MCSA-5871 is the Vision Evaluation Report of the Federal Motor Carrier Safety Administration (FMCSA), part of the U.S. Department of Transportation. An ophthalmologist or optometrist completes it for an individual who has "monocular vision," as FMCSA defines it, or who did not meet FMCSA's vision standard at a physical qualification examination. On this page you can fill out the form online on FillingPDF and download or print the completed PDF. The Georgia Department of Driver Services (DDS) lists the form on its DDS Forms page, where the official PDF is published.
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What is MCSA-5871?
Form MCSA-5871, Vision Evaluation Report, is a Federal Motor Carrier Safety Administration (FMCSA) form on which an ophthalmologist or optometrist records an individual's vision test results, as part of deciding whether the individual meets FMCSA's vision standard to operate a commercial motor vehicle in interstate commerce.
The report does not decide anything by itself. The form states that the determination of whether the individual meets the vision standard and is physically qualified to drive a commercial motor vehicle is made by a medical examiner on FMCSA's National Registry of Certified Medical Examiners.
The eye doctor reports the date of the evaluation, distant visual acuity (uncorrected and corrected, for each eye), field of vision in degrees with a copy of the formal perimetry test, recognition of red, green and amber traffic signal colors, the date of the last comprehensive eye examination, whether the individual has monocular vision, any progressive eye condition, whether the vision deficiency is stable, and whether evaluations are needed more often than annually.
FMCSA defines monocular vision as distant visual acuity of at least 20/40 (with or without corrective lenses) and a field of vision of at least 70 degrees in the horizontal meridian in the better eye, combined with either distant visual acuity of less than 20/40 with corrective lenses or a field of vision of less than 70 degrees in the horizontal meridian, or both, in the worse eye.
The form carries OMB No. 2126-0006 (expiration date 03/31/2028) and is marked as containing sensitive information for official use only. The Georgia DDS forms page lists it as Vision Evaluation Report (Form MCSA-5871), separately from the DDS CDL Vision Form (DDS-MR-274OLCDL), which is its own listed form.
Who needs to file MCSA-5871?
The ophthalmologist or optometrist who evaluates the individual completes and signs Form MCSA-5871. The form says the report is required to provide information for an individual who has "monocular vision," as FMCSA defines it, or who did not meet FMCSA's vision standard at a physical qualification examination.
- The individual being evaluated: you take the completed, signed report to the medical examiner. The form's note to the individual says the medical examiner must receive it and begin the physical qualification examination not more than 45 calendar days after the eye doctor signs.
- Ophthalmologists and optometrists: you complete the report to the best of your ability based on your evaluation of the individual and your knowledge of the individual's medical history. The attestation at the end states that you are an ophthalmologist or optometrist and that the information is true and correct to the best of your knowledge.
- Medical examiners: the form places the final determination with a medical examiner on FMCSA's National Registry of Certified Medical Examiners.
The form does not provide for anyone else to complete the clinical sections. It does not describe who may act for the individual.
When to file MCSA-5871
The triggering event is a vision evaluation of an individual who has monocular vision as FMCSA defines it, or who did not meet FMCSA's vision standard at a physical qualification examination. The form sets one time limit: the medical examiner must receive the report and begin the physical qualification examination not more than 45 calendar days after the ophthalmologist or optometrist signs it. A report signed longer ago than that is outside the window stated on the form, so schedule the medical examiner visit soon after the eye evaluation. Line 13 asks the eye doctor whether a vision evaluation is required more often than annually and, if so, how often and why. The form prints no other deadline.
Documents you need
- A copy of the formal perimetry test for each eye, attached at line 4 (field of vision); the form requires formal perimetry and the results interpreted in degrees.
- Additional pages for line 14 (Additional comments), attached only as needed.
How to fill out MCSA-5871
Enter the individual's identifying details
At the top of page 1, enter the individual's name, date of birth (DOB), driver's license number and state. The name and DOB repeat at the top of pages 2 and 3.
Identify the evaluator and evaluation date
Line 1: check ophthalmologist or optometrist. Line 2: enter the date of the vision evaluation as MM/DD/YYYY.
Record distant visual acuity
Line 3: enter 20/ values for the right and left eye, uncorrected and corrected, or select N/A if there is no vision in an eye. Check the type of correction, Glasses or Contacts.
Record the field of vision
Line 4: enter degrees for the right and left eye, not "normal" or "full", using a modality that tests to at least 120 degrees in the horizontal. Name the test used and attach the formal perimetry test for each eye.
Answer color recognition and exam date
Line 5: check Yes or No for recognition of standard red, green and amber traffic control signal colors. Line 6: enter the date of the last comprehensive eye examination as MM/DD/YYYY, or check Date unknown.
