JJ KELLER part description

Alert: Regulation Change to the Medical Examination Report Form, MCSA–5875 - Effective September 7, 2021
The updated form includes an OMB expiration date of 11/30/2021. As a result, we expect additional form changes from the OMB in the future.


  • Includes the following forms:
    • Medical Examiner's Certificate
    • Medical Examination Report
    • Certificate Of Road Test
    • Driver Qualification & ID Certificate
    • Driver Application Form
    • Record Of Road Test
    • Medical Examiner's National Registry Verification
    • Previous Pre-Employment Employee Alcohol & Drug Test Statement
    • Motor Vehicle Driver's Certification Of Violations/Annual Review Of Driving Record
    • Safety Performance History Records Request
  • Also includes 9-1/2" x 11-3/4" file folder

JJ Keller® is an industry expert in safety and compliance. It provides organizations of all sizes with the right tools and expert advice to create productive, safe, and compliant workplaces. While it does offer managed and consulting services regarding safety and compliance for DOT regulations, it also supplies a wide range of training materials and tools and a comprehensive list of digital and printed publications, forms, and supplies. DOT compliance for fleets has never been easy with JJ Keller. Its wide assortment of decals, placards, and flags helps keep employees and drivers safe and in compliance while on the job.

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