures, epilepsy medication. Drivers information driver must complete this section.

Driver medical evaluation ds 326 pdf back to main forms page. The commercial motor vehicle driver medical examination. Dot physical exam brea urgent care walk in clinic brea, ca. Drivers information driver completes this section drivers name last, first, middle social security no.

Also, the driver should be advised to ake the t necessary steps to correct. Medical examination report form for commercial driver medical. Drivers information driver completes this section drivers name last, first. Medical examination report mer form, mcsa5875 fmcsa. Birthdate m d y age sex m f new certification recertification followup date of exam address city, state, zip code work tel. Driver s information driver must complete this section. A medical examiner on the national registry will need to complete the fmcsa medical examination report for commercial driver fitness determination as well as the certificate at the end of the packet.

Wv commerical driver licensee cdl medical selfcertification affidavit. Driver licensing program 118 west capitol avenue pierre, sd 57501 fax. These form are custom bonded into padded form, in the amount that you order. Revised blood pressure guidelines for commercial drivers. Drivers information drivers name last, first, middle social security no.

Having been examined and approved by a cardiologist for medical fitness. Walk out with a completed medical examination report for commercial driver fitness determination and a medical examiners certificate. Lung disease, emphysema, asthma, chronic bronchitis. Driver s information driver completes this section driver s name last, first, middle social security no. Medical examination report washington state patrol. Get, create, make and sign medical examination report form. List all medications including overthecounter medications used regularly or recently. Dot medical examination report for commercial driver fitness determination. Free download medical examination report for commercial driver fitness determination pdf, 322kb and customize with our editable templates, waivers and forms for your needs. Medical examination report for commercial driver fitness determination section 7.

The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Commercial driver fitness determination specialist. Please mail the selfcertification form and medical certificate if. The commercial motor vehicle driver medical examination aafp. This document provides guidelines for medical eligibility criteria for commercial drivers and class a and b noncommercial licensed drivers. Medical examiner report fife for commercial driver. Medical examination report form for commercial driver medical certification u. Also, the driver should be advised to take the necessary. Driver s information driver completes this section date of exam m recertification m d y driver s name last, first, middle social security no. Drivers name last, first, middle social security no. New guidelines and medical examiner report as of september 30, 2004, the fmcsa requires the use of the new form, medical examiner report for commercial driver fitness determination, which reflects the revised blood pressure guidelines.

The medical programs page provides links to commonly requested information and documents. Physical examination certification status note certification status here. Even if a condition does not disqualify a driver, the medical examiner may consider. Drivers name first, last, middle social security no. 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. You must still provide your employer with the medical examination report for commercial driver fitness determination long form. Division of motor vehicles west virginia department of. Medical examiners are required to complete the medical examination report form for every driver physical examination performed in accordance with 49 cfr 391. Medical examination report for commercial driver fitness determination 1. Commercial driver fitness determination specialist somerset. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. When a medical examiner grants medical certification, he or she certifies the driver to perform any job duty required of a commercial motor vehicle driver, not just the drivers current job duties.