WebMedical Examination Report (MER) Form, MCSA-5875 - This form is an example of what patients can expect. The MER will be completed online at the center and does not need to be printed and completed beforehand. Medical Examiner's Certificate (MEC), Form MCSA-5876 - This form is an example of what certified drivers can expect. WebForm MCSA-5876 Medical Examiner's Certificate Preview Fill PDF Online Download PDF What Is Form MCSA-5876? This is a legal form that was released by the U.S. Department of Transportation - Federal Motor Carrier Safety Administration and used country-wide.
FMCSA releases updated medical forms - J. J. Keller
WebRegional, federal, and federal government websites often end in .gov. State of Georgia government websites press email systems exercise “georgia.gov” either “ga.gov” with the end of an address. Prior sharing sensitive or personal information, construct save you’re on an official state website. Dot Physical Exam Lithonia, GA Web18 dec. 2024 · FMCSA medical forms with a new 12/31/2024 OMB expiration date include: The Medical Examination Report Form (MCSA-5875), The Medical Examiner’s … pooky wall lighting
Medical Examination Report Form - UMass
WebForm MCSA-5875 OMB No. 2126-0006 Expiration Date: 8/31/2024 Last Name: First Name: DOB: Exam Date: DRIVER HEALTH HISTORY (continued) Do you have or have you … WebForm MCSA-5875 OMB No. 2126-0006 Expiration Date: 11/30/2024 MEDICAL EXAMINER DETERMINATION (State) Use this section for examinations performed in accordance … WebForm MCSA-5875 OMB No. 2126-0006 Expiration Date: 11/30/2024 Last Name: First Name:DOB: Exam Date: DRIVER HEALTH HISTORY (continued) Do you have or have you ever had: Yes No Not Sure 1. Head/brain injuries or illnesses (e.g., concussion) 2. Seizures, epilepsy 3. Eye problems (except glasses or contacts) 4. Ear and/or hearing problems 5. pool 12ft x 36in