Fillable Medical Examination For School Bus Drivers And Attendants printable pdf download

STATE OF NEW MEXICO

Department of Education

MEDICAL EXAMINATION for SCHOOL BUS DRIVERS and ATTENDANTS

(EXAMINERS: PLEASE READ THE REVERSE SIDE FOR MEDICAL REQUIREMENTS, DISQUALIFYING CONDITIONS, & OTHER REQUIREMENTS / INFORMATION)

1. DRIVER/ATTENDANT'S INFORMATION (Driver or Attendant completes this section)

Birthdate (D/M/Y)

Age

Date of Exam

Driver or Attendant's Name (Last, First, Middle)

SS#____________________

_____/______/_____

_____ _____/_____/_____

___________________________________________________

New certification

Bus Driver

Address (include City, State, Zip)

Work (_____)_________________

Re-certification

Bus Attendant

Follow-up

____________________________________________________ Home(_____)_________________

Drivers

Lic.#_________________________

2. HEALTH HISTORY (Driver or Attendant completes this section, but medical examiner is encouraged to discuss with him/her)

Yes No

z . Surgery / Hospitalization in last 5 years?

. . Heart surgery (bypass or any other) .

z z Missing or impaired hand , foot,

Digestive disorders

. . Serious illness in last 5 years ?

. . High blood pressure

Nervous / Psychiatric disorders

finger or toe

. . Head / Brain injuries, disorders, or illnesses

z z Shortness of breath

z z Fainting, dizziness

z z Spinal injury or disease

. . Seizures, epilepsy

z