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

Helps you comply with 49 CFR §391.43 DOT medical card requirements.

Product Code:47375
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Regulatory Alert: Effective April 1, 2025
The FMCSA has reissued its Medical Examiner’s Certificate and Medical Examination Report Form with a new OMB expiration date of “3/31/2028” in the upper right corner and a revision (rev) date of “3/27/25” in the lower right corner. The FMCSA is allowing medical examiners to use up their existing stock of older forms. FMCSA is encouraging, but not requiring, state licensing agencies to continue accepting them. However, motor carriers and medical examiners are advised to switch to the new forms as soon as possible.

Temporarily on backorder. Expected availability 4/23/2025 (subject to change).

Product Information
  • 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”

View Sample

View a sample Medical Examination Report.

Number of Plies: 1

Compliance Topic: Injury & Illness Recordkeeping, Driver Qualification & Hiring

Size: 8.5" x 11"

Format: Sheet

Need to Purchase a Case?: 500 per case

Industry: Transportation, Human Resources

Average Rating: 4.8

BVNumberOfReviews: 6

UNSPSC Number: Examination booklets or forms - 14111533, 14111812

Advantage Savings: Advantage Savings

Country Of Origin: USA