DOT FORM.pdf


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Effective April 20, 2016 the Department of Transportation (DOT) Medical Examination Report
(MER) form has changed. The MER amendment addresses required regulatory compliance set
forth by the Federal Motor Carrier Safety Administration. The form contain the same valuable
information for UPS and the medical provider, however, it will now be completed on a fillable
PDF form.
Overview:
1. You are required to complete the UPS Medical Release Form, Privacy Act Statement and
DOT Medical Examination Part I – Driver Information, which includes: Personal Information
and Driver Health History. Your signature and the date are also required on pages 2, 3 and 4.
2. Once complete, you must print the DOT form (9 pages) and Medical Release (1 page) and
bring them with you to your examination. To print these forms use your computer system
Print function. Note: The DOT form, UPS Medical Release and instructions are collectively
12 pages.
3. Upon completion of your examination, the medical provider must fax a copy of the Medical
Examiner’s Certificate (MEC) and the Medical Release form to the UPS H. R. Service
Center (HRSC) by faxing to 1-877-251-4409.
4. The HRSC will review the MEC for accuracy and completeness. Once the review is
complete, confirmation of your medical status will be sent to your manager.
5. You will also need to select a UPS approved medical provider. Proceed to the UPS
Approved Medical Provider List on the DOT Medical Examination landing page or select it
from the Related Links. The UPS Approved Medical Provider list will help you identify a
medical provider who can perform your DOT examination.