Medical reporting cycles for commercial licence holders class a, b, c, e and f applicants for a class a, b, c, e and f licence are required to submit a medical report on application. New version wisconsin dmv medical examination report most. Periodic medical examination form exam answers free. Driver s information driver completes this section driver s name last, first, middle social security no. Comment on the drivers responses to the health history questions that may affect the drivers safe operation of a commercial motor vehicle cmv.
Wisconsin dmv official government site medical exam report. Medical examination report instructions to the driver. Adobe reader or any alternative for windows or macos are required to access and complete fillable content. The state requires the driver to submit to the state two separate medical examination reports mv3644 completed by two different health care providers. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration. Cdl dot medical what is a dot medical exam it is an exam that indicates an individual is physically qualified to operate a commercial motor vehicle in accordance with 49 cfr 391.
If this person holds or is applying for a commercial driver license, and has had an episode of altered consciousness or loss of bodily control since the last report. Aug 18, 2015 commercial driver medical examination data from 88,246 commercial drivers between 2005 and 2012 were analyzed for associations between bmi, medical disorders, and driver certification. Mv3644 fill online, printable, fillable, blank pdffiller. Many drivers who file a medical examination report mv3644 or certificate of vision examination by competent authority mv3030v are found to meet medical standards for licensing. Many drivers who file a medical examination report mv3644 or certificate of vision examination by competent authority mv3030v. The complete standards and instructions for conducting this examination are found in section 6.
This document contains statebystate tnstructions for submitting medical certificates for cdl drivers to the state licensing agencies. Walkin today and get your driver s medical completed with no delay. Federal guidelines for holding a commercial driver license require you to keep a good driving record and to pass a physical exam every two years. We will send you the forms at the time they are required. Commercial driver medical examination data from 88,246 commercial drivers between 2005 and 2012 were analyzed for associations between bmi, medical disorders, and driver certification. As part of the physical, drivers are required to fill out the medical history portion of the medical examination report mer form, mcsa5875.
When performing a commercial motor vehicle driver medical examination, the examiner must consider the federal medical standards, plus related recommendations and guidance, to reach a. Medical examination report for commercial driver fitness determination testing medical examiner completes section 3 through 7 section 3. Annual permit for transportation of hazardous materials. Fmcsa standards require states to issue commercial drivers licenses only after a driver passes stateadministered knowledge and skills tests. Commercial driver medical examination report georgia. Apr 17, 2007 medical examination report mv3644 32007 clear form ch. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. If a state accepts mailed in medical certificates, faxed medical certificated, andor emailed medical certificates. Please use these links, forms and publications as needed if you or someone you know has. Applicant name operator license number street address. Our formula of lowcost and quickaccess is why drivers always visit our clinic first. When performing a commercial motor vehicle driver medical examination, the examiner must consider the federal medical standards, plus related recommendations and guidance, to reach a certification. The federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners. Drivers aged 46 64 are required to submit a medical report every three years.
Drivers information driver completes this section date of exam m recertification m d y drivers name last, first, middle social security no. Medical examination reports must meet the requirements of 391. Dec 16, 2019 dot medical exam and commercial motor vehicle certification about the exam. Medical examination report commercial driver fitness.
Alternatively, medical providers with access to the internet can print the dme, complete and sign it, and forward it to the driver. Medical history and physical examinationapplicants must be examined for each of the following medical conditions using the criteria as set out in the canadian council of motor transport name date of birth yyyymmddtelephone numbercity townprovincepostal codeoccupationclass of licence requiredoperators licence. Applicant name operator license number street address birth. Commercial driver licensing endorsements, mv3030v certificate of vision examination by competent authority, and mv 3644 medical examination report. Download a blank fillable mv3644 medical examination report in pdf format just by clicking the download pdf button. You must use this medical examination report when applying for a commercial california driver license. Form search results wv department of transportation. Driver s information driver completes this section date of exam m recertification m d y driver s name last, first, middle social security no. You must use this medical examination report when applying for a commercial california driver license cdl or certificates school bus, youth bus, spab, gppv, or farm labor that require a medical examination.
Driver medical evaluation ds 326 pdf back to main forms page. Driver medical concerns driving with a disability driving with a medical condition. The superintendent will also notify the driver, in writing, of any drivers licence status changes which occur as a result of the information on the report. Walkin today and get your drivers medical completed with no delay. Mv3644 t583 medical examination report wisconsin dot. Department of transport medical assessment certificate. The secretary of the department of transportation is, by statute, responsible for the driver licensing decision. Driver medical evaluation ds 326 california department of. Mv3644 t583 medical examination report town of rome. An update on commercial driver medical examination rules. Each original 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. Drivers must carry a valid certification card and comply medical restrictions.
