Form MCSA-5872 Non-Insulin-Treated Diabetes Mellitus Assessment Form

OMB No.: 2126-0081
Expiration Date: 01/31/2027

MCSA-5872
U.S. Department of Transportation
Federal Motor Carrier Safety Administration

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 2126-0081. Public reporting for this collection of information is estimated to be approximately 8 minutes per response,
including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. 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.

NON-INSULIN-TREATED DIABETES MELLITUS ASSESSMENT FORM
Driver Name:

DOB:

The individual named above is being evaluated to determine whether the individual meets the physical qualification standards
of the Federal Motor Carrier Safety Administration to operate a commercial motor vehicle in interstate commerce. During
the medical evaluation, it was determined this individual has a diagnosis of non-insulin-treated diabetes mellitus. Although
there is not a standard specific to non-insulin-treated diabetes mellitus, this information will be used by the certifying
medical examiner to evaluate any diabetes-related complications and/or target organ damage and to determine whether the
individual’s physical condition is adequate to enable the individual to operate a commercial motor vehicle safely. The final
determination as to whether the individual listed in this form is physically qualified to drive a commercial motor vehicle
will be made by the certifying medical examiner.
As the certifying medical examiner, I request that you review and complete this form, and return it to me via the individual,
or at the mailing address, email address, or fax number specified below.
Printed Name of Certified Medical Examiner

Signature of Certified Medical Examiner

Date

Email

Phone Number

Fax Number

Street Address

City, State, Zip Code

1
**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.**
Rev 1/26/24

OMB No.: 2126-0081
Expiration Date: 01/31/2027

MCSA-5872
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Driver Name:

Non-Insulin-Treated Diabetes Mellitus Diagnosis
1. Date of diabetes mellitus diagnosis:
2. Medications - List all diabetes-related medications, dosage, and date treatment initiated
(attach additional pages if necessary)
Medication:

Dosage:

Date started:

Medication:

Dosage:

Date started:

Medication:

Dosage:

Date started:
ATTACH FILE

Blood Glucose Self-Monitoring
3. How many times per day is the individual testing blood glucose levels?
4. Is the individual compliant with glucose monitoring based on the individualized diabetes treatment plan?
Yes

No

Diabetes Management and Control
5. Has the individual been on a stable individualized diabetes treatment plan with good glucose control?
Yes

No

If no, explain why not (attach additional pages if necessary):

ATTACH FILE

6. Has the individual experienced any recent severe hypoglycemic episodes (e.g., episodes requiring the assistance of
others or resulting in loss of consciousness, seizure, or coma)?
Yes

No

If yes, provide date(s) of occurrence and associated details (attach additional pages if necessary):

ATTACH FILE

7. Has the individual experienced any recent significant hyperglycemic episodes (e.g., diabetic ketoacidosis and diabetic
hyperglycemic hyperosmolar syndrome)?
Yes

No

If yes, provide date(s) of occurrence and associated details (attach additional pages if necessary):

ATTACH FILE

2
**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.**

OMB No.: 2126-0081
Expiration Date: 01/31/2027

MCSA-5872
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Driver Name:

Hemoglobin A1c (HbA1c) Measurements
8. Has the individual had HbA1c measured intermittently over the last 12 months?
Yes

No

If yes, attach the most recent result.

ATTACH FILE

Diabetes Complications
9. Does the individual have signs of diabetes complications or target organ damage?
a. Renal disease/renal insufficiency (e.g., diabetic nephropathy, proteinuria, nephrotic syndrome)?
Yes

No

If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:

b. Cardiovascular disease (e.g., coronary artery disease, hypertension, transient ischemic attack, stroke, peripheral
vascular disease)?
Yes

No

If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:

c. Neurological disease/autonomic neuropathy (e.g., cardiovascular, gastrointestinal, genitourinary)?
Yes

No

If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:

d. Peripheral neuropathy (e.g., sensory loss, decreased sensation, loss of vibratory sense, loss of position sense)?
Yes

No

If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:

e. Lower limb (e.g., foot ulcers, amputated toes/foot, infection, gangrene)?
Yes

No

If yes, provide the date of diagnosis, current treatment, and whether the condition is stable:

3
**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.**

OMB No.: 2126-0081
Expiration Date: 01/31/2027

MCSA-5872
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Driver Name:

f.

Other?
Yes

No

If yes, provide the condition, date of diagnosis, current treatment, and whether the condition is stable:

Diabetic Retinopathy
10. Date of last eye examination:
11. Has the individual been diagnosed with either severe non-proliferative diabetic retinopathy or proliferative diabetic
retinopathy?
Yes

No

If yes, provide date of diagnosis:
Comments (if necessary):

I am the treating healthcare provider for the above individual.
Yes

No

Comments (if necessary):

Printed Name of Treating Healthcare Provider

Signature of Treating Healthcare Provider

Professional License Number and State

Date

Phone Number

Email

Street Address

City, State, Zip Code

4
**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.**