Address monocular vision
Line 7: check Yes or No for monocular vision as FMCSA defines it, and if Yes describe the cause. Line 8: enter the date the monocular vision began. Line 9: enter the current treatment or N/A.
Report progressive eye conditions
Line 10: check Yes or No. If Yes, use lines a, b and c to give each condition or disease, date of diagnosis, severity (Mild, Moderate or Severe), current treatment and whether it is stable, with the reason if it is not.
Give your medical opinion on stability
Line 11: check whether the vision deficiency is stable and, if Yes, enter the date it became stable. Line 12: check whether sufficient time has passed for the individual to adapt and drive a commercial motor vehicle safely.
Answer frequency and add comments
Line 13: check whether a vision evaluation is required more often than annually; if Yes, state how often and why. Line 14: add comments and attach additional pages as needed.
Complete the attestation block
Enter the date, printed name and medical credential, professional license number and state, phone number, email, street address, and city, state and ZIP code. The ophthalmologist or optometrist then signs.
Review, sign and download the PDF
Check that every line is answered, dates use MM/DD/YYYY, and the perimetry copies are ready to attach. Download or print the completed PDF from FillingPDF, sign it, and give it to the individual for the medical examiner.
How to submit MCSA-5871
The form names no portal, mailing address or office to which the report is sent. It is handed to the medical examiner who performs the physical qualification examination.
- Eye doctor to individual: the ophthalmologist or optometrist completes and signs the report, with the copy of the formal perimetry test for each eye attached to line 4 and any additional pages attached to line 14.
- Individual to medical examiner: the medical examiner must receive the report and begin the physical qualification examination not more than 45 calendar days after the eye doctor signs.
The address printed at the top of the form (Medical Programs Division, Federal Motor Carrier Safety Administration, 1200 New Jersey Avenue SE, Washington, DC 20590) is for comments about the paperwork burden estimate, not for sending the completed report. The form is marked as containing sensitive information for official use only; keep it under the control of authorized persons. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Writing "normal" or "full" for the field of vision at line 4; the form says neither is acceptable and asks for the result in degrees for each eye.
- Leaving out the copy of the formal perimetry test for each eye, which line 4 says to attach.
- Entering a visual acuity value for an eye that has no vision instead of selecting N/A at line 3.
- Letting more than 45 calendar days pass between the eye doctor's signature and the start of the medical examiner's physical qualification examination.
- Having someone other than an ophthalmologist or optometrist complete the report; the attestation is made by one of those two professionals.
- Answering Yes at line 10 (progressive eye condition) without giving the condition, date of diagnosis, severity, current treatment and whether it is stable.
- Writing dates in another format; lines 2, 6, 8 and 11 ask for MM/DD/YYYY.
- Omitting the signature, license number and state, or the contact details in the attestation block at the end of the form.
Frequently asked questions
What is Form MCSA-5871 used for?
Form MCSA-5871 is the FMCSA Vision Evaluation Report. An ophthalmologist or optometrist uses it to report an individual's vision results when the individual has monocular vision as FMCSA defines it, or did not meet FMCSA's vision standard at a physical qualification examination.
Who fills out the MCSA-5871 form?
An ophthalmologist or optometrist completes and signs it. The attestation at the end states that the signer is one of those professionals and that the information is true and correct to the best of their knowledge. The individual being evaluated does not complete the clinical lines.
How long is the MCSA-5871 valid before the medical exam?
The medical examiner must receive the report and begin the physical qualification examination not more than 45 calendar days after the ophthalmologist or optometrist signs it. The form prints no other validity period.
Who decides whether I meet the vision standard?
A medical examiner on FMCSA's National Registry of Certified Medical Examiners decides whether you meet the vision standard and are physically qualified to drive a commercial motor vehicle. The eye doctor's report supplies information for that determination.
What do I attach to the MCSA-5871?
Attach a copy of the formal perimetry test for each eye at line 4, where formal perimetry is required and results must be in degrees. Attach additional pages at line 14 only if the eye doctor needs more room for comments.
Where do I send the completed MCSA-5871?
The form names no address or portal. It is given to the medical examiner who performs the physical qualification examination, within 45 calendar days of the eye doctor's signature. The Washington, DC address on the form is only for paperwork-burden comments.
What is monocular vision under FMCSA's definition?
In the better eye, distant visual acuity of at least 20/40 and a field of vision of at least 70 degrees horizontally; in the worse eye, acuity below 20/40 with corrective lenses, a field below 70 degrees, or both. Line 7 asks the eye doctor to say whether the individual meets this definition.
Can I fill out Form MCSA-5871 online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not affiliated with FMCSA or Georgia DDS, and it does not submit the report; it goes to the medical examiner through the individual.
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