Medical Examination Report (MER) Form MCSA 5875 DOT FORM MOD 02.26.2016
Form Mcsa 5875. New expiration date on the forms is 12/31/2024. Medical examiner's certificate expiration date medical examiner's signaturemedical examiner's telephone number medical examiner's name (please print or type)
Medical examination report form (u.s. 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. Medical examiner information medical examiner’s signaturemedical examiner’s telephone number medical examiner’s name (please print or type) Yes no yes no not sure not sure. Driver health history (continued) cmv driver’s signature driver health history review do you have or have you ever had: Head/brain injuries or illnesses (e.g., concussion) 16. /3 /202 page 2 last name: Pdf versions of the forms are available at these links on the fmcsa website: New expiration date on the forms is 12/31/2024. Department of transportation) form is 5 pages long and contains:
Medical examiner's certificate expiration date medical examiner's signaturemedical examiner's telephone number medical examiner's name (please print or type) Medical examiner information medical examiner’s signaturemedical examiner’s telephone number medical examiner’s name (please print or type) Medical examination report form (u.s. Pdf versions of the forms are available at these links on the fmcsa website: Department of transportation federal motor carrier safety administration. Head/brain injuries or illnesses (e.g., concussion) 16. Driver health history (continued) cmv driver’s signature driver health history review do you have or have you ever had: New expiration date on the forms is 12/31/2024. Medical examiner's certificate expiration date medical examiner's signaturemedical examiner's telephone number medical examiner's name (please print or type) Yes no yes no not sure not sure. 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.
