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Instructions:\n\n·AIl commercial driver's license(CDL)holders,Class A,B or C,must complete and submit this self-certification form for initial,renewal or change in class application.Refer to the Tennessen Warning on the back of this form.  \n·Drivers who check Category 1 or Category 3 below must also submit a current medical examiner's certificate from a certifiedmedical examiner and any applicable waivers.  \n●All CDL holders with a school bus endorsement MUST submit a current medical examiner's certificate from a certified medicalexaminer.  \n·If there is a change in your medical status or interstate/intrastate status you MUSTprovide a new self-certification form.  \n·If you have any questions or concerns,contact Driver and Vehicle Services by phone(651)297-5029.  \n·Please submit this completed self-certification form and your medical examiner's certificate from a certified medical examinerand/or medical waiver,if applicable by mail:Driver and Vehicle Services Division,445 Minnesota Street,Suite 175,St.Paul,MN 55101-5175,by fax to (651)297-4447 or in person at any driver exam station or driver license office that acceptsapplications.Refer to the Driver and Vehicle Services Website for a list oflocations  \n   \n## Driver Information:\n\nPrint Name(First,Middle,Last)  \nDate of Birth(mm/dd/yyyy)  \nMinnesota Driver's License Number:  \n## Please check only one of the following self-certification categories that apply to you:\n\nI certify my commercial operating status is--check only one category box below:(Checking more than one category box will delay processing this form)  \n□ Category 1-Non-exempt Interstate,subject to 49 CFR part 391(Current medical examiner's certificate from a certified medical examiner must be submitted).  \n□ Category 2-Exempt Interstate,exempt from medical examination requirements of 49 CFR part 391  \n□ Category 3-Non-exempt Intrastate,subject to state medical examination requirements of Minn.Stat.,ch.221(Current medical examiner's certificate from a certified medical examiner must be submitted).  \n□ Category 4-Exempt Intrastate,exempt from state medical examination requirements listed in Minn.Stat.,ch.221  \n## Please answer the following two questions:\n\n1.Are you submitting a copy of your medical examiner's certificate from a certified medical examiner?□Yes □No  \n2.Are you submitting a copy of a medical waiver?□Yes □No  \n   \nForm MCSA-5875  \nPublic Burden Statement  \nA Federal agency may not conduct or sponsor,and a person is not required to respond to,nor shall a person be subject to a penaltyfor failure to comply with a collectionof information subject to the requirments ofthe Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.The OMB Control Numberfor this information collection is 2126-0006.Public reporting for this collectionof information is estimated to be approximately 25minutes per response,includingthe time for reviewing instructions,gathering the data needed,and completing and reviewing the collection of information.Allresponses to this collection o information are mandatory.Send commentsregarding this burdenestimate or any other aspect of this collection of information,including suggestions for reducing this burden to:Information Collection Clearance ficet,Federal Motor Carier Safety Administration,MC-RRA,1200 New Jersey Avenue,SE,Washington,D.C.20590.U.S.Department of TransportationFederal Motor CarrierMedical Examination Report FormSafety Administration(for Commercial Driver Medical Certification)  \nMEDICAL RECORD\\#  \n\n| SECTION1.Driver Information (to befledoutbythe drve)   |  | Cell Provider   | (or sticker)   |\n| --- | --- | --- | --- |\n| PERSONALINFORMATION   |  |  |  |\n| ____   _____First Name:  \u003Cbr>Last Name:_________   |  | ____________Middle lnitial:   | ___Date of Birth:__________Age:_   |\n| Street Address:_   |  | State/Province:___","cbCaionsSZGZm77M","https://ap.wps.com/l/cbCaionsSZGZm77M","pdf",4179103,"English","# Instructions\n# Driver Information\n# Self-certification Categories\n# Medical Submission Questions\n# Public Burden Statement\n# Driver Health History\n## Driver Health History (continued)","[{\"question\":\"Who must complete and submit this CDL medical self-certification form?\",\"answer\":\"All commercial driver license (CDL) holders in the specified classes must complete and submit the self-certification for initial, renewal, or change in class application.\"},{\"question\":\"Which medical document(s) are required for Category 1 or Category 3?\",\"answer\":\"Drivers who select Category 1 or Category 3 must submit a current medical examiner’s certificate from a certified medical examiner, along with any applicable waivers.\"},{\"question\":\"What information does the form collect in the driver health history section?\",\"answer\":\"It asks about surgery history, current medications, and whether the driver has had various health conditions (including neurologic, vision/hearing, cardiovascular, and musculoskeletal issues), with space for outcomes and follow-up details.\"}]","Commercial Driver License Medical Self-certification Form | PDF",1789770056]