Form Eb.001 - School Bus Driver'S Application For Physician'S Certificate - Virginia Board Of Education

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FORM EB.001
SCHOOL BUS DRIVER’S APPLICATION FOR PHYSICIAN’S CERTIFICATE
Rev. 9-12
This form is required under the provision of Section 22.1-178 of the Code of Virginia
and Regulations of the Virginia Board of Education
APPLICANT NAME _____________________________________ SCHOOL DIVISION ______________________________________
APPLICANT SOCIAL SECURITY NO. ____________________
BIRTH DATE _____________________________________________
ADDRESS _______________________________________________________________________________________________________
Medical History (to be completed by the Applicant)
Please check if you have any history of the following:
_____ Diabetes
_____ Muscle Disease
_____ Loss of Vision
_____ Seizure Disorder
_____ Heart Disease
_____ Loss of Hearing
_____ Head Injury causing symptoms
_____ High Blood Pressure
_____ Tuberculosis
_____ Brain Tumor
_____ Paralysis of any Type
_____ Back Injury
_____ Shoulder Injury
Have you every received treatment for or been recommended by a physician
for treatment of alcoholism or drug abuse?
_____ Yes
_____ No
Do you currently feel that you use alcohol to excess?
_____ Yes
_____ No
Do you currently use psychoactive drugs such as marijuana, cocaine, or other
similar drugs?
_____ Yes
_____ No
Are you currently taking any prescribed medications?
_____ Yes
_____ No
If yes, identify the medication(s): __________________________________________________________________________
Do you have hay fever or other minor illnesses which require you to
take over the counter (nonprescription) medications at times?
_____ Yes
_____ No
If so, identify the medication(s):___________________________________________________________________________
I certify I have answered the above questions truthfully and to the best of my ability. I hereby authorize the physician to
release the information contained on this certificate to the school division.
Date ___________________________
Signature of Applicant _______________________________________
Comments on History of Applicant by Examining Physician/Nurse Practitioner:_____________________________________
____________________________________________________________________________________________________________
PHYSICAL QUALIFICATIONS FOR SCHOOL BUS DRIVERS
g.
Has no known medical history or clinical diagnosis of
1.
No person shall drive a school bus unless that person is
rheumatic, arthritic, orthopedic, muscular,
physically qualified to do so and has submitted a Certificate
neuromuscular, or vascular disease which would
signed by the applicant and the doctor for the applicable
interfere with the ability to control and operate a school
employment period.
bus safely without reasonable accommodations;
2.
A person is physically qualified to drive a school bus if the
h.
Has no known medical history or clinical diagnosis of
individual:
epilepsy or any other condition which is likely to cause
a.
Has no loss of a foot, a leg, a hand, or an arm which
loss of consciousness or any loss of ability to control a
interferes with the ability to control and safely drive a
school bus without reasonable accommodations;
school bus without reasonable accommodations;
i.
Has no known mental, nervous, organic, or functional
b.
Has no impairment of the use of a foot, a leg, a hand,
disease or psychiatric disorder likely to interfere with the
finger, or an arm, and no other structural defect or
ability to drive a school bus safely without reasonable
limitation likely to interfere with the ability to control
accommodations;
and safely drive a school bus without reasonable
j.
Has both distant and near visual acuity of at least 20/40
accommodations;
in each eye, and at least a field of 140 degrees of
c.
Has no known medical history or clinical diagnosis of
horizontal vision or a comparable measurement that
diabetes mellitus currently requiring insulin for control
demonstrates a visual field within this range, and the
likely to interfere with the ability to control and safely
ability to recognize the colors of traffic signals and
drive a school bus without reasonable accommodations;
devices showing standard red, green, and amber;
d.
Has no current clinical diagnosis of myocardial
k.
First perceives a forced-whispered voice in the better ear
infarction, angina pectoris, coronary insufficiency,
at not less than 5 feet with or without the use of a
thrombosis, or any other cardiovascular disease of a
hearing aid or, if tested by use of an audiometric device,
variety known to be accompanied by syncope, dyspnea,
does not have an average hearing loss in the better ear
collapse, or congestive cardiac failure;
greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000
e.
Has no known medical history or clinical diagnosis of a
Hz with or without a hearing aid when the audiometric
respiratory dysfunction likely to interfere with the ability
device is calibrated to American National Standard
to control and drive a school bus safely without
(formerly ASA Standard) Z24.5-1951; and
reasonable accommodations;
l.
Does not use an amphetamine, narcotic, or any habit-
f.
Has no known current clinical diagnosis of high blood
forming drug without appropriate physician supervision.
pressure likely to interfere with the ability to operate a
school bus safely without reasonable accommodations;

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