This template is designed for the commercial driver and contains four main parts. How to selfcertify or change your current selfcertification status. Physicals nondot health screenings usa provides medical physical examinations at testing centers nationwide for nondot regulated employees in need of a physical to determine work performance. Electronic notification of medical qualification to sdlas. The information that will be provided in this document is as follows. Download dot physical form for free page 5 formtemplate. How can i update my usdot number company information. Attach certification specifying the exempt immunizations. With these changes outlined above there is a new chain of custody form for drug testing. Phmsa gas distribution ia question set pdf phmsagasdistirbutioniaquestionset202001.
Pdf versions of the forms are available at these links on the fmcsa website. The dot physical form is a template of the medical examination report. Stage 1 hypertension, blood pressure between 14090 15999. Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Here are some dot physical tips that can help you be ready and do your best. Visit a driver licensing office location to selfcertify or to change your selfcertification status. Some of the main types of drivers include the following. The fmcsa was established as a separate administration within the u.
Introduction pa drivers manual iintroduction this manual is designed to help you become a safe driver. What is a dot medical exam it is an exam that indicates an individual is physically qualified to operate a commercial motor vehicle in accordance with 49 cfr 391. Driver health history do you have or have you ever had. I hereby authorize the social security administration to release to the department of transportation information. Cdl drivers dot physical exam form 5875 pdf medical card. Commercial drivers license cdl medical certification. It presents many of pennsylvanias laws governing driving. What pilots should know about the faa airman medical. If one were to use a dot physical form, then the results of these types of forms can show whether or not a person is capable of handling commercial motorized vehicles.
Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. The date found on the top right corner of the medical. Old dot med forms no longer allowed, new ones on the way. New dot medical exam forms to be required april 20 catto.
Mdea will be removes as of 112018 from the list of amphetamines. This document contains statebystate tnstructions for submitting medical certificates for cdl drivers to the state licensing agencies. Sections iii medical conditions, iv medications and v physical examination of the cg 719k. Mndot library minnesota department of transportation.
You must use this medical examination report when applying for a commercial california driver license. If you have problems with acrobat reader or our pdf form, select pdf troubleshooting. These guidelines, together with the 49 cfr part 40, and the dot operating. New versions of the medical examination report form and medical examiners certificate were announced on april 23, 2015, and were to be used beginning december 22, 2015, for all commercial. Department of transportation federal motor carrier. Dot correspondence handbook us department of transportation. Release of information form 49 cfr part 40 drug and alcohol testing suggested format dot agency specific documents.
For large quantities, please read ordering dmv forms in large quantities. Drivers conversations you should have with your doctor. The diabetes standard final rule that was published on 09292018, stated that the insulintreated diabetes mellitus assessment form, mcsa5870 is posted on the fmcsa and national. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Documents and forms us department of transportation. The medical certificate will be restricted to entrylevel. Omb is taking public comment on the new insulin form until november 19, 2018, so it will not be able to approve the forms until sometime after that date. Insulintreated diabetes mellitus assessment form, mcsa. Yes o o o o o o o o o o o o o o o o no o o o o o o o o o o o o o o o o not sure o o o o o o o o o o o o o. New dot medical certification forms mcsa dot physical doctors. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. Federal regulations require that anyone holding or applying for a commercial drivers license cdl or commercial learners permit clp certify to one of the four following.
Medical applications and forms medical examinations. In order for the certified medical examiner to complete the dot physical examination. Medical examination report form with certificate mcsa 5875. Alabama department of e alabama bus driver physical. Download fmcsa dot physical medical forms and state department of motor. The mec information for clpcdl applicantsholders will. Dot physical form fill online, printable, fillable, blank pdffiller. New cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. Dot medical examination formscertificate download dot. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. As you may or may not know, all cdl drivers and anyone who operates vehicles that require a hoisting license must possess a dot medical card. Medical examination report mer form, mcsa5875 fmcsa. The primary mission of the federal motor carrier safety administration fmcsa is to reduce crashes, injuries and fatalities involving large trucks and buses. Medical examiners certificate mec, form mcsa5876 fmcsa.
This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Nddot forms north dakota department of transportation. The department of transportation dot requires commercial motor vehicle cmv operators to have the dot physical exam to maintain their driver certification. 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 complete and provide the driver with a medical examiners certificate mec, form mcsa5876. Insulintreated diabetes mellitus assessment form, mcsa5870. About the medical examiners certificate mec, form mcsa5876. Dont drink coffee or smoke cigarettes 30 minutes before having your blood pressure measured. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. New york state department of transportation coordinates operation of transportation facilities and services including highway, bridges, railroad, mass transit, port, waterway and aviation facilities. New mexico ifta decal request form mvd11212 download pdf. 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 complete and provide the driver with a medical examiners certificate mec. As a part of the medical certification process for insulin treated diabetes mellitus itdm individuals, the federal motor carrier safety administration requires that the insulin treated diabetes mellitus assessment form itdm, mcsa5870, be completed by the itdm individuals treating clinician attesting that the.