The Medical Examination Report - Form MCSA-5875

One Form, Two Very Different Sections

The Medical Examination Report (MER), Form MCSA-5875, is the working clinical document behind every DOT physical. It has two sections with two different authors: Section 1 is the driver-completed health history covered in Section 2.2 of this chapter; Section 2 is the Examination Report, completed entirely by the medical examiner (ME), and it is where the ME's clinical findings and certification decision live. MEs must always use the current, FMCSA-published version of the form - using an outdated or expired revision is not compliant, so an ME's office should confirm it is working from the form currently listed on the FMCSA website before each exam.

What Section 2 Captures

Section 2 walks through the exam in a fixed order, and every part of it maps to a specific piece of the certification test's blueprint. The section opens with the driver ID verification field, noting the type of photo ID checked at intake, then moves through the ME's review and discussion of the driver's Section 1 health-history answers - for every significant or affirmative response, the ME writes a comment keyed to the item number, noting whether it affects the driver's ability to safely operate a CMV.

The Body-System Walk-Through

The physical-exam portion of Section 2 requires the ME to mark each body system as normal or abnormal and comment on any abnormal finding. The body systems listed on the form are: general appearance; eyes; ears; mouth and throat; neck; heart (cardiovascular); lungs and chest; abdomen; spine and other musculoskeletal structures; extremities; neurological; and psychiatric/mental status. Chapter 3 of this guide covers the technique for examining each of these regions in depth; this chapter's focus is on the form itself - every one of these systems must be addressed and documented, and any "abnormal" finding must be discussed with an explanation of whether it affects CMV operation.

From Findings to Determination

Section 2 ends with the ME's certification decision. This is not a separate document - it is the culmination of everything recorded earlier in Section 2: the history discussion, the vital signs, the urinalysis, the vision and hearing results, and the body-system findings all feed into a single judgment about whether the driver meets the 391.41(b) standards, and if so, for how long. Chapter 6 covers the full set of determination outcomes and interval rules that follow from this step. The ME then signs and dates the MER and provides a full name, office address, and telephone number, completing the record.

Why the Form Structure Matters for the Test

Because the certification test draws heavily on the Physical Examination and Evaluation content area, expect items that ask you to identify which Section 2 field a given clinical detail belongs in - for example, distinguishing whether a recorded blood-pressure reading, a urinalysis result, or a body-system comment answers a particular question stem. Knowing the fixed order of Section 2 (ID verification, then history discussion, then vitals and labs, then vision and hearing, then the body-system exam, then the determination) makes those items far easier to answer correctly under time pressure.

Where the MER Lives After the Exam

Unlike the certificate discussed in Section 2.5, the MER itself is not handed to the driver. It is the ME's own clinical record and stays in the ME's files, or in a centralized records system the ME can access, as the documentation supporting the certification decision. This distinction matters in practice: a driver or motor carrier asking for proof of medical qualification should be pointed to the Medical Examiner's Certificate, not the MER, since the MER contains detailed personal health information that only the ME's office needs to retain.

Consistency Between the Form and the Underlying Exam

A completed Section 2 should read as a faithful record of an exam that happened in the order described on the form, not a checklist filled in from memory afterward. Think of Section 2 as a chronological narrative: identity confirmed first, the driver's history reviewed next, objective measurements and screening after that, the hands-on body-system exam following, and the ME's determination built last on everything recorded before it.

Key Takeaway for Test-Takers

When a test item describes a specific clinical measurement - a blood pressure reading, a urinalysis result, a vision or hearing finding, an abnormal body-system note - it is describing Section 2 of the MCSA-5875, always ME-authored. When it describes the driver's self-reported symptoms or history, it is describing Section 1. And remember: the MER captures everything from the exam, while the certificate covered in Section 2.5 reports only the outcome.