Form MCSA-**** OMB No.: ****-**** Expiration Date: 12/31/2024

Page 1

U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Rev 11/2/2021

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590. Medical Examination Report Form

(for Commercial Driver Medical Certification)

Last Name: Middle Initial:

Street Address:

Driver’s License Number:

E-Mail (optional): CLP/CDL Applicant/Holder*:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Have you ever had surgery? If “yes,” please list and explain below. Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If “yes,” please describe below.

First Name:

City: State/Province:

Issuing State/Province:

Zip Code:

Phone:

Driver ID Verified By**:

SECTION 1. Driver Information (to be filled out by the driver) Date of Birth: Age:

Yes

Yes

Yes

Yes

No

No

No

No

Not Sure

Not Sure

Not Sure

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.** MEDICAL RECORD #

(or sticker)

PERSONAL INFORMATION

DRIVER HEALTH HISTORY

*CLP/CDL Applicant/Holder: See instructions for definitions. **Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport.

(Attach additional sheets if necessary)

2051577

Frazier Brandon t 11/02/1984 37

7415 beechnutt st houston TX 77074

45642204 TX 346-***-****

adwioh@r.postjobfree.com X

CDL

X

X

X

Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024 Page 2

Last Name: First Name: DOB: Exam Date:

DRIVER HEALTH HISTORY (continued)

CMV DRIVER’S SIGNATURE

DRIVER HEALTH HISTORY REVIEW

Do you have or have you ever had: Yes No Yes No

Not

Sure

Not

Sure

1. Head/brain injuries or illnesses (e.g., concussion) 16. Dizziness, headaches, numbness, tingling, or memory loss

17. Unexplained weight loss

18. Stroke, mini-stroke (TIA), paralysis, or weakness 19. Missing or limited use of arm, hand, finger, leg, foot, toe 20. Neck or back problems

21. Bone, muscle, joint, or nerve problems

22. Blood clots or bleeding problems

23. Cancer

24. Chronic (long-term) infection or other chronic diseases 25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

26. Have you ever had a sleep test (e.g., sleep apnea)? 27. Have you ever spent a night in the hospital?

28. Have you ever had a broken bone?

29. Have you ever used or do you now use tobacco?

30. Do you currently drink alcohol?

31. Have you used an illegal substance within the past two years?

32. Have you ever failed a drug test or been dependent on an illegal substance?

2. Seizures/epilepsy

3. Eye problems (except glasses or contacts)

4. Ear and/or hearing problems

5. Heart disease, heart attack, bypass, or other heart problems

6. Pacemaker, stents, implantable devices, or other heart procedures

7. High blood pressure

8. High cholesterol

9. Chronic (long-term) cough, shortness of breath, or other breathing problems

10. Lung disease (e.g., asthma)

11. Kidney problems, kidney stones, or pain/problems with urination

12. Stomach, liver, or digestive problems

13. Diabetes or blood sugar problems

Insulin used

14. Anxiety, depression, nervousness, other mental health problems

15. Fainting or passing out

Other health condition(s) not described above:

Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below: Yes

Yes

No

No

Not Sure

Not Sure

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B. Review and discuss pertinent driver answers and any available medical records. Comment on the driver’s responses to the “health history” questions that may affect the driver’s safe operation of a commercial motor vehicle (CMV). Driver’s Signature: Date:

SECTION 2. Examination Report (to be filled out by the medical examiner)

(Attach additional sheets if necessary)

(Attach additional sheets if necessary)

Frazier Brandon 11/02/1984 04/07/2022

X X

X

X X

X X

X X

X

X X

X

X X

X

X

X X

X

X

X X

X X

X X

X X

X X

X X

X

X

04/07/2022

Denies Hx of hypertension, diabetes, seizures, cardiac disease or sleep apnea. Denies Rx or OTC med use. Denies Surgery or Hospitalization in Hx. Smoker: smokes 1/2 packs per day, but notes he quit smoking a week ago. Driver reports last medical card was a 2 year certification. Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024 Page 3

Last Name: First Name: DOB: Exam Date:

TESTING

PHYSICAL EXAMINATION

Pulse Rate: Pulse rhythm regular: Yes No Height: feet inches Weight: pounds Blood Pressure Systolic Diastolic

Sitting

Second reading

(optional)

Urinalysis Sp. Gr. Protein Blood Sugar

Urinalysis is required.

Numerical readings

must be recorded.

Other testing if indicated

Vision

Acuity

Body System

1. General 8. Abdomen

2. Skin 9. Genito-urinary system including hernias 3. Eyes 10. Back/spine

4. Ears 11. Extremities/joints

5. Mouth/throat 12. Neurological system including reflexes 6. Cardiovascular 13. Gait

7. Lungs/chest

Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver’s ability to operate a CMV. Enter applicable item number before each comment.

