Form MCSA-5875 OMB No.

: 2126-0006 Expiration Date: 03/31/2025

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.

U.S. Department of Transportation

Federal Motor Carrier
Medical Examination Report Form
Safety Administration (for Commercial Driver Medical Certification)

MEDICAL RECORD #
3381792
(or sticker)
SECTION 1. Driver Information (to be filled out by the driver)

PERSONAL INFORMATION

Last Name: Mohamed First Name: Abdirizak Middle Initial: Date of Birth: 11/30/2001 Age: 22

Street Address: 4234 rerserve way City: Irving State/Province: TX Zip Code: 75038

Driver’s License Number: 45591703 Issuing State/Province: TX Phone: (469) 4455157

E-Mail (optional): [email protected] CLP/CDL Applicant/Holder*: X Yes No

Driver ID Verified By**: Driver's License

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Yes X No Not Sure
*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.

DRIVER HEALTH HISTORY

Have you ever had surgery? If “yes,” please list and explain below. Yes X No Not Sure

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? Yes X No Not Sure
If “yes,” please describe below.

(Attach additional sheets if necessary)

**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.**

Rev 2/28/2023 Page 1

Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 03/31/2025

Last Name: Mohamed First Name: Abdirizak DOB: 11/30/2001 Exam Date: 10/14/2024

DRIVER HEALTH HISTORY (continued)

Not Not
Do you have or have you ever had: Yes No Sure Yes No Sure
1. Head/brain injuries or illnesses (e.g., concussion) X 16. Dizziness, headaches, numbness, tingling, or memory X
loss
2. Seizures/epilepsy X
17. Unexplained weight loss X
3. Eye problems (except glasses or contacts) X
18. Stroke, mini-stroke (TIA), paralysis, or weakness X
4. Ear and/or hearing problems X
19. Missing or limited use of arm, hand, finger, leg, foot, toe X
5. Heart disease, heart attack, bypass, or other heart X
problems 20. Neck or back problems X
6. Pacemaker, stents, implantable devices, or other heart X 21. Bone, muscle, joint, or nerve problems X
procedures
22. Blood clots or bleeding problems X
7. High blood pressure X 23. Cancer X
8. High cholesterol X 24. Chronic (long-term) infection or other chronic diseases X
9. Chronic (long-term) cough, shortness of breath, or X
other breathing problems 25. Sleep disorders, pauses in breathing while asleep, X
daytime sleepiness, loud snoring
10. Lung disease (e.g., asthma) X 26. Have you ever had a sleep test (e.g., sleep apnea)? X
11. Kidney problems, kidney stones, or pain/problems X
with urination 27. Have you ever spent a night in the hospital? X
12. Stomach, liver, or digestive problems X 28. Have you ever had a broken bone? X
13. Diabetes or blood sugar problems X 29. Have you ever used or do you now use tobacco? X
Insulin used X 30. Do you currently drink alcohol? X
14. Anxiety, depression, nervousness, other mental health X 31. Have you used an illegal substance within the past X
problems two years?
15. Fainting or passing out X 32. Have you ever failed a drug test or been dependent X
on an illegal substance?

Other health condition(s) not described above: Yes X No Not Sure

Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below: Yes X No Not Sure

(Attach additional sheets if necessary)

CMV DRIVER’S SIGNATURE

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.
Driver’s Signature: Date: 10/14/2024

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

DRIVER HEALTH HISTORY REVIEW

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).
Discussed annual check ups with Primary for disease prevention.

(Attach additional sheets if necessary)

Page 2
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 03/31/2025

Last Name: Mohamed First Name: Abdirizak DOB: 11/30/2001 Exam Date: 10/14/2024

TESTING

Pulse Rate: 78 Pulse rhythm regular: X Yes No Height: 5 feet 7 inches Weight: 173 pounds

Blood Pressure Systolic Diastolic Urinalysis Sp. Gr. Protein Blood Sugar
Sitting 134 86 Urinalysis is required.
Second reading Numerical readings 1.010 negative negative negative
(optional) must be recorded.

