FMCSA Form MCSA-5876 template
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DOT Card Form
Medical Examiner's Certificate
This document is a Medical Examiner's Certificate for commercial driver certification in the United States. It includes a public burden statement about the Paperwork Reduction Act and mandatory reporting requirements. The certificate confirms that the named individual has been examined and found qualified to operate a Commercial Motor Vehicle (CMV), based on Federal Motor Carrier Safety Regulations. Various medical conditions and waivers are listed, along with the examiner's contact information, driver's license number, and state of issue. The document also provides information about the CMV driver.
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