Selfcertification medical examiners certification pa. If you have problems with acrobat reader or our pdf form, select pdf troubleshooting. Cdl third party skills testing examiner signature card. Report of driver under article 19a form ds874 or the equivalent usdot medical examination report form form mcsa5875. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer. Return to medical exam office for followup on must be 45 days or less. Commercialdriverlicensecdlmedicalcertification requirement. If you are required to maintain a dot medical certificate, be sure to send a copy of that and any variance you may have along with the selfcertification affidavit. Cdl drivers dot physical exam form 5875 pdf medical card. Commercial driver license cdl medical certification requirement. Dot medical examination formscertificate download dot. Department of transportation federal motor carrier. Patient information form every patient must complete and sign this form for hisher visit.
Physical requirements to earn a cdl you must certify, on the application form for a cdl, and provide proof, in the form of a medical examiners report, that you meet all of the physical requirements in. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Get answers, save time and pass your cdl exam test the first time around. Indiana dot physical exam for cdl federal guidelines mandate that anyone applying for a cdl must pass the dot health exam. Indiana cdl physical form fill online, printable, fillable. Physical examination report failure to return this completed form by. The dot 649 f form does not require any additional documents. The most secure digital platform to get legally binding, electronically signed documents. Department of transportation dot medical examiners certificate is required to be on file with the department. Certification of physical exemption form cdl10 texas dps. Fill out, securely sign, print or email your louisiana cdl physical form instantly with signnow.
Cdl drivers dot medical exam form 649f pdf1 updated 1162015. Failure to return this form to the alabama law enforcement agency will result in the cancellation of your commercial driver license. I further certify that i am exempt from the physical provisions of 49 cfr, part 391 390, and will operate a commercial motor vehicle only in the following capacity. This form may be printed and completed in advance, or a copy will be made available when the patientemployee arrives at a concentra. South carolina department of motor vehicles commercial drivers license cdl holders medical certification requirements dl405a rev. Louisiana dot physical form fill out and sign printable pdf. Includes cdl nrcme medical card certificate on page 9. Welcome to the forms resource page for the division of driver licensing. This medical examination report is called the preemployment physical and. Louisiana dot physical form fill out and sign printable. Guide for new jersey commercial driver license cdl holders.
Recent changes in federal regulations 49 cfr 383, 384, 390 and 391 require drivers of. The purpose of this test is to check whether an applicant is fit enough to drive safely at the present time as well as in the foreseeable future. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. This form is required before a medical examiners certificate form mcsa5876 can be issued to a certified driver. Driver certification for issuance of a commercial drivers permit or license mvd11222 download pdf. Barthelmes 603 2274000 commissioner of safety richard c. I further certify that i am exempt from the physical provisions of 49 cfr, part 3990, and will operate a commercial motor vehicle only in the following capacity. Medical examination report mer form, mcsa5875 fmcsa. Cdl drivers dot medical exam form 649f pdf 9 pages. Medical certification of driver type for commercial driver. The driver must selfcertify as one of the following classifications.
Only professional drivers will receive and keep a commercial driver license cdl. These instructions and the form must be used in conjunction with the ode webbased data entry system. At the ksp hazmat fingerprinting site, applicants will need to show two forms of identification, their cdl permit along with regular operators license or commercial license, and another form of identification, i. But is it the same as the dot physical or dot physical exam lets get some clarity on these questions regarding the cdl physical. Any physical exam performed on or after 04202016 must be completed on form mcsa5876. To record results of a drivers physical examination, to determine. A physical form is a type of form that is used as a means of evaluating an individuals physical capabilities so as to. Department of transportation dot medical examiners certificate is required to. Name last, first, middle date of birth area code daytime telephone number driver license number consent to release information. Pdf versions of the forms are available at these links on the fmcsa. Certification of physical exemption 49 cfr part 3990 cdl10. Are the cdl physical exam the same as the dot physical. Each employer must provide a paper t8 form to the physician for the documentation of the school driver physical. Cdl drivers dot physical exam form 649f pdf medical card.
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Cdl physicals in massachusetts in massachusetts, a dot physical must be completed by all cdl drivers that are licensed within the state. The purpose of this test is to check whether an applicant is fit enough to. Medical applications and forms medical examinations. This dot physical exam requirement ensures that cmv drivers meet. This form is mandatory after april 16, 2016 for all dot cdl physicals and replaces the old form 649f. Some of the main types of drivers include the following. Medical examination report for commercial driver fitness. Cdl drivers dot medical exam form certificate mcsa 5875 pdf new cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876. Physical examination report department of licensing.
Includes instructions to physician, minimum requirements, physical qualifications and cdl medical certificate for commercial drivers. Commercial driver license cdl medical certification. Yet, as with most professional licenses, holding a cdl proves. Selfcertification affidavit please print name of driver. Dot medical card pdf pa dot medical card form self certification cdl ma form. Cdl drivers are required to submit a selfcertification form in addition to their physical examination form and medical examiners certificate. Cdl dot medical 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.
