DOT Physical Exam Forms [Download Now]

Routine Exam Forms

  • Medical Examination Report (MER) Form (MCSA-5875)

    This is commonly referred to as the “long form,” and is completed by every individual who presents for a DOT physical.

    The first two pages are completed by the driver and the remainder is completed by the medical examiner. The driver portion details any surgeries, medication or other health conditions (past or present). The medical examiner portion is the documented evaluation and findings of the physical itself. 

    Pages 6-9 of the downloadable packet give specific details for completing each section of the paperwork correctly.

  • Medical Examiner’s Certificate, Form MCSA-5876

    This is the DOT medical card and is completed and signed by the medical examiner and the driver. The certificate will include the expiration date, any needed waivers or exemptions as well as the licensing information and national registry nnumber of the medical examiner. CDL holders will upload (or mail) this form to the Massachusetts Registry with their self certification information (more below).

  • 391.41 CMV Driver Medication Form, MCSA-5895

    This form is optional and is used when a medical examiner requests additional information regarding any medication a driver may be prescribed to insure that it will not interfere with his ability to safely operate a commercial vehicle. This is most commonly needed for medications used to treat anxiety, depression and other forms of mental illness as well as medications with known sedating side effects. 

Assessment Forms

These assessment forms are only needed if an individual has been diagnosed with either of the following conditions. Each form needs to be completed by the supervising physician of said condition PRIOR TO the actual DOT physical. 

  • Insulin-Treated Diabetes Mellitus Form (IDDM) (MCSA-5870)

    Any individual with IDDM must bring this completed form with him to his DOT physical. This form must be completed by the physician that oversees the management of one’s IDDM (typically the PCP or endocrinologist). This form must be completed no more than 45 days prior to the DOT physical and the driver’s most recent Ha1c results must be attached to the packet for consideration. 

  • Monocular Vision Form (Coming February 2022) 

Interstate Waivers

The Federal government offers waiver exemptions programs for drivers who conduct commerce across state lines, but do not pass the DOT exam due to the following medical conditions. 

  • Vision

The federal vision exemption program is being eliminated in February 2022, and will be replaced by the new Monocular Vision Assessment (see above). Those with a current federal vision exemption will be grandfathered in until their current DOT medical card expires. 

  • Hearing

  • Seizures

All federal exemptions are only granted if the individual can operate at a safety level equivalent to those who do not need the exemption.

Detailed information regarding each exemption program is available here on the FMCSA website. 

Massachusetts Intrastate Waivers

Intrastate waivers are granted by the Mass RMV and will restrict a driver to operating only within the Commonwealth. There is one general intrastate waiver application/form (available here on the Mass RMV website). Whatever section is pertinent to the individual will need to be completed by the supervising physician of said condition and mailed to the RMV. Conditions with an intrastate waiver opportunity include:

  • Vision

  • Hearing Impairment

  • Cardiovascular Impairment

  • Loss Of Limb

  • Diabetes

CDL Self Certification Form

Any Massachusetts CDL holder is required to complete the self certification process every two years. Drivers can complete the Massachusetts CDL self certification process on the MA RMV self service portal. This is the preferred submission method of the RMV.

For those who prefer to submit the self certification via mail, you’ll need to download and complete the corresponding form. Then mail the form and a copy of your DOT medical certification (Form MCSA-5876) to the address below. While not required, we recommend sending the paperwork via certified mail. 

Mail to:
MassDOT, RMV Division, Driver Licensing
PO Box 55889
Boston, MA 02205

One can also submit the forms in person at any Mass RMV branch location.

Question about the DOT physical forms?

For those with more complex medical histories, the paperwork part of the DOT physical can be confusing. If you have any questions regarding your unique health situation, do not hesitate to contact our office during normal business hours. 

To schedule an appointment, call our office or self-schedule using our simple and safe online booking system.