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FORM EB.001

Revised 9-12

PHYSICIAN’S CERTIFICATE

APPLICANT’S NAME _____________________________________

1. Visual Acuity Without Corrective Lenses

Distant

R20/ ___________

L20/ ___________

Near

R20/ ___________

L20/ ___________

2. Visual Acuity with Corrective Lenses

Distant

R20/ ___________

L20/ ___________

Near

R20/ ___________

L20/ ___________

3. Color Vision ___________________ Visual fields to 140 degree Horizontal sweep ________________________

4. Hearing

R_____________

L ______________

5. Audiometry (May be completed by other qualified persons if authorized by examining physician)

Decibel Loss with Hearing Aid at

R500 Hz ___________

1000 Hz ___________

2000 Hz ___________

L500 Hz ___________

1000 Hz ___________

2000 Hz ___________

Decibel Loss without Hearing Aid at

R500 Hz ___________

1000 Hz ___________

2000 Hz ___________

L500 Hz ___________

1000 Hz ___________

2000 Hz ___________

6. Audiometric Test Performed by _____________________________________________________________________

7. Height _____________

Weight _____________

B.P. ______________

Pulse ______________

8. Check if Normal:

Head

_______

Lungs

_______

Extremities _______

Eyes (including Fundi) _______

Heart

_______

Neurologic _______

Ears

_______

Abdomen _______

Urinalysis _______

Throat

_______

Genitalia _______

X-ray, EKG, and TB Skin Test Data (if indicated):

____________________________________________________________

I am a duly licensed physician/nurse practitioner in Virginia, License No. _______________. I certify that I have reviewed the

Medical History as written hereon, examined the patient as noted above and with the knowledge of his duties and the “Physical

Qualifications for School Bus Drivers”, I find that he/she is mentally and physically fit to operate a school bus: without restriction

___________, with corrective lenses ___________, with a hearing aid ___________.

As best I can determine, this individual does not have any conditions which might impair level of consciousness, perception,

judgement, motor/mechanical functions, or otherwise impair the ability to safely operate a school bus.

As best I can determine by reviewing the history and exam as above, I have no reason to suspect that the applicant uses illegal

drugs or excessive amounts of alcohol.

Signed _____________________________________

Address _____________________________________________

Name Printed ________________________________

____________________________________________________

Date _______________________________________

Phone _______________________________________________

Notes: 1. The examining physician/nurse practitioner should be aware of the physical demands and mental and emotional

responsibilities placed on a school bus driver. In the interest of public safety, the examining physician is required to certify

that the driver does not have any physical, mental or organic defect of such a nature as to affect the driver’s ability to

operate safely a school bus.

2. The following duties may be required of a school bus driver: the ability to open a school bus hood; stoop and inspect under

a vehicle; operate emergency doors, roof hatches and windows; assist students from emergency exits or vehicle by lifting

children out of wheelchairs, out of emergency doors, roof hatches and/or emergency windows; installing tire chains as

applicable; operate push pull handle for bus entrance doors; operate wheelchair lifts including stooping and/or bending to

secure wheelchairs for transportation; lift preschool children in and out of the vehicles, operate a standard transmission if

necessary.

3. This report must be signed personally by the physician/nurse practitioner and returned to the school division requesting the

certificate.

Form Eb.001 - School Bus Driver'S Application For Physician'S Certificate - Virginia Board Of Education Page 2

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