Justification for Nonsubstantive Change to MCSA-5875 07.08.20

Justification for Nonmaterial/Non-substantive Change for

OMB Control Number 2126-0006 IC

Medical Qualification Requirements

This justification for a nonmaterial/non-substantive change is to request the Office of Management and Budget’s (OMB) approval for a non-substantive change to the Federal Motor Carrier Safety Administration’s (FMCSA) Information Collection (IC) titled Medical Qualification Requirements, covered by OMB Control Number 2126-0006. This IC currently contains all information collection requirements for interstate commercial motor vehicle (CMV) drivers, Medical Examiners (MEs) conducting medical examinations of CMV drivers, and motor carriers that are subject to 49 CFR part 391, including the use of certain forms to record medical examinations of CMV drivers, results of medical examinations conducted, and driver qualification decisions. Forms required in 49 CFR part 391 include the Medical Examination Report (MER) Form, MCSA-5875, CMV Driver Medical Examination Results Form, MCSA-5850 (electronic only), and the Medical Examiner’s Certificate (MEC), Form MCSA-5876. FMCSA is requesting an expedited review and approval of this ICR to update the attached form that is included as in 49 CFR 391 as part of the medical certification process for interstate CMV drivers. The requested update is detailed below.

Changes to the MER Form, MCSA-5875

In 49 CFR 391.43(f), FMCSA is making the changes reflected in the table below, most of which are de minimus changes, to the Medical Examination Report Form, MCSA-5875, in an effort to improve clarity and accuracy. In addition to the changes in the table below, the font used for the pages containing the Instructions for Completing the Medical Examination Report Form (MCSA-5875) was changed to be consistent with the form. The public will be provided sufficient time to make any necessary information technology (IT) changes before use of the revised form becomes effective.

Current OMB-Approved Version	Proposed Version
Page 1, Personal Information section – Telephone:	Page 1, Personal Information section – Phone:
Page 2, Driver Health History section, #13 – (Insulin used)	Page 2, Driver Health History section, #13 – Insulin used
Page 3, Testing section, Hearing - … feet OR average …	Page 3, Testing section, Hearing - … feet OR average …
Page 4, Medical Examiner Determination (Federal) section – Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41 – 391.49):	Page 4, Medical Examiner Determination (Federal) section – Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41 – 391.49):
Page 4, Medical Examiner Determination (Federal) section – Other practitioner	Page 4, Medical Examiner Determination (Federal) section – Other Practitioner
Page 5, Medical Examiner Determination (State) section – Other practitioner	Page 5, Medical Examiner Determination (State) section – Other Practitioner
Page 6, Instructions, Section I: Driver Information – Question: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years?	Page 6, Instructions, Section I: Driver Information – Has your USDOT/FMCSA medical certificate ever been denied or issued for less than two years?
Page 7, Instructions, Section 2: Examination Report – missing information regarding hearing testing	Page 7, Instructions, Section 2: Examination Report – Hearing: The current hearing standard is provided on the form. Hearing can be tested using either a whisper test or audiometric test. Record the test results in the corresponding section for the test used.
Page 7, Instructions – In this next section, you will be completing either the Federal or State determination, not both.	Page 7, Instructions – In this next section, you will be completing either the Federal or State determination, not both.
Page 7, Instructions – Meets standards, but periodic monitoring is required: Select this option …is qualified for, and if selecting other specify the time frame.	Page 8, Instructions – Meets standards, but periodic monitoring is required: Select this option …is qualified for, and if selecting “other” specify the time frame.
Page 8, Instructions – Medical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.	Page 8, Instructions – Medical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.
Page 8, Instructions – Meets standards, but periodic monitoring is required: Select this option …is qualified and if selecting other, specify the time frame.	Page 9, Instructions – Meets standards, but periodic monitoring is required: Select this option …is qualified for, and if selecting “other” specify the time frame.
Page 8, Instructions – Medical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.	Page 9, Instructions – Medical Examiner’s Certificate Expiration Date: Enter the date the driver’s Medical Examiner’s Certificate (MEC) expires.