Insulin Treated Diabetes Mellitus Report Form
As a part of the medical certification process for insulin treated diabetes mellitus (ITDM) individuals, the Federal Motor Carrier Safety Administration requires that the Insulin Treated Diabetes Mellitus Assessment Form (ITDM), MCSA-5870, be completed by the ITDM individual’s Treating Clinician attesting that the individual has a stable insulin regimen and properly controlled diabetes. ITDM individuals are required to provide the ITDM Assessment Form, MCSA-5870, to the Certified Medical Examiner within 45 days of completion by the Treating Clinician. Download the ITDM Assement form. If you are an Insulin treated Diabetic, please have this form completed by your treating clinician and bring it with you to your examination.