Medical examination report mer form, mcsa5875 fmcsa. Report for commercial driver fitness determination, which reflects the revised blood pressure guidelines. Please mail the selfcertification form and medical certificate if. Your medical examination report for commercial driver fitness determination will be send electronically to the commercial drivers license information system cdlis, along with your dot physical forms. Walk out with a completed medical examination report for commercial driver fitness determination and a medical examiners certificate. Commercial driver fitness determination specialist. New jersey medical examination form medical examination form to be completed by a licensed medical doctor or osteopathic physician. School bus driver record evaluation penalty point system sbt12. Medical examination report for commercial driver fitness determination 649f 6045 1. Cedar rapids iowa fmcsa certified medical examiners, dot.
Medical examination report for commercial driver fitness determination submit this medical certification form to the iowa dot when applying for a commercial drivers license. At jersey medical weight loss center in the somerset. Youll submit a completed medical examination reportfor commercial driver fitness determination form 649f. The commercial motor vehicle driver medical examination. Dot medical examination formscertificate download dot. If the form is available in electronic format, click on name of the form to open.
The driver and vehicle services division must receive your completed certificate on or before the expiration date of your physical exam deadline. Drivers information driver must complete this section. Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Medical examination report for commercial driver fitness determination the drivers role responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Your practitioner will complete your medical examination report for commercial driver fitness determination form, provide a summary, a receipt and a medical examiners certificate, as appropriate. Medical examination report for commercial driver fitness determination author. Drivers information drivers name last, first, middle social security no. Aparna chandrasekaran is a board certified medical examiner who is qualified to perform the commercial driver fitness determination examinations as per federal motor carrier safety administration guidelines. Each time you turn the key, you are responsible for your own safety, as well as the safety of all the people who share the road with you. If your physician chooses to use this process, be sure that you complete the form prior to returning it to the driver safety office. Interstate is when you drive from one state to another state or foreign country or your commercial motor vehicle crosses at any point from one state to another state or foreign country or if you drive only within your state but the cargo is part of a trip that will end in another. To determine your type of driving and self certify. Driver s information driver completes this section driver s name last, first, middle social security no. Driver medical evaluation ds 326 pdf back to main forms page.
You must pass all dot physical requirements in order to be cleared for your cdl medical card. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. You will need to carry a copy of this certificate with you when operating a commercial motor vehicle. Alternatively, medical providers with access to the internet can print the dme, complete and sign it, and forward it to the driver. Annual diabetes assessment package for exempted drivers. Medical examination report federal motor carrier safety administration.
Lung disease, emphysema, asthma, chronic bronchitis headbrain injuries, disorders or illnesses kidney disease, dialysis. If you drove trucks in the military, you may be able to get a cdl without having to take a skills test or meet training requirements. To save the hassle of having to wait in line at a driver and vehicle service center, this allows you to renew by mail. Medical examination report for commercial driver fitness. Some of the main types of drivers include the following. Medical examination report for commercial driver fitness determination. The summary of your visit can be sent to your primary care provider with your permission. Birthdate m d y age sex m f new certification recertification followup date of exam address city, state, zip code work tel. Driver medical evaluation ds 326 california department of. Qualification to drive a commercial vehicle requires the driver to complete a department of transportation dot medical exam. A medical examiner on the national registry will need to complete the fmcsa medical examination report for commercial driver fitness determination as well as the certificate at the end of the packet. If a driver fails or is not recertified for a dot medical.
Physicians do have some latitude regarding drivers and blood pressure, for example to rule out blood pressures physiologic variations and measurement. Genesis is a medical management organization with over 25 years of experience. Exceptions may be made and a restricted commercial license may be issued. Drivers information driver completes this section date of exam m recertification m d y drivers name last, first, middle social security no. Texas department of public safety courtesy, service, protection. Medical examination report for commercial driver fitness determination use this form to disclose your medical history and pertinent medical information as part of a pennsylvania commercial drivers license application. Health history driver completes this section, but medical examiner is encouraged to discuss with driver. Birthdate age sex new certification date of exam m recertification m d y f follow up 2. Our dot physical is the quickest and most convenient dot medical exam on all of long island nassau, suffolk, queens. Commercial driver license training provider initial or update registration driver medical examination for commercial driver fitness determination report and certificate. Vehicle and boat licensing services may vary across the state. Dot safety regulations require commercial drivers to renew their physical every 2 years. The pennsylvania department of transportation penndot will mail you a renewal notice about 3 months prior to the expiration date of your commercial driver s license cdl.
