Alabama School Bus Driver Physical Examination Report

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LABAMA
EPARTMENT OF
DUCATION
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labama
chool
us
river
hysical
xamination
eport
The purpose of this physical examination is to detect the presence of physical and/or mental defects of such a character and extent
as to affect the driver’s ability to safely perform the required duties of a school bus driver in normal and/or emergency circumstances.
Directions:
This form must be completed and signed by a duly licensed physician and the driver. The original copy must be filed in the superintendent's
office of the employing local board of education. From the completed form, employing boards of education will be able to issue a
certificate of compliance to their drivers. Certificates of compliance are available on the Pupil Transportation Section of the Alabama
Department of Education Website at or by calling 334-242-9730.
I. Driver's Information: (to be completed by driver)
Employing Local BOE:
Name:
Last
First
MI
Address:
DOB:
Last
mm/dd/yyyy
Street
City
State
SSN: XXX-XX-
Phone Numbers:
Home:
Cell:
II. To be Completed by a Duly Licensed Physician:
(or PA, NP)
NO
Will this condition adversely affect the
A person is physically qualified to drive a school bus in Alabama if that
(complete
driver's ability to control and safely operate a
person satisfies all of the requirements below.
YES
next
school bus? If NO, provide an explanation in
column)
Check YES if the following statements are TRUE for the School Bus
the Waiver Section (V).
Driver being examined. Check NO if they are not TRUE.
Has no loss of a foot, a leg, a hand, or an arm.
YES
NO
1.
Has no impairment of any of the following:
A hand or finger which interferes with prehension or power grasping.
YES
NO
a.
2.
An arm, foot, or leg which interferes with the ability to perform
YES
NO
b.
normal tasks associated with driving a school bus.
Has no established medical history or clinical diagnosis of diabetes
YES
NO
3.
mellitus requiring insulin for control.
Has no current clinical diagnosis of myocardial infarction, angina
pectoris, coronary insufficiency, thrombosis, or any other cardiovascular
YES
NO
4.
disease of a variety known to be accompanied by syncope, dypsea,
collapse, or congestive cardiac failure.
Has no established medical history or clinical diagnosis of a respiratory
dysfunction likely to interfere with his/her ability to control and safely
YES
NO
5.
operate a school bus.
Has no current clinical diagnosis of high blood pressure likely to
YES
NO
6.
interfere with his/her ability to control and safely operate a school bus.
Has no established medical history or clinical diagnosis of rheumatic,
arthritic, orthopedic, muscular, neuromuscular, or vascular disease which
7.
YES
NO
interferes with his/her ability to control and safely operate a school bus.
Has no established medical history or clinical diagnosis of epilepsy or
YES
NO
8.
any other condition which is likely to cause loss of consciousness or any
loss of ability to control and safely operate a school bus.
Has no mental, nervous, organic, or functional disease or psychiatric
YES
NO
9.
disorder likely to interfere with his/her ability to control and safely
operate a school bus.
Has distance visual acuity of at least 20/40 (Snellen) in each eye without
corrective lenses or visual acuity separately corrected to 20/40 (Snellen)
or better with corrective lenses, distant binocular acuity of at least 20/40
(Snellen) in both eyes with or without corrective lenses, field of vision of
YES
NO
10.
at least 70 degrees in the horizontal meridian in each eye, and the ability
to recognize the colors of traffic signals and devices showing standard
red, green, and amber.

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