Fillable mv3644 medical examination report printable pdf. Check box if there is no health disorder to report in this section check box if there is no health disorder to report in this section check box if there is no health disorder to report in this section without correction with correction. Medical examiners are required to complete the medical examination report form for every driver physical examination performed in accordance with 49 cfr 391. An unofficial guide to commerical drivers medical certification. Section g health care professional recommendations for all applicants medical examiner. Drivers under the age of 46 are required to submit a medical report every five years. The medical certificate and medical report must be signed by the medical examiner who performs the examination. Transportation and infrastructure renewal drivers medical. You will need to carry evidence of a clean medical exam report i. Wisconsin department of transportation, medical examination report, form mv3644 rev. Residents of mexico and canada may be certified by doctors.
Please read the detailed medical assessment instructions m106a for the applicant and health professional. Dl 51, medical examination report fo commercial driver fitness. Birthdate age sex date of exam address city, state, zip code work tel. Our clinic has conducted thousands of driver medicals for truck, bus, tractortrailer, and emergency vehicle e. Examination by competent authority, and mv 3644 medical examination report. Chapter trans 112 medical standards for driver licensing. Medical examination report of driver under article 19a. Drivers information driver completes this section drivers name last, first, middle social security no. The form, mcsa5875, includes a medical examiners certificate mcsa5876 that is signed by a health care professional, when the driver meets the federal requirements. This medical examination report must remain on file with the department. At least 70 peripheral in horizontal meridian measured in each eye. Medical examination report for commercial driver fitness determination 649f 6045 1. The purpose of this examination is to determine a drivers physical qualification to operate a commercial motor vehicle cmv in interstate commerce according to. Drivers information driver must complete this section.
Once completed, this form can be faxed, emailed or mailed to us at any of the addresses listed to the right. Medical examination report mer form, mcsa5875 fmcsa. Applicant details to be completed by applicant or department of transport. Nov 26, 2018 the federal motor carrier safety administration requires that interstate commercial motor vehicle drivers maintain a current medical examiners certificate mec, form mcsa5876 to drive. Dot medical examination report for commercial driver fitness determination. The state, not the cme, will determine whether the driver is qualified to operate a commercial motor vehicle. Medical examination for motor vehicle operators affix microfilm sticker here a. The commercial motor vehicle driver medical examination. Drivers name first, last, middle social security no. An update on commercial driver medical examination rules and. This report also meets united states deparment ot f tarnsporatiot n dot requirementsa. The exam must be current within the past 90 days, unless otherwise stated and complete. Ontario drivers medicals rapidaccesstomedicalspecialists.
Driver s name first, last, middle social security no. Bds353 wisconsin state waiver information for cdl drivers. Wisconsin dmv official government site driver medical. Many drivers who file a medical examination report mv3644 or certificate of vision examination by competent authority mv3030v are found to meet medical standards for. Examination report continued check nothing to report or check and complete applicable conditionss c respiratory nothing to report m q 1. Dot medical exam and commercial motor vehicle certification about the exam. A department of transportation dot physical examination must be conducted by a licensed medical examiner listed on the federal motor carrier safety administration fmcsa national registry. Medical examination report for commercial driver fitness. Drivers medical examination report dmer province of. Wisconsin dmv official government site medical exam. The information that will be provided in this document is as follows. Birthdate m d y age sex m f new certification recertification followup date of exam address city, state, zip code work tel.
Specialists, such as cardiologists and endocrinologists, may perform additional medical evaluation, but it is the medical examiner who decides if the driver is medically qualified to drive. Medical history and physical examinationapplicants must be examined for each of the following medical conditions using the criteria as set out in the canadian council of motor transport name date of birth yyyymmddtelephone numbercity townprovincepostal codeoccupationclass. Jul 01, 2012 federal guidelines for holding a commercial driver license require you to keep a good driving record and to pass a physical exam every two years. If your physician chooses to use this process, be sure that you complete the form prior to returning it to the driver safety office. Medical examination reports are returned to the licensing.
At least 2040 acuity snellen in each eye withwithout correction. Please use these links, forms and publications as needed if you or someone you know has a medical concern that may affect safe driving. Application for motor carrier identification number. Commercial driver medical examination report commercial driver medical examination report 649f 6045 medical examination report 414. Medical examination report for commercial driver fitness determination 1. Medical assessment certificate fitness to drive form m107a. If the report satisfies our concerns, this may be all that is required. Transportation and infrastructure renewal drivers medical examination report page 1 of 2 rev 0217 rep 32 if you have any questions, please call the medical fitness section at 9024245732. Medical examination report mv3644 32007 clear form ch. Determining driver medical fitness for duty is a critical element of the fmcsa safety program.
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