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. Dot physical forms and others to fill out before your visit. Iowa department of transportation office of driver services p. Dont drink coffee or smoke cigarettes 30 minutes before having your blood pressure measured. Dec 18, 2019 medical applications and forms medical examinations.
Where can i get a dot medical exam click here to find a fmcsa certified medical examiner in your area. Medical examination report mer form, mcsa5875 fmcsa. Dot physical form fill online, printable, fillable, blank pdffiller. How to selfcertify or change your current selfcertification status.
To order printed forms complete dt1435 request for forms or contact maps and publications, wisconsin department of transportation, p. 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. Download fmcsa dot physical medical forms and state department of motor vehicles self certification forms and medical examiners certificate. This template is designed for the commercial driver and contains four main parts. The two files available for download contain the publicly available inspection and violation data used for the current months sms calculations. These are the same standards required of motor carrier drivers by the federal highway administration of the 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. Below you will find links to frequently used forms, also a link to all our external forms in pdf version. This form is required before a medical examiners certificate form mcsa5876 can be issued to a certified driver. Cdl dot medical department of revenue motor vehicle. To download revised medical examination report form mcsa5875 click. To obtain a form by mail, call dmvs automated phone service 24 hours a day, 7 days a week at 180077703.
Kansas department of revenue division of vehicles medical. These are to see if the person has any conditions that could prevent him or her from driving. 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. The inspection file contains identifying information for the inspection such as the u. Completing this form gives a minor in your care consent to apply for their pa drivers license. Drivers who have certified to operate at tier 2, 3 or 4 are not required to upload their fed med card. 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. Sections iii medical conditions, iv medications and v physical examination of the cg 719k. Medical applications and forms federal motor carrier safety.
Has your usdotfmcsa medical certificate ever been denied or issued for less than 2 years. The cdl driver that is physically qualified to operate a motor vehicle must carry a valid medical examiners certificate. Record what type of photo id was used to verify the identity of the driver, e. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Download dot physical form for free page 5 formtemplate. Get expiration alerts before your medical card expires. Dot medical exam and commercial motor vehicle certification about the exam. Driver safety cdl guidelines california department of. 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. Documents and forms us department of transportation.
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. If you have problems with acrobat reader or our pdf form, select pdf troubleshooting. 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. Welcome to the washington state department of transportation forms management webpage. Fmcsa form mcsa5875 us department of transportation clpcdl applicantholder. 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. Driver licensing docking state office building attn. 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.
Upload your current fed med card or view your tier of. The department of transportation dot physical is one of the most important qualifications for any c ommercial motor vehicle cmv driver. Completing the form before your appointment will help to obtain your cdl medical card more quickly. Includes instructions to physician and commercial drivers minimum requirements for a. 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. Dot medical certificate federal dot medical examiners certification. Dot cdl physical exam locations and forms georgia a l. Download and create your own document with dot physical form 32kb 9 pages for free. The purpose of this test is to determine whether a potential driver is physically capable of driving safely now and in the foreseeable future. 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. Collection of most popular forms in a given sphere.
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. Certificate from december 22, 2015 until april 20, 2016. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. Dot physical medical forms are forms for those who need to take part in the medical exam of the dot physicals. Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Medical certification form paper application please correctly fill out your medical self certification form and include a copy of your dot physical card. Here are some dot physical tips that can help you be ready and do your best. You can also call gardner express care 417 9522369 to schedule a dot physical. 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. Alaska dot physical exam for cdl it is mandated by federal guidelines that all commercial drivers pass the department of transportation health exam.
Dotd offers access to numerous public documents, including final reports, manuals, guides, plans and forms. 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. Fill, sign and send anytime, anywhere, from any device with pdffiller. Must be signed in the presence of a notary or penndot driving. Sign, fax and printable from pc, ipad, tablet or mobile with pdffiller. 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. Dot, cdl physical examination forms austin tx north. Georgia dot physical exam for cdl it is mandated by federal guidelines that all commercial drivers pass the dot health exam. The dot physical form is a template of the medical examination report. This examination contains the aspects of mental, physical, and emotional issues that may affect the state and safety of the driver. Dot physical forms cdl medical examination report mer form, mcsa5875 this form is an example of what patients can expect. Department of transportation medical examination form.
Upload your current fed med card or view your tier of operation. 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. Free download excel customer contact database template templates and free excel customer database template. Click the links below to read andor download publications. 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. 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. Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. Visit a driver licensing office location to selfcertify or to change your selfcertification status. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Medical applications and forms medical examinations.
More information about reporting an unsafe driver can be found under the faq section. 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. The medical practitioner must document the results of the physical examination in this section. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. We provide services to wsdot staff by designing and implementing the forms that are necessary for our department. Includes instructions to physician and commercial drivers minimum requirements for a cdl license. However, you may still be required to have a fed med card due to state statutes or employer policy. Download the dot physical exam report form by clicking the link below.
Dot physical exam forms are the main forms used to guarantee that the person is able to take the exam. 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. Federal law requires drivers of commercial motor vehicles cmvs to receive regular physical examinations under the department of transportation. Faxing the certificate to the office of driver services at. Medical examination report for commercial driver fitness. The mer will be completed online at the center and does not need to be printed and completed beforehand. Medical examiners certificate mec, form mcsa5876 fmcsa. Dot physical form download free documents for pdf, word and. Cdl drivers dot physical exam form 5875 pdf medical card. About the medical examiners certificate mec, form mcsa5876. Fmcsa form mcsa5875 us department of transportation. You must use this medical examination report when applying for a commercial california driver license. Dot physical application forms are the kind of forms that are utilized by those people who want to take the physical. Once your physical is complete, the medical examiner will give you a medical examiners certificate form mcsa5876.
The medical certificate will be restricted to entrylevel only. Some of the main types of drivers include the following. The purpose of this test is to determine whether a potential driver is fit enough to drive safely now and in the foreseeable future. Insulintreated diabetes mellitus assessment form, mcsa5870.
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