Forms
The following documents may be required for completion of your DOT Physical. If you are unsure whether or not a form is required to be completed, please give us a call.
Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870
If you are diabetic and utilize insulin, you will need this form completed by your Treating Clinician attesting that you have a stable insulin regimen and properly controlled diabetes.
You will need to schedule and complete your DOT physical exam within 45 days of the form being filled out.
Vision Evaluation Report, Form MCSA–5871
This report is required to provide information for an individual who has “monocular vision,” as defined by FMCSA, or did not meet FMCSA’s vision standard at a physical qualification examination.
If you are required to have this report completed, you will need to:
- Get an Annual Vision Evaluation and get your Vision Evaluation Report, Form MCSA–5871, completed and signed by your ophthalmologist or optometrist.
- Schedule and complete your DOT physical examination within 45 days of the Vision Evaluation Report being signed.
Medical Release Form
This form provides authorization to the Federal Motor Carrier Safety Administration to publish hearing or seizure exemption information in a public docket.
Only required if you are seeking a hearing or seizure exemption.
Federal Hearing Exemption Application (New Applicants)
This form is to apply for an exemption from the hearing standard at 49 CFR 391.41(b)(11) of the Federal Motor Carrier Safety Regulations.
This form must be accompanied by a Medical Release Form.
Federal Hearing Exemption Application (Renewal)
This form is to renew your exemption from the hearing standard at 49 CFR 391.41(b)(11) of the Federal Motor Carrier Safety Regulations.
This form must be accompanied by a Medical Release Form.
Federal Seizure Exemption Application (New Applicants)
This form is for applying for an exemption if you have a history of epilepsy or any other condition likely to cause of loss of consciousness or any loss of ability to control a commercial motor vehicle. Federal regulation 49 CFR 391.41(b)(8).
This form must be accompanied by a Medical Release Form.
Federal Seizure Exemption Application (Renewal)
This form is for applying for an exemption if you have a history of epilepsy or any other condition likely to cause a loss of consciousness or any loss of ability to control a commercial motor vehicle. Federal regulation 49 CFR 391.41(b)(8).
This form must be accompanied by a Medical Release Form.