Form MCSA-5870. Insulin-Treated Diabetes Mellitus Assessment

The Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870, is a crucial document for commercial motor vehicle (CMV) drivers who have insulin-treated diabetes mellitus (ITDM). This form serves as an evaluation tool to assess the driver's medical fitness and ability to safely operate a CMV while under insulin treatment.

The form is divided into several sections, including:

• Applicant Information: This section collects personal information, such as the driver's name, address, phone number, and date of birth.
• Diabetes History: This section gathers information about the driver's diabetes diagnosis, treatment history, and related medical complications.
• Examiner Information: This section captures the details of the treating clinician, including their contact information, credentials, and their assessment of the driver's diabetes management.

The most crucial fields in this form include:

• The driver's personal information and diabetes history to evaluate eligibility.
• The treating clinician's assessment of the individual's diabetes management, including blood glucose monitoring, insulin administration, and adherence to prescribed treatment.

This form is compiled by commercial drivers with ITDM who must undergo a medical evaluation as part of the Federal Motor Carrier Safety Administration (FMCSA) requirements. The document is completed by the driver, their treating clinician, and potentially a medical examiner if required.

When completing this form, several features should be considered, such as:

• Ensuring accurate and up-to-date information is provided.
• Obtaining relevant medical documentation to support the application.
• The treating clinician's assessment being conducted within 45 days of submission to ensure accurate conclusions.

The advantages of the MCSA-5870 form include:

• Helping drivers with ITDM demonstrate their ability to safely operate a CMV.
• Comprehensive evaluation of the driver's medical fitness for duty.
• Facilitating communication and documentation among the driver, the treating clinician, and the FMCSA.

Potential problems when filling out the form include:

• Incomplete or inaccurate information leading to delays or denial of medical certification.
• Failure to submit the form within the required timeframe.

Some related documents include:

• Medical Examination Report (MER) Form, MCSA-5875: Required for all commercial driver's license (CDL) applicants regardless of medical conditions.
• Medical Examiner's Certificate (MEC), Form MCSA-5876: The certificate issued by the medical examiner after a satisfactory health assessment, which must be carried by the driver during operation of a CMV.

The completed MCSA-5870 form should be submitted to the medical examiner who will make the final determination regarding the driver's medical certification. If approved, the form will become part of the driver's medical record, and the medical examiner must keep the document for at least three years from the date of examination.