CDME Module 7: Insulin-treated Diabetes Mellitus and Renal Disease (2025)-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870

Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870

Pdf Summary

The document is a form (MCSA-5870) from the U.S. Department of Transportation's Federal Motor Carrier Safety Administration, expiring on 03/31/2025, and is used for assessing individuals treated for insulin-dependent diabetes mellitus in relation to their qualification to operate commercial motor vehicles. It is crucial due to the sensitive nature of the information, and it's emphasized that it should be handled securely and properly disposed of when no longer needed as per regulatory requirements.<br /><br />The form serves as an assessment tool to determine if an individual meets the physical qualification standards required by the FMCSA or has had a recent severe hypoglycemic episode. A treating clinician, defined as a healthcare professional managing and prescribing insulin, must complete the form with details about the individual’s medical history.<br /><br />Key assessment areas include:<br /><br />1. **Diabetes Management:** Confirmation of ongoing self-monitoring of blood glucose levels with an electronic glucometer for at least the past 3 months, which must be reviewed by the treating clinician.<br />2. **Blood Glucose Monitoring Compliance:** Information on how frequently the individual checks their blood glucose levels and their compliance with their treatment plan.<br />3. **Medical History:** Records of any severe hypoglycemic episodes, measured HbA1C levels, and signs of diabetic complications or organ damage.<br />4. **Diabetes Complications:** Includes evaluation of potential complications such as kidney disease, cardiovascular issues, neurological diseases, peripheral neuropathy, lower limb problems, and eye conditions like diabetic retinopathy or other ocular diseases.<br />5. **Clinician Attestation:** The form requires a clinician's verification that the provided information is accurate, the insulin regimen is stable, and the condition of diabetes is well-managed.<br /><br />The information from the form is utilized by a certified medical examiner to determine the individual’s capacity to safely drive commercial vehicles. Filling out and timely submission of this form within 45 days of signature is necessary prior to a medical certification examination post a hypoglycemic episode.

Keywords

MCSA-5870

FMCSA

insulin-dependent diabetes

commercial motor vehicles

blood glucose monitoring

hypoglycemic episodes

diabetes complications

medical examiner

clinician attestation

medical certification