CDME Module 1: Overview-Medical Examiner's Certificate Form

Medical Examiner's Certificate Form

Pdf Summary

The document is titled "Medical Examiner's Certificate" and is used for commercial driver medical certification. The document includes a public burden statement, stating that a person is not required to respond to the collection of information unless it displays a valid OMB Control Number. The estimated time to respond to the information collection is one minute per response. The document is issued by the U.S. Department of Transportation, Federal Motor Carrier Safety Administration.<br /><br />The certificate includes sections for the examiner to certify that they have examined the driver and found them qualified according to the Federal Motor Carrier Safety Regulations. The examiner must indicate if the driver is qualified when wearing corrective lenses, a hearing aid, accompanied by a waiver/exemption, accompanied by a Skill Performance Evaluation (SPE) Certificate, driving within an exempt intracity zone, qualified by operation of 49 CFR 391.64, or grandfathered from state requirements.<br /><br />The examiner must provide their true and complete findings regarding the physical examination and state that a complete Medical Examination Report Form (MCSA-5875) with any attachments is on file in their office. The certificate includes spaces for the medical examiner's signature, the driver's signature, the driver's address, driver's license number, issuing state, and the medical examiner's contact information.<br /><br />The document also includes sections for the medical examiner's state license, certificate, or registration number, the medical examiner's name, date of certificate signing, and national registry number. It further includes a space for the medical examiner to indicate their profession (MD, Physician Assistant, Advanced Practice Nurse, DO, Chiropractor, Other Practitioner) and the issuing state/province.<br /><br />The document concludes with a reminder that it contains sensitive information for official use only and should be handled and secured appropriately to prevent inadvertent disclosure.

Keywords

Medical Examiner's Certificate

commercial driver medical certification

Federal Motor Carrier Safety Administration

Federal Motor Carrier Safety Regulations

corrective lenses

waiver/exemption

Medical Examination Report Form (MCSA-5875)

medical examiner's signature

driver's license number

sensitive information