Medical certification form paper application please correctly fill out your medical self certification form and include a copy of your dot physical card. This examination contains the aspects of mental, physical, and emotional issues that may affect the state and safety of the driver. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. We provide services to wsdot staff by designing and implementing the forms that are necessary for our department. Download a drivers dot exam form redeem access to a dot physical exam form securely using the drivers temporary access code and last four of their ssn. Alaska dot physical exam for cdl it is mandated by federal guidelines that all commercial drivers pass the department of transportation health exam. Must be signed in the presence of a notary or penndot driving. Driver safety cdl guidelines california department of. 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. Some of the main types of drivers include the following. Dont drink coffee or smoke cigarettes 30 minutes before having your blood pressure measured. Dot physical form fill online, printable, fillable, blank pdffiller. Free download excel customer contact database template templates and free excel customer database template. Fill, sign and send anytime, anywhere, from any device with pdffiller.
Georgia dot physical exam for cdl it is mandated by federal guidelines that all commercial drivers pass the dot health exam. Download and create your own document with dot physical form 32kb 9 pages for free. Beginning 11012014, louisiana department of transport and development dotd will no longer offer hardcopy reproduction and shipping services for files located on the dotd website. There are various types of these kinds of dot physical assessment forms that allow any company or person to see if theyre ready to operate any kind of commercial vehicle for any purpose. Completing this form gives a minor in your care consent to apply for their pa drivers license. The dot physical form is a template of the medical examination report. I hereby authorize the social security administration to release to the department of transportation information concerning my social security identification number for the purpose of identification. However, you may still be required to have a fed med card due to state statutes or employer policy. To avoid a downgrade or cancellation of your cdlclp, you must take this certificate to the dmv when you apply for your clpcdl, or faxemail it to the ny state dmv medical certification unit. Uil preparticipation physical evaluation form physical form texas association of private and parochial schools tapps austin austin waldorf school, brentwood christian school, hill country christian school, hyde park baptist high school, regents school of austin, st. Dot medical examination formscertificate download dot. The medical certificate will be restricted to entrylevel only.
Get expiration alerts before your medical card expires. After december 12, 2015, mcs150 and opseries forms can only be used to update company records or apply for additional authorities, not for initial registration with fmcsa. Dot physicals are highly regulated for the drivers safety and are designed to detect physical, mental, and emotional issues that can affect a drivers ability to safely drive a commercial vehicle. Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. The department of transportation dot physical is one of the most important qualifications for any c ommercial motor vehicle cmv driver. More information about reporting an unsafe driver can be found under the faq section. Driver and my medical examiners certificate, that submission of fraudulent or intentionally false medical examination report form. Great east austin youth association physical form g. A summary of the regulated procedures and protocols is provided on the reverse side of the mandated dot medical examination form entitled physical examination of drivers. You do not have to furnish a copy of the card to the dmv, unless you are a tier 3 driver applying for a license renewal or replacement at a dmv. How to selfcertify or change your current selfcertification status. Download fmcsa dot physical medical forms and state department of motor vehicles self certification forms and medical examiners certificate. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. Upload your current fed med card or view your tier of.
To download revised medical examination report form mcsa5875 click. Collection of most popular forms in a given sphere. These are the same standards required of motor carrier drivers by the federal highway administration of the department of transportation. Fmcsa form mcsa5875 us department of transportation clpcdl applicantholder. You must use this medical examination report when applying for a commercial california driver license. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration fmcsa national registry. Welcome to the washington state department of transportation forms management webpage. Here are some dot physical tips that can help you be ready and do your best. If you have problems with acrobat reader or our pdf form, select pdf troubleshooting. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. This template is designed for the commercial driver and contains four main parts. Below you will find links to frequently used forms, also a link to all our external forms in pdf version. 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. The free teamcme driver mobile app is the quick and convenient solution for an expiring medical certificate or alcoholdrug test collection, when at home or away.
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. To order printed forms complete dt1435 request for forms or contact maps and publications, wisconsin department of transportation, p. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. The cdl driver that is physically qualified to operate a motor vehicle must carry a valid medical examiners certificate. Cdl drivers dot physical exam form 5875 pdf medical card. Documents and forms us department of transportation. The inspection file contains identifying information for the inspection such as the u. Driver licensing docking state office building attn. These are to see if the person has any conditions that could prevent him or her from driving. Certificate from december 22, 2015 until april 20, 2016.
