Newest DOT Physical Forms Now Available

Posted on 17th Dec 2021 @ 9:27 AM

Get the Newest DOT Physical Forms:

The expiration date on the Medical Examination Report Form, MCSA-5875, Medical Examiner's Certificate, MCSA-5876, and Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, has been updated to 12/31/2024, and all forms are posted below. Please note that the only change to the forms is the change in the OMB expiration date from 11/30/2021 to 12/31/2024.

Medical Examiners should start using the forms with the 12/31/2024 date as soon as possible. However, MEs that have purchased these forms in bulk, or require time to reprogram electronic system forms, may continue to use the old forms until stocks have been depleted or forms have been reprogrammed but should transition to use of the new forms as quickly as possible. Based on this guidance, SDLAs are encouraged to continue to accept these forms.

• CDL Drivers DOT Medical Exam Form MCSA-5875 & CDL Medical Card MCSA-5876 PDF New Forms Expire 12/31/24

9 pages. Print in Portrait. Includes CDL Medical Card Certificate on Last page. Scroll down.

• DOT Physical Insulin Diabetes Assessment Form MCSA 5870 PDF New Form Expires 12/31/24

As a part of the medical certification process for insulin treated diabetes mellitus (ITDM) individuals, the Federal Motor Carrier Safety Administration (FMCSA) requires that the Insulin Treated Diabetes Mellitus Assessment Form (ITDM), MCSA-5870, be completed by the ITDM individual’s Treating Clinician attesting that the individual has a stable insulin regimen and properly controlled diabetes. ITDM individuals are required to provide the ITDM Assessment Form, MCSA-5870, to the Certified Medical Examiner within 45 days of completion by the Treating Clinician.

• DOT Physical CMV Driver Medication Form MCSA 5895 PDF New Form Expires 04/30/23

The 391.41 CMV Driver Medication Form - MCSA-5895 - Requests additional information from CDL drivers regarding medications prescribed by the their treating physician for Medical Examiners to use in determining if a driver is medically qualified under 49 CFR 391.41.