New dot medical certification forms mcsa dot physical doctors. Why do i have to send in my medical examiners certificate to mvc. The complete standards and instructions for conducting this examination are found in section 6. Download fmcsa dot physical medical forms and state department of motor. Submit only the medical doctor or osteopathic physician evaluation. Medical examination report of driver under article 19a. Texas commercial driver license selfcertification affidavit. Commercial driver license cdl holders must inform the department of motor vehicles dmv regarding the type. It takes special skills and a professional attitude to safely operate large trucks and buses. The selfcertification authorization form and the medical examiners certificate can be submitted by mail, fax, email, or a deputy registrar. Individuals name date of birth colorado drivers license number signature date this completed form can be faxed to 3032055709 attn. Your medical professional will provide the appropriate form at the time of your examination.
Endorsement and i submit the physical form every two years. Individuals name date of birth colorado drivers license number signature date this completed form can be faxed to 3032055709. Start a free trial now to save yourself time and money. The links below provide access to both electronic and printonly versions of the forms. Fmcsa form mcsa5875 us department of transportation. The fmcsa has requested that all medical examiners continue providing drivers with a paper copy of the medical examiners certificate form mcsa5876, so that commercial drivers license cdl holders. If you need assistance with completing any of the forms below. Completed t8s will be returned to the employer, and the results of the physical must be entered into odes reporting system. Per federal regulations all other forms must be rejected by the department of state. Submit only the medical doctor or osteopathic physician evaluation page, located at the end of this form, to employer for drivers 70 years of age and older authority.
Earning and keeping a commercial drivers license cdl is an investment of time, energy and experience. California commercial driver license self certification. Cdl dot medical department of revenue motor vehicle. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. Medical examination report form for commercial driver medical certification u. The date found on the top right corner of the medical. Guide for new jersey commercial driver license cdl. Guide for new jersey commercial driver license cdl holders frequently asked questions. Bureau of motor vehicles cdl compliance unit 29 state house station augusta, me 043330029. This dot physical exam requirement ensures that cmv drivers meet the physical and mental health standards that are set and regulated by the federal motor carrier safety administration fmcsa. Failure to submit this form to the alabama law enforcement agency will result in the cancellation of your commercial driver license. Adobe reader is required for all pdf files and microsoft excel and word or open office for all excel and word documents. Failure to return this form to the alabama law enforcement. You are an interstate nonexcepted driver and must meet the federal dot medical card requirements.
At the ksp hazmat fingerprinting site, applicants will need to show two forms of identification, their cdl permit along with regular operators license or commercial license, and another form of identification. Entrylevel driver training eldt the federal motor carrier safety administration fmcsa established new minimum training standards for certain individuals applying for a class a or class b commercial drivers license cdl for the first time. Cdl drivers dot medical exam form certificate mcsa pdf is mandatory after april 16, for all dot cdl physicals and replaces the old form f. Recent changes in federal regulations 49 cfr 383, 384, 390 and 391 require drivers of commercial motor vehicles to certify the type of operation theyre engaged in.
The department of transportation physical card will also be examined. Certification of physical exemption 49 cfr part 3990 cdl 10 these forms allow you to certify to one of the cdl categories listed below, which determines if a medical variance or a u. Please mail the selfcertification form and medical certificate if. Insulintreated diabetes mellitus assessment form, mcsa5870. Email the new form filled out and a scanned copy of the driver license and medical card in pdf form we must have all 3.
Dot physical form fill online, printable, fillable, blank pdffiller. Department of transportation federal motor carrier safety administration. Massdot, rmv division, driver licensing po box 55889 boston, ma 02205 submit. Pass a dot physical examination and provide the bmv with an valid medical examination report mer and medical examiners certificate mec. Understand the new dot physical certification forms mcsa5875. A cdl is proof of your professional skills and aptitude. Cdl agreement between dps dl division and cdl third party tester. Obtain a commercial drivers license learners permit. Preemployment cdl driver qualification file checklist. For your convenience, many dmv pdf forms can be filled in online and then printed. All s endorsement holders will have to submit a fed med card or form mv3030b to the wi dmv if the driver is tier 1, the proof of physical fitness needs to be a fed med card. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds.
Driver license surrender form mvd10231 download pdf request for hearing form mvd10792 download pdf vehicle certification form mvd10414 download pdf employers submission of controlled substance test results for new mexcio cdl holders mvd11174 download pdf driver certification for issuance of a commercial drivers permit or license mvd11222 download pdf. Employers submission of controlled substance test results for new mexcio cdl holders mvd11174 download pdf. The cdl physical exam is a requirement for all commercial dot drivers. Cdl drivers dot medical exam form certificate mcsa 5875 pdf. Cdl third party skills testing provider surety bond. The completed form is permanently filed in the patients chart. The cdl selfcertification authorization form and the medical examiners certificate, if applicable, must be submitted to the ohio bureau of motor vehicles and processed prior to the issuance of the cdl. All information on this application must be in ink. All s endorsement holders will have to submit a fed med card or form mv3030b to the wi. Pdf versions of the forms are available at these links on the fmcsa website. Ohio department of education school transportation driver. Preemployment cdl driver qualification file checklist preemploymentdriver qualification file checklist this document can serve as a hiring checklist to help the municipality make sure that it is complying. 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. New cdl drivers dot medical exam form, mcsa5875, and cdl medical card certificate, mcsa5876.
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