WebApr 1, 2014 · Medical Examiners should have a release form signed by the driver if the employer wishes to obtain a copy of the medical examination form (long form). ... Federal Motor Carrier Safety Administration. 1200 NEW JERSEY AVENUE, SE. WASHINGTON, DC 20590. 1-800-832-5660. Subscribe to email updates. About. About FMCSA; … Web1 day ago · maintaining a Medical Examination Report Form, MCSA–5875, and, if the individual is physically qualified, issuing a Medical Examiner’s Certificate, Form MCSA–5876. The FMCSRs in §391.41(b)(1) through (13) generally include the physical qualification standards required for the medical certification of individuals who

DOT Medical Examination Forms-Certificate (download)

WebThe information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form, MCSA-5875, with any attachments, embodies my findings completely and correctly, and is on file in my office. Medical Examiner’s Certificate Expiration Date Medical Examiner’s Telephone Number Web(paper or electronic) completed Medical Examination Report Form must be retained on file at the office of the medical examiner for at least 3 years from the date of examination. … how do i center text in markdown

Medical Examination Report Form - downloads.regulations.gov

WebMar 22, 2024 · The expiration date on the Medical Examination Report Form, MCSA-5875, Medical Examiner's Certificate, MCSA-5876, Insulin-Treated Diabetes Mellitus … WebPrinted Name of Certified Medical Examiner: Signature of Certified Medical Examiner: Street Address: Date: Email Address: Fax Number: City, State, Zip Code: Rev 4/10/2024 CERTIFIED MEDICAL EXAMINER’S REQUEST FOR INFORMATION. 49 CFR 391.41\(b\) how do i center text in css