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Medical Examination Report Form (010464)
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Medical Examination Report Form

Helps you comply with 49 CFR §391.43 DOT medical card requirements. Read more.

Regulatory Alert: Effective January 16, 2024, the FMCSA revised its Medical Examiner’s Certificate and Medical Examination Report Form to remove an obsolete reference. Learn More

Product Code: 47375
List Price: $9.59

Overview

Regulatory Alert: Effective January 16, 2024,
The FMCSA revised its Medical Examiner’s Certificate and Medical Examination Report Form to remove an obsolete reference. The new forms may be identified by a revision (rev) date, respectively, of “3/1/23” and “2/28/2023” in the lower corner (the date in the upper corner remains 3/31/2025). The FMCSA is allowing medical examiners to use up their existing stock of older forms, and is encouraging state licensing agencies to continue accepting them, beyond the January 16 deadline. However, motor carriers and medical examiners are advised to switch to the new forms as soon as possible.

  • Helps you comply with 49 CFR §391.43
  • Form MCSA-5875
  • Both the Medical Examination Form and Medical Examination Certificate are required by the DOT
  • This DOT medical examination form is 9 pages long
  • Contains applicable regulations, instructions to the medical examiner, and the form itself
  • Measures 8-1/2" x 11”

Volume Pricing

Volume Pricing
Product Code Description 1 - 9 10 - 49 50 - 99
Higher quantities available. Pricing reflected in shopping cart or call 1-877-564-2333 to order.
47375
Medical Examination Form Only
$9.59
$6.16
$3.48

Specification

Specification
Product Code Description Format Number of Plies Size Need to Purchase a Case? Country Of Origin
47375
Medical Examination Form Only
Sheet
1
8.5" x 11"
500 per case
USA

View Sample

View a sample Medical Examination Report.

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