Search and choose from hundreds of dot physical exam locations or dot alcohol and drug testing locations using your mobile devices gps location, or by city and state. Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. Dot physical form download free documents for pdf, word. Insulintreated diabetes mellitus assessment form, mcsa5870. The mer will be completed online at the center and does not need to be printed and completed beforehand. Completing the form before your appointment will help to obtain your cdl medical card more quickly. The purpose of this test is to determine whether a potential driver is physically capable of driving safely now and in the foreseeable future. Dot cdl physical exam locations and forms georgia a l.
Medical examination report mer form, mcsa5875 fmcsa. Dot medical exam and commercial motor vehicle certification about the exam. Page includes various formats of dot physical form for pdf, word and excel. Dot physical application forms are the kind of forms that are utilized by those people who want to take the physical. Department of transportation medical examination form. Has your usdotfmcsa medical certificate ever been denied or issued for less than 2 years. Medical applications and forms federal motor carrier safety. Once your physical is complete, the medical examiner will give you a medical examiners certificate form mcsa5876. Depending on how you selfcertify determines what cdl medical documents will be required.
Fmcsa form mcsa5875 us department of transportation. Medical examiners certificate mec, form mcsa5876 fmcsa. Dot physical form download free documents for pdf, word and. Download dot physical form for free page 5 formtemplate. Includes instructions to physician and commercial drivers minimum requirements for a cdl license.
To obtain a form by mail, call dmvs automated phone service 24 hours a day, 7 days a week at 180077703. About the medical examiners certificate mec, form mcsa5876. Visit a driver licensing office location to selfcertify or to change your selfcertification status. Faxing the certificate to the office of driver services at.
Download the dot physical exam report form by clicking the link below. The purpose of this test is to determine whether a potential driver is fit enough to drive safely now and in the foreseeable future. Dot, cdl physical examination forms austin tx north lamar chiro. Medical examination report for commercial driver fitness. Dot physical medical forms are forms for those who need to take part in the medical exam of the dot physicals. Dec 18, 2019 medical applications and forms medical examinations. Dot physical forms and others to fill out before your visit. Medical applications and forms medical examinations. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875.
You can also call gardner express care 417 9522369 to schedule a dot physical. Dot physical exam forms are the main forms used to guarantee that the person is able to take the exam. Release of information form 49 cfr part 40 drug and alcohol testing suggested format dot agency specific documents. Click the links below to read andor download publications. Includes instructions to physician and commercial drivers minimum requirements for a. The two files available for download contain the publicly available inspection and violation data used for the current months sms calculations. Dot, cdl physical examination forms austin tx north. Dotd offers access to numerous public documents, including final reports, manuals, guides, plans and forms.
Where can i get a dot medical exam click here to find a fmcsa certified medical examiner in your area. The medical practitioner must document the results of the physical examination in this section. 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. A federal motor carrier safety administration physical is required when applying for a cdl unless exempted by fmcsa part 390. Dot medical certificate federal dot medical examiners certification. To find help on which form you need, or if you cannot find the form you are looking for, please visit the wisdot contacts page or the division of motor vehicles dmv contacts.
Sections iii medical conditions, iv medications and v physical examination of the cg 719k. Form used to verify a minor in your care has completed the required number of hours of driving practice while holding a pennsylvania learners permit. Its purpose is intended to help ensure the safety of both the commercial drivers license cdl holder and the other drivers sharing the road with himher. This form is required before a medical examiners certificate form mcsa5876 can be issued to a certified driver.
If you have a concern about a driver, you can submit a signed request for reexamination form 431030 for a driver with a known or suspected physical, mental, cognitive, or vision condition that can impair driving. Cdl dot medical department of revenue motor vehicle. For large quantities, please read ordering dmv forms in large quantities. Dot physical forms cdl medical examination report mer form, mcsa5875 this form is an example of what patients can expect. Drivers who have certified to operate at tier 2, 3 or 4 are not required to upload their fed med card. Federal law requires drivers of commercial motor vehicles cmvs to receive regular physical examinations under the department of transportation. Kansas department of revenue division of vehicles medical. Record what type of photo id was used to verify the identity of the driver, e. Iowa department of transportation office of driver services p. Upload your current fed med card or view your tier of operation.