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Updated Driver Medical Examination Forms

Updated Driver Examination Forms Posted

The date found on the top right corner of the Medical Examination Report Form, MCSA-5875 and Medical Examiner’s Certificate, MCSA-5876, is the date of expiration for the Office of Management and Budget (OMB) approved information collection 2126-0006, that includes the Medical Examination Report Form, MCSA-5875 and Medical Examiner’s Certificate, MCSA-5876. FMCSA has received approval from OMB for the information collection 2126-0006 that now also includes the Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870. Therefore, the expiration date on the Medical Examination Report Form, MCSA-5875 and Medical Examiner’s Certificate, MCSA-5876, has been updated to11/30/2021, this expiration date has been added to the Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, and all forms are posted on the FMCSA website. Please note that the only change to the forms is the change in the OMB expiration date from 09/30/2019 to 11/30/2021. In a previous message, we notified you that we anticipated this future publication of the revised versions with a new expiration date and requested that Medical Examiners plan accordingly in managing their inventory of existing forms dated 09/30/2019. Therefore, moving forward, we expect Medical Examiners to start using the forms with the 11/30/2021 date as soon as possible. However, while Medical Examiners are transitioning to use of the OMB approved Medical Examination Report Form, MCSA-5875 and Medical Examiner’s Certificate, MCSA-5876 with the 11/30/2021 date, FMCSA is encouraging the State Driver’s Licensing Agencies (SDLAs) to accept these forms with expiration dates of 08/31/2018, 09/30/2019, and 11/30/2021 since the only revision to forms is the OMB expiration date. The forms can be found at https://www.fmcsa.dot.gov/medical/driver-medical-requirements/medical-applications-and-forms.

Received from KMCA

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