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

MCSA-5895  

OMB Control Number: 2126-0064
Expiration Date: 04/30/2020

United States 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 2126-0064. Public reporting for this collection of information is estimated to be approximately 8 minutes per response,
including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All 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
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.
CERTIFIED MEDICAL EXAMINER’S REQUEST FOR INFORMATION

Driver Name:

Date of Birth:

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(b), 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 habit-forming 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.

Printed Name of Certified Medical Examiner:

Date:

Street Address:
Email Address:

City, State, Zip Code:
Fax Number:

Signature of Certified Medical Examiner:

Use of this form by the certified medical examiner is voluntary.
This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and
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.

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Rev 4/7/2020

MCSA-5895  

OMB Control Number: 2126-0064
Expiration Date: 04/30/2020

PRESCRIBING HEALTHCARE PROVIDER DATA
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 1), 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
(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

Printed Name of Prescribing Healthcare Provider:

State of Licensure:

Street Address:
Email Address:

City, State, Zip Code:

American
Alaska
Alabama
District
Delaware
Connecticut
Colorado
California
Arkansas
Arizona
Marshall
Maine
Louisiana
Kentucky
Kansas
Iowa
Indiana
Illinois
Idaho
Hawaii
Guam
Georgia
Florida
Nevada
Nebraska
Montana
Missouri
Mississippi
Minnesota
Micronesia
Michigan
Massachusetts
Maryland
New
North
Northern
Puerto
Pennsylvania
Palau
Oregon
Oklahoma
Ohio
Rhode
South
Virgin
Vermont
Utah
Texas
Tennessee
West
Washington
Virginia
Wyoming
Wisconsin
Hampshire
Jersey
Mexico
York
Virginia
Carolina
Dakota
Carolina
Dakota
Island
Islands
Rico
ofIslands
Marianas
Samoa
Columbia

Date:

Fax Number:

Signature of Prescribing Healthcare Provider:

Use of this form by the certified medical examiner is voluntary.
This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and
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.

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