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:47375Regulatory Alert
The FMCSA Medical Examiner’s Certificate and Medical Examination Report expiration date in the upper-right corner is 3/31/2025. Sometime in March, FMCSA is expected to communicate the new expiration date (no other changes are expected per FMCSA) and whether existing forms with the expiration date of 3/31/2025, can continue to be used beyond that date. FMCSA in the past has allowed the use of forms past the expiration until the current supply is exhausted, but that is not a guarantee.
- 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: 14111812, Examination booklets or forms - 14111533
Advantage Savings: Advantage Savings
Country Of Origin: USA