Transcription of Medical Examination Report Form Federal Motor Carrier
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Medical Examination Report Form Federal Motor Carrier
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024 Page Department of TransportationFederal Motor CarrierSafety AdministrationRev 12/ 5/2021 Public Burden StatementA 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 25 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.
(prescription, over-the-counter, herbal remedies, diet supplements)? If “yes,” please describe below. First Name: City: State/Province: Issuing State/Province: ... driver’s safe operation of a commercial motor vehicle (CMV). Driver’s Signature: Date: SECTION 2. Examination Report (to be filled out by the medical examiner) 49 CFR 390.35 ...
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