Transcription of 391.41 CMV DRIVER MEDICATION FORM
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391.41 CMV DRIVER MEDICATION FORM
MCSA-5895 OMB Control Number: 2126-0064 Expiration Date: 04/30/2023 Page 1 of 2 Use of this form by the certified medical examiner is voluntar document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulator y States Department of Transportation Federal Motor Carrier Safety CMV DRIVER MEDICATION FORMA 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 regulations as noted below, complete this form, and return it to me at the mailing address, email address, or fax number specified below. The final determination as to whether the individual listed in this form is physically qualified to drive a CMV will …
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