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

Vision Hearing
Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. Standard: Must first perceive whispered voice at not less than 5 feet OR average
At least 70° field of vision in horizontal meridian measured in each eye. The use of hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).
corrective lenses should be noted on the Medical Examiner’s Certificate.
Acuity Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test: Right EarLeft Ear X Neither

Right Eye: 20/ 20 20/ Right Eye: 85 degrees Whisper Test Results Right Ear Left Ear
Record distance (in feet) from driver at which a forced
Left Eye: 20/ 20 20/ Left Eye: 85 degrees whispered voice can first be heard 5 5
Both Eyes: 20/ 20 20/ Yes No OR
Applicant can recognize and distinguish among traffic control X Audiometric Test Results
signals and devices showing red, green, and amber colors Right Ear: Left Ear:
Monocular vision X 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz
Referred to ophthalmologist or optometrist? X
Received documentation from ophthalmologist or optometrist? X Average (right): Average (left):

PHYSICAL EXAMINATION
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.
Body System Normal Abnormal Body System Normal Abnormal
1. General X 8. Abdomen X
2. Skin X 9. Genito-urinary system including hernias X
3. Eyes X 10. Back/spine X
4. Ears X 11. Extremities/joints X
5. Mouth/throat X 12. Neurological system including reflexes X
6. Cardiovascular X 13. Gait X
7. Lungs/chest X 14. Vascular system X
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.

(Attach additional sheets if necessary)

Page 3
Form MCSA-5875 OMB No.: 2126-0006 Expiration Date: 03/31/2025

Last Name: Mohamed First Name: Abdirizak DOB: 11/30/2001 Exam Date: 10/14/2024

Please complete only one of the following (Federal or State) Medical Examiner Determination sections:

MEDICAL EXAMINER DETERMINATION (Federal)

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):
● Meets standards in 49 CFR 391.41; qualifies for 2-year certificate
Meets standards, but periodic monitoring required (specify reason):
Driver qualified for: 3 months 6 months 1 year other (specify):
Wearing corrective lenses Wearing hearing aid Accompanied by a waiver/exemption (specify type):
Accompanied by a Skill Performance Evaluation (SPE) Certificate
Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal)
Determination pending (specify reason):
Return to medical exam office for follow-up on (must be 45 days or less):
Medical Examination Report amended (specify reason):
(if amended) Medical Examiner’s Signature: Date:
Incomplete examination (specify reason):

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.
Medical Examiner’s Signature:

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

Medical Examiner’s Address: 1007 W. Mitchell Street Suite 201 City: Arlington State: TX Zip Code: 76013

Medical Examiner’s Telephone Number: (817) 914-1336 Date Certificate Signed: 10/14/2024

Medical Examiner’s State License, Certificate, or Registration Number: 06827 Issuing State: TX
MD DO Physician Assistant ■ Chiropractor Advanced Practice Nurse
Other Practitioner (specify):

National Registry Number: 3847321537 Medical Examiner’s Certificate Expiration Date: 10/14/2026

Page 4
Form MCSA-5876 OMB No.: 2126-0006 Expiration Date: /31/20

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
Medical Examiner’s Certificate
Safety Administration (for Commercial Driver Medical Certification)

I certify that I have examined Last Name: Mohamed First Name: Abdirizak 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 Accompanied by a waiver/exemption Driving within an exempt intracity zone (49 CFR 391.62) (Federal)
Wearing hearing aid Accompanied by a Skill Performance Evaluation (SPE) Certificate Grandfathered from State requirements (State)

Medical Examiner’s Certificate Expiration Date

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. 10/14/2026

Medical Examiner’s Signature Medical Examiner’s Telephone Number Date Certificate Signed
(817) 914-1336 10/14/2024
Medical Examiner’s Name (please print or type) MD Physician Assistant Advanced Practice Nurse
Gene Lott DO ● Chiropractor Other Practitioner (specify)
Medical Examiner’s State License, Certificate, or Registration Number Issuing State National Registry Number

06827 TX 3847321537

Driver’s Signature Driver’s License Number Issuing State/Province

45591703 TX
Driver’s Address CLP/CDL Applicant/Holder
Street Address: 4234 rerserve way City: Irving State/Province: TX Zip Code: 75038 ●Yes No

**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.**

Rev
1/23