Non-Insulin-Treated Diabetes Mellitus Assessment Form

This is a non-substantive change request to update the form no. MCSA-5872, "Non-Insulin-Treated Diabetes Mellitus Assessment Form" with the correct expiration date. FMCSA seeks the Office of Management and Budget’s (OMB) approval of a new ICR titled, Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872. This ICR is voluntary and may be utilized by medical examiners (ME), who issue Medical Examiner’s Certificates, Form MCSA-5876, to individuals who operate commercial motor vehicles (CMV) in interstate commerce, to communicate with treating healthcare providers responsible for managing the individuals’ diagnosed non-insulin-treated diabetes mellitus. The purpose of the Non-Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5872, is to assist the ME in determining whether an individual diagnosed with non-insulin-treated diabetes mellitus is physically qualified and the individual’s physical condition is adequate to enable the individual to operate a CMV safely. Because this collection is voluntary, there is no set schedule for CMV operators or MEs to complete the form MCSA-5872. FMCSA estimates that MEs will request that forms be completed for 242,057 individuals with a corresponding number of treating healthcare providers.

The latest form for Non-Insulin-Treated Diabetes Mellitus Assessment Form expires 2027-01-31 and can be found here.