The expiration date on the Medical Examination Report Form, MCSA-5875, Medical Examiner's Certificate, MCSA-5876, and Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, has been updated to 12/31/2024, and all forms are posted below. Please note that the only change to the forms is the change in the OMB expiration date from 11/30/2021 to 12/31/2024.
Medical Examiners should start using the forms with the 12/31/2024 date as soon as possible. However, MEs that have purchased these forms in bulk, or require time to reprogram electronic system forms, may continue to use the old forms until stocks have been depleted or forms have been reprogrammed but should transition to use of the new forms as quickly as possible. Based on this guidance, SDLAs are encouraged to continue to accept these forms.
Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870
Federal Motor Carrier Safety Administration
1200 New Jersey Avenue SE
Washington, DC, DC 20590
Phone: (202) 366-4001
9:00am-5:00pm ET, M-F