Form MCSA-5850 CMV Driver Medical Examination Results Form

Form MCSA-5850 (Revised: 04/23/2015)

Expiration Date:

OMB No. 2126-

Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of
the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection
of information is estimated to be approximately 2 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All
responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

U.S. Department of Transportation
Federal Motor Carrier
Safety Administration

CMV Driver Medical Examination Results Form

You are required to submit the following driver medical examination data for each physical examination performed by midnight (local time) of
the next calendar day.
CMV Driver Name and Address (use Legal Name as listed on Government-Issued Identification)
First Name:

Middle Name:

Last Name:

Suffix (Jr., Sr., III, etc.):

(enter 'NMN' if driver does not have a middle name)

Street:

City:

(optional)

State/Province:

Zip Code:

E-mail:

CMV Driver's License Information
Number:

Issuing State/Province:

Date of Birth:
(use mm/dd/yyyy format)

CLP/CDL Applicant/Holder:

Yes

No

Examination Information (please complete only one of the Examination Information sections below)
Examinations performed in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49):
Examination Result:

or

Examinations performed in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49), with any applicable state variances:
Examination Date:

Medically Qualified

(use mm/dd/yyyy format)

Date MEC signed/issued:
(use mm/dd/yyyy format)

Medically Unqualified

Examination Result:

Medically Qualified
Incomplete Examination

Date of examination/determination:
(use mm/dd/yyyy format)

Pending Determination

Medical Examiner's Certificate Expiration Date:
(applicable when "Medically Qualified" is selected above)

Date of examination:

(use mm/dd/yyyy format)

(use mm/dd/yyyy format)

Incomplete Examination
Date of examination:

(use mm/dd/yyyy format)

Medical Examiner's Certificate Expiration Date:
(applicable when "Medically Qualified" is selected above)

(use mm/dd/yyyy format)

Restrictions and Variances (check all that apply)
Wearing corrective lenses

Accompanied by a Skill Performance Evaluation Certificate (SPE)

Wearing hearing aid

Driving within an exempt intracity zone (49 CFR 391.62) (Federal)

Accompanied by a waiver/exemption
Type of waiver/exemption:
vision
If "other," please explain:

Qualified by operation of (49 CFR 391.64) (Federal)
diabetes

other

Grandfathered from State requirements (State)