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It includes a Public Burden Statement and Privacy Act notices specifying authority, purpose, routine uses, and mandatory information provision. The form requires the driver’s signature and acknowledgment, and contains a structured medical history section covering surgeries and current medications, plus condition checklists across neurological, visual, auditory, cardiac, respiratory, musculoskeletal, and vascular categories.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/medical-examination-report-form-safety-administration-for-commercial-driver-medical-certification/298548/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/medical-examination-report-form-safety-administration-for-commercial-driver-medical-certification/298548.png","ImageObject",300,407,{"name":92,"@type":93},"Felix Montgomery","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-21","2026-09-18",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",12,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What information must be provided on the form for commercial driver medical certification?","Question",{"text":113,"@type":114},"The form collects the driver’s personal information, examination date, and results of health history questions, including surgery history and current medication use, plus condition checklists covering multiple body systems.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What is the Privacy Act statement on the form used for?",{"text":118,"@type":114},"It explains the legal authority, purpose for recording examination results, routine uses of the collected information, and the requirement that the driver provides the information for the medical qualification determination.",{"name":120,"@type":111,"acceptedAnswer":121},"How are medical exam records handled after the exam?",{"text":122,"@type":114},"Completed Medical Examination Report Forms must be retained on file by the medical examiner for at least 3 years from the date of examination, and made available within 48 hours to authorized enforcement representatives after a 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collection of information subject to the requirements ofthe Paperwork Reduction Actunless that collection of informattiondisplays acurrent 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 perresponse,indluding the time for reviewing instructions,gathering the data needed,and completing and reviewing the collection of infomation.Alresponses to this collection of information are mandatory.Send comments regarding this burden estimate orany other aspect of this collection of information,including suggestionsfor reducing thisburden ta:Information Collection Clearance ffice,Federal Motor Carier Safety Administration,MC-RRA,1200 New Jersey Avenue,SE,Washington,DC.20590.U.S.Department of TransportationFederal Motor CarrierMedical Examination Report FormSafety Administration(for Commercial Driver Medical Certification)  \n| PRIVACY ACT STATEMENT:This statement is provided pursuant to the Privacy Act of 1974,5 USC5552a.  \u003Cbr>AUTHORITY:Title 49,United States Code (USC),49 USC 31133(a)(8)and 31149(c)(1)(E).  \u003Cbr>PURPOSE:To record results of a driver's physical examination,to determine qualification to operate a commercial motor vehicle (CMV),and  \u003Cbr>topromote driver health in interstate commerce according to the requirements in 49CFR391.41-49.Providing this information is mandatory.  \u003Cbr>f this information is not provided,the medical examiner will not be able to determine qualification to operate a CMV in interstate commerce  \u003Cbr>according to the requirements in 49CFR391.41-49.To record results of a dnive's physical examination and to determine qualification to operate   | MEDICAL RECORD\\#   |\n| --- | --- |\n|  | (orsticker)   |\n| a CMVin intrastate commerce when the driver is required by a State to beexamined by a medical examiner listed on the National Registry of Certified Medical Examiners in accordance  \u003Cbr>with the provisions of 49CFR 391.41-49andany variances from the physical qualification standards adopted by such State.  \u003Cbr>Medical examiners are required to complete the Medical Examination ReportForm for every driverphysical examination performed in accordance with49 CFR391.41.Each original  \u003Cbr>(paper or electronic)completed Medical Examination Report Form must be retained on file at the office of the medical examiner for at least 3 years from the date of examination.The  \u003Cbr>medical examiner must make all records and infomation in these files available to an authorized representative of FMCSA oran authorized Federal,State,or local enforcement agency  \u003Cbr>representative,within 48 hours after the request is made[49CFR 391.43(i)].  \u003Cbr>ROUTINE USES:The information is used for the purpose set forth above and may be forwarded to Federal,State,or locallaw enforcement agencies for their use.Medical Examination  \u003Cbr>Report Forms collected by FMCSA will be stored in FMCSA's automated NationalRegistry ofCertified MedicalExaminers System and wll be used to monitor the performance of medi-  \u003Cbr>cal examiners listed on the National Registry.  \u003Cbr>In addition to those disclosures permitted under 5 USC 552a(b)of the Privacy Act of 1974,additional disclosures may bemade in accordance with the U.S.Department of Transporta-  \u003Cbr>tion(DOT)Prefatory Statement of General Routine Uses published in the Federal Register on December 29,2010(75 FR82132),under\"Prefatory Statement of General Routine  \u003Cbr>Uses\"(available at http://www.dot.gov/privacy/privacyactnotices).  \u003Cbr>ACKNOWLEDGMENT:Iunderstand the provisions of the Privacy Act of1974 as relatedto me through the above-mentionedstatement.  \u003Cbr>Driver's Signature:  \u003Cbr>____      ______Date:___    _   |  |\n\n# SECTION 1.Driver Information (to befilled out by the driver)\n\n\n| PERSONAL INFORMAT","cbCaibaDO9Nh940K","https://ap.wps.com/l/cbCaibaDO9Nh940K","pdf",1279616,"English","# SECTION 1. Driver Information\n## Personal information\n# DRIVER HEALTH HISTORY\n## Surgery and medication questions\n# DRIVER HEALTH HISTORY (continued)\n## Medical condition checklist","[{\"question\":\"What information must be provided on the form for commercial driver medical certification?\",\"answer\":\"The form collects the driver’s personal information, examination date, and results of health history questions, including surgery history and current medication use, plus condition checklists covering multiple body systems.\"},{\"question\":\"What is the Privacy Act statement on the form used for?\",\"answer\":\"It explains the legal authority, purpose for recording examination results, routine uses of the collected information, and the requirement that the driver provides the information for the medical qualification determination.\"},{\"question\":\"How are medical exam records handled after the exam?\",\"answer\":\"Completed Medical Examination Report Forms must be retained on file by the medical examiner for at least 3 years from the date of examination, and made available within 48 hours to authorized enforcement representatives after a request.\"}]","Medical Examination Report Form - Safety Administration (for Commercial Driver Medical Certification) | PDF",1789759499,23]