14. Vascular system

Normal Abnormal Body System Normal Abnormal

Right Eye:

Left Eye:

Both Eyes:

20/

20/

20/

20/

20/

20/

Right Eye:

Left Eye:

degrees

degrees

Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test: Right Ear:

Average (right): Average (left):

500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz

Left Ear:

Whisper Test Results

Audiometric Test Results

Right Ear Left Ear

Record distance (in feet) from driver at which a forced whispered voice can first be heard

Hearing

OR

Protein, blood, or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.

Standard: Must first perceive whispered voice at not less than 5 feet OR average hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid). Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 field of vision in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner’s Certificate. Yes No

Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could result in a more serious illness that might affect driving. Check the body systems for abnormalities.

Monocular vision

Referred to ophthalmologist or optometrist?

Received documentation from ophthalmologist or optometrist? Right Ear Left Ear Neither

(Attach additional sheets if necessary)

Frazier Brandon 11/02/1984 04/07/2022

75

5 11 200

124 87

1.020 negative negative negative

X

30 80

30 80 6 6

25

X

X

X

X

X X

X X

X X

X X

X X

X X

X X

BMI=27.9. Smoker=Yes

X

Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 12/31/2024 Page 4

Last Name:

Medical Examiner’s Signature:

Medical Examiner’s Name (please print or type):

Medical Examiner’s Address:

Medical Examiner’s Telephone Number:

Medical Examiner’s State License, Certificate, or Registration Number: City:

Date Certificate Signed:

National Registry Number: Medical Examiner’s Certificate Expiration Date: State:

Issuing State:

Zip Code:

First Name: DOB: Exam Date:

MEDICAL EXAMINER DETERMINATION (Federal)

Please complete only one of the following (Federal or State) Medical Examiner Determination sections: Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49): Does not meet standards (specify reason):

Determination pending (specify reason):

Incomplete examination (specify reason):

Meets standards, but periodic monitoring required (specify reason): Wearing corrective lenses

MD

Accompanied by a Skill Performance Evaluation (SPE) Certificate Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal) Qualified by operation of 49 CFR 391.64 (Federal)

Wearing hearing aid

DO

Accompanied by a waiver/exemption (specify type):

Physician Assistant Chiropractor Advanced Practice Nurse Return to medical exam office for follow-up on (must be 45 days or less): Other Practitioner (specify):

Medical Examination Report amended (specify reason): Driver qualified for: 3 months 6 months 1 year other (specify): Meets standards in 49 CFR 391.41; qualifies for 2-year certificate

(if amended) Medical Examiner’s Signature: Date:

If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner’s Certificate as stated in 49 CFR 391.43(h), as appropriate. I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that, to the best of my knowledge, I believe it to be true and correct. Frazier Brandon 11/02/1984 04/07/2022

l

n

Jason Bollenbaugh, DC

7135 Centennial Place Nashville TN 37209

615-***-**** 04/07/2022

2614 TN

n

888-***-**** 04/07/2024

Form MCSA-5876 OMB No.: 2126-0006 Expiration Date: 12/31/2024 Medical Examiner’s Certificate

(for Commercial Driver Medical Certification)

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately one minute per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590. U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

I certify that I have examined Last Name: First Name: in accordance with (please check only one): the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply) OR the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations), and, with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when (check all that apply): Wearing corrective lenses

Wearing hearing aid

Accompanied by a waiver/exemption

Accompanied by a Skill Performance Evaluation (SPE) Certificate Driving within an exempt intracity zone (49 CFR 391.62) (Federal) Qualified by operation of 49 CFR 391.64 (Federal)

Grandfathered from State requirements (State)

The information I have provided regarding this physical examination is true and complete. A complete Medical Examination Report Form, MCSA-5875, with any attachments, embodies my findings completely and correctly, and is on file in my office. Medical Examiner’s Certificate Expiration Date

Medical Examiner’s Telephone Number

Driver’s License Number

Issuing State

Medical Examiner’s Signature

Driver’s Signature

Driver’s Address CLP/CDL Applicant/Holder

Street Address: City: State/Province: Zip Code:

Medical Examiner’s State License, Certificate, or Registration Number Medical Examiner’s Name (please print or type)

Date Certificate Signed

National Registry Number

MD Physician Assistant Advanced Practice Nurse

DO Chiropractor Other Practitioner (specify)

Issuing State/Province

Yes No

Rev 1/5/22

** This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.** Frazier Brandon

l

n

04/07/2024

Jason Bollenbaugh, DC

2614

615-***-**** 04/07/2022

TN 888-***-****

l

45642204 TX

7415 beechnutt st houston TX 77074 l

Contact this candidate