Notice of Decision on Use of DOT Medical Forms

Medical Form.pdf

On October 27, 2016 Federal Motor Carrier Safety Administration (FMCSA) announced its decision (81 FR 74700) to allow certified Medical Examiners (MEs) to use the Medical Examination Report (MER) Form, MCSA–5875, and Medical Examiner’s Certificate (MEC), Form MCSA–5876, with October, November, and December, 2015 revision dates that are located in the top left corner of the forms until existing stocks are depleted.  For MEs in an office where these forms have been programmed into an electronic system that will require IT programming, the current approved versions of the forms should be programmed as soon as practicable. FMCSA published sample versions of the forms in October and November 2015 prior to posting fillable Portable Document Format (PDF) versions in December 2015. Based on the fact that the October and November 2015 forms contain minor differences yet collect the same information as the fillable PDF version, FMCSA determined the October and November versions are acceptable. In addition, MEs are also allowed to continue to use the versions of the MER Form, MCSA–5875, that include the Privacy Act Statement on page one until stocks are depleted. For MEs in an office where these forms have been programmed into an electronic system that will require IT programming, the current approved versions of the forms should be programmed as soon as practicable. The versions of the forms currently posted by FMCSA include nonsubstantive changes that were approved by the Office of Management and Budget (OMB) on April 7, 2016 and September 6, 2016, and no longer include the Privacy Act Statement or a revision date in the top left corner. State Driver’s Licensing Agencies (SDLAs) should not accept versions of the MEC that have not been approved by OMB, and do not display both the FMCSA form number (MCSA–5876) and the OMB expiration date of August 31, 2018.