Form MCSA 5895 MCSA 5895 391.41 CMV Driver Medication Form MCSA 5895

MCSA-5895

OMB Control Number: 2126-00XX
Expiration Date:

U.S. Department of Transportation
Federal Motor Carrier Safety Administration

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a
collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control
Number. The OMB Control Number for this information collection is 2126-00XX. Public reporting for this collection of information is estimated to be approximately
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responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue,
SE, Washington, D.C. 20590.

391.41 CMV DRIVER MEDICATION FORM
Driver Name: ______________________________________________________
DOB:__________________________
The above patient/driver is being evaluated to determine whether he/she meets the medical standards of the Federal Motor
Carrier Safety Administration (FMCSA) to operate a commercial motor vehicle (CMV) in interstate commerce. During
the medical evaluation, it was determined this individual is taking medication(s) that may impair his/her ability to safely
operate a CMV. As the certified Medical Examiner (ME), I request that you review the regulations as noted below,
complete this form, and return it to me at the mailing address, email address, or fax number specified below. The final
determination as to whether the individual listed in this form is physically qualified to drive a CMV will be made by the
certified ME.
49 CFR 391.41, Physical Qualifications for Drivers: A person is physically qualified to drive a CMV if that person … (12)(i)
Does not use any drug or substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or other habitforming drug. (ii) Does not use any non-Schedule I drug or substance that is identified in the other Schedules in 21 part 1308
except when the use is prescribed by a licensed medical practitioner, as defined in § 382.107, who is familiar with the driver’s
medical history and has advised the driver that the substance will not adversely affect the driver’s ability to safely operate a
CMV.

1. List all medications and dosages that you have prescribed to the above named individual.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2. List any other medications and dosages that you are aware have been prescribed to the above named individual by
another treating health care provider.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. What medical conditions are being treated with these medications?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4. It is my medical opinion that, considering the mental and physical requirements of operating a CMV and with
awareness of a CMV driver’s role (consistent with “The Driver’s Role” statement on page 2), my patient:
(a) has no medication side effects from medication(s) that I prescribe that would adversely affect the ability to safely
operate a CMV; and
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Use of this form by the certified medical examiner is voluntary.

(b) has no medical condition(s) that I am treating with the above medication(s) that would adversely affect the ability
to safely operate a CMV.
____Yes

_____No

(check response)

_____________________________________________

_______________________________

Signature of Prescribing Healthcare Provider

Date

_____________________________________________

_______________________________

Printed Name of Prescribing Healthcare Provider

State of Licensure

Street Address

City, State, Zip Code

_____________________________________________

_______________________________

Phone/Fax

Email

391.41 CMV DRIVER MEDICATION FORM
THE DRIVER'S ROLE
49 CFR 391.43
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of
driving that they do. Some of the main types of drivers include the following: turn around or short relay (drivers return to their home
base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-duty period), straight through haul (cross
country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.) The
following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which
may result in irregular sleep patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family
and friends, which may result in lack of social support; tight pickup and delivery schedules, with irregularity in work, rest, and eating
patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading cargo in
order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature.
Transporting passengers or hazardous materials may add to the demands on the commercial driver. There may be duties in addition to
the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling
trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs.
of freight after sitting for a long period of time without any stretching period); inspecting the operating condition of tractor and/or
trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and, lifting heavy tarpaulins to
cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to
inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or
trailer(s). In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to
make quick decisions, when necessary, and the manipulative skills to control an oversize steering wheel, shift gears using a manual
transmission, and maneuver a vehicle in crowded areas.

_____________________________________________

_______________________________

Signature of Certified Medical Examiner

Date

_____________________________________________

_______________________________

Printed Name of Certified Medical Examiner

Email

_____________________________________________

_______________________________

Street Address

City, State, Zip Code

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Use of this form by the certified medical examiner is voluntary.
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secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this
document when no longer required to be maintained by regulatory requirements.**