Driver Examination Forms

Attention Certified Medical Examiners

Until December 22, 2015, Certified Medical Examiners are required to continue to use current driver examination forms found on the Federal Motor Carrier Safety Administration (FMCSA) website at http://www.fmcsa.dot.gov/medical/driver-medical-requirements/medical-applications-and-forms.

On December 22, 2015, Certified Medical Examiners will be required to use the newly revised driver examination forms discussed in the Medical Examiner's Certification Integration final rule published on April 23, 2015. A copy of this rule in its entirety can be found in the National Registry Resource Center.

FMCSA has received numerous calls and emails from various stakeholders requesting to review the newly revised driver examination forms that will go into effect on December 22, 2015. To accommodate these requests, FCMSA has posted PDF samples of the new driver examination forms on the National Registry website which can be accessed by clicking the links below. Please note that these forms are samples only and are prohibited from being used prior to the December 22, 2015 compliance date.

Medical Examination Report (MER) Form, MCSA-5875 (Sample)

CMV Driver Medical Examination Results Form, MCSA-5850 (Sample)

Medical Examiner's Certificate (MEC) Form, MCSA-5876 (Sample)

FMCSA will be announcing future Q&A sessions to address any questions that may arise from stakeholder's review of the new driver examination forms discussed in this notice. In addition, fillable PDF versions of the Medical Examination Report (MER) Form, MCSA-5875 and Medical Examiner's Certificate (MEC) Form, MCSA-5876 will be made available for download from the National Registry (https://nationalregistry.fmcsa.dot.gov) and FMCSA (www.fmcsa.dot.gov) websites at a later date to be announced in the near future, by December 22, 2015.