Medical examiner certificate

MCSA-5876 free printable template

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Jjkeller. com Printed in the United States 651-FS-L2 MEDICAL EXAMINER S CERTIFICATE I certify that I have examined in accordance with the Federal Motor Carrier Safety Regulations 49 CFR 391. SIGNATURE OF MEDICAL EXAMINER TELEPHONE MD DATE DO Physician Assistant Chiropractor Advanced Practice Nurse DRIVER S LICENSE NO. ADDRESS OF DRIVER MEDICAL CERTIFICATE EXPIRATION DATE DISTRIBUTION 1 COPY TO THE DRIVER 1 COPY TO THE MOTOR CARRIER STATE. ALL WRITTEN OR PRINTED INFORMATION MUST BE...

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MCSA-5876 Form Versions

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Form Popularity

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MCSA-5876 2022

4.8 Satisfied (40 Votes)

MCSA-5876 2021

4.2 Satisfied (89 Votes)

MCSA-5876 2018

4.4 Satisfied (8923 Votes)

MCSA-5876 2015

4.4 Satisfied (1904 Votes)

How to fill out medical examiner certificate form

How to fill out medical examiner certificate:

01

Obtain the necessary form or template from the relevant authorities or organization responsible for issuing the certificate.

02

Carefully read and understand all the instructions provided on the form or template.

03

Provide your personal information accurately, including your full name, contact details, and any other required identification information.

04

Fill in the specific details of the examination, including the date and time it was conducted, as well as the location.

05

Record any findings or observations from the examination, ensuring that they are clear and concise.

06

Sign and date the certificate, acknowledging that the information provided is accurate and true to the best of your knowledge.

07

Submit the completed certificate to the appropriate authority or organization that requires it.

Who needs medical examiner certificate:

01

Individuals applying for certain job positions that require a medical examination or assessment.

02

Professional drivers obtaining or renewing their commercial driver's license (CDL) in some jurisdictions.

03

Organizations or institutions conducting medical research or clinical trials, where an examination certificate may be necessary for participation.

What is the Medical Examiner’s Certificate?
What is the Medical Examiner’s Certificate for?
When is the Medical Examiner’s Certificate Due?

What is the Medical Examiner’s Certificate?

The Medical Examiner’s Certificate is the document that enables you to use a commercial motor vehicle. It must be completed by a medical examiner who examines you and makes a decision according to the results of this medical examination. The examiner gives you the original of the certificate after its completion and keeps a copy of it for about 3 years.

What is the Medical Examiner’s Certificate for?

This document is designed to determine if you are physically qualified to drive a CMV (commercial motor vehicle). It is possible to receive this document in the form of a card. For this you must buy a special medical card from the provider of motor carrier templates before the examination so that the examiner could complete it and sign. You may also print it on card stock paper. This way it is possible to change the size of the certificate according to your needs.

When is the Medical Examiner’s Certificate Due?

The Medical Examiner’s Certificate can remain valid for maximally two years after you receive it. When it expires, you must be examined by a medical specialist again to renew the document.

Is the Medical Examiner’s Certificate Accompanied by Other Forms?

No, the certificate is a single document that you need to be eligible to drive any CMV.

What Information do I Include in the Medical Examiner’s Certificate?

The examiner certifies in this document that the applicant was examined according to the Federal Motor Carrier Safety Regulations. The name of the applicant is indicated first. The examiner determines that you are able to drive if one of the following is applicable:

you wear corrective lenses or hearing aid;
you drive within an exempt intercity zone;
you can provide a Skill Performance Evaluation Certificate;
or you are qualified by operation of 49 CFR 391.64.

The certificate must include the information about the medical examiner: name, address, telephone number, status (chiropractor, MD, Doctor of Osteopathic Medicine, physician assistant, advanced practice nurse, etc.), license or certification number, signature. The driver’s name, address and license are also required. Additionally, the examiner must establish the expiration date and indicate it in the certificate.

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What is medical examiner certificate?

A medical examiner certificate is a document that certifies a driver's physical and mental fitness to safely operate a commercial motor vehicle. It is also known as a Department of Transportation (DOT) medical card, and it is issued by a qualified medical examiner listed on the Federal Motor Carrier Safety Administration's National Registry.

Who is required to file medical examiner certificate?

The Federal Motor Carrier Safety Administration requires that all interstate commercial motor vehicle drivers must file a medical examiner's certificate (form MCSA-5876) with their respective employers. The certificate must be issued by a qualified and licensed medical examiner listed on the National Registry of Certified Medical Examiners.

How to fill out medical examiner certificate?

To fill out a medical examiner certificate, you will need to provide the following information: 1. Your name and address. 2. Your Social Security Number. 3. Your driver's license number. 4. The date of your most recent physical exam. 5. Your physician's name, address, and phone number. 6. The results of your physical exam. 7. Whether or not you have any physical, mental, or emotional conditions that might affect your ability to drive. 8. Any medications or treatments you are taking. 9. Whether or not you have any vision, hearing, or cardiovascular problems. 10. Any other information about your medical condition. 11. Your signature, date, and the signature of your physician.

What is the purpose of medical examiner certificate?

A Medical Examiner's Certificate (MEC) is a document issued by a medical examiner certified by the Federal Motor Carrier Safety Administration (FMCSA) that certifies that a driver is medically fit to operate a commercial motor vehicle (CMV) in interstate commerce. The MEC must be obtained by a driver before he or she can obtain a valid commercial driver's license (CDL). The document is designed to ensure that CMV drivers meet minimum physical requirements and are medically qualified to safely operate a CMV.

What information must be reported on medical examiner certificate?

The medical examiner certificate must include the following information: name and address of the driver; date of birth; medical examiner’s name and address; National Registry number; date of examination; type of medical examination; results of the medical examination; and a statement that the driver is medically qualified to operate a commercial motor vehicle.

When is the deadline to file medical examiner certificate in 2023?

The deadline to file a medical examiner certificate in 2023 is June 30th, 2023.

What is the penalty for the late filing of medical examiner certificate?

The penalty for the late filing of a medical examiner certificate can vary depending on the state. Generally, the penalties for late filing can range from a warning letter or fine to license suspension or revocation.

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