Commercial driver fitness determination specialist somerset. Trusted commercial driver fitness determination specialist serving somerset, nj. Physicians do have some latitude regarding drivers and blood pressure, for example to rule out blood pressures physiologic variations and measurement errors or. Driver medical fitness for duty drivers are critical to highway safety for commercial motor vehicle cmv drivers, the most important safety feature is you the driver. Commercial vehiclescdl iowa department of transportation.
Medical examination report for commercial driver fitness determination 1. Driver safety cdl guidelines california department of. Under the new requirement by the federal motor carrier safety administration, all states must begin collecting and maintaining medical certification information. Listed below are some areas that will be evaluated during the exam, along with qualification criteria.
Form search results west virginia department of transportation. Driver safety cdl guidelines california department of motor. The medical programs page provides links to commonly requested information and documents. This is a directory of dot cdl license physical exam locations throughout the.
We help you meet documentary compliance requirements mandated by the department of transportation pertaining to commercial drivers license eligibility. Contact us at 7326596650 or visit us at 1527 route 27, suite 2100, somerset, nj 08873. The drivers license application will be used to update the voter registration record of currently registered voters in the state of hawaii, unless the applicant affirmatively declines on page 2 of this application national voter registration act of 1993. We will complete the medical examination report for commercial driver fitness determination form and supporting documents, including dot physical forms.
Commercial driver license medical exam before we issue the medical examination report that you need, we put you through driver fitness determination tests that include a series of medical exams. Fmcsa certified medical examiners in cedar rapids, iowa dot physical exam locations. We perform the dmv eye examination and dot required urine test onsite takes 2 minutes. 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. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875. Health history address city, state, zip code work tel.
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. Again, your dot medical certification is good for 2 years unless your health status necessitated an exemption. Revised blood pressure guidelines for commercial drivers. The commercial motor vehicle driver medical examination aims to ensure that commercial drivers can safely perform all driving and nondriving workrelated tasks. Driver s information driver s name last, first, middle social security no. Determine the type of commerce you are involved in. If the information on this translated website is unclear, please contact us at 360. Drivers information driver completes this section drivers name last, first, middle social security no. Physicians do have some latitude regarding drivers and blood pressure, for example to rule out blood pressures physiologic variations and measurement errors or white coat hypertension. The driver fitness basic addresses the requirements within the federal motor carrier safety regulations fmcsrs, specifically 49 cfr parts 383 and 391, and refers to the operation of commercial motor vehicles cmvs by drivers who are unfit to operate a cmv.
For commercial motor vehicle cmv drivers, the most important safety feature is you the driver. Texas department of public safety courtesy, service. The driver may be granted a waiver pursuant to title 49, 391. We provide patients, insurance companies, businesses, employers, government agencies and other entities direct access to multispecialty physicians with expertise in conducting medical evaluations, comprehensive diagnostic testing, and support services. Drivers seeking information about the commercial drivers license cdl program medical requirements should start by visiting the fmcsas commercial drivers license program website and the cdl medical overview and medical programs pages. Driver medical fitness for duty drivers are critical to highway safety. To obtain a cdl, the applicant must provide a valid medical examination report for commercial driver fitness determination and medical examiners certificate medical report and medical examiners certificate, pass applicable vision and. Driver s information driver completes this section date of exam m recertification m d y driver s name last, first, middle social security no. Dot medical examination report for commercial driver fitness determination. Dec 17, 2019 driver medical fitness for duty drivers are critical to highway safety.
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