Medical Examination Report Form - 1-Ply, 8-1/2" W x 11” L

Regulatory Alert: Effective January 16, 2024,
The FMCSA revised its Medical Examiner’s Certificate and Medical Examination Report Form to remove an obsolete reference. The new forms may be identified by a revision (rev) date, respectively, of “3/1/23” and “2/28/2023” in the lower corner (the date in the upper corner remains 3/31/2025). The FMCSA is allowing medical examiners to use up their existing stock of older forms, and is encouraging state licensing agencies to continue accepting them, beyond the January 16 deadline. However, motor carriers and medical examiners are advised to switch to the new forms as soon as possible.

• Helps you comply with 49 CFR §391.43
• Form MCSA-5875
• Both the Medical Examination Form and Medical Examination Certificate are required by the DOT
• This DOT medical examination form is 9 pages long
• Contains applicable regulations, instructions to the medical examiner, and the form itself
• Measures 8-1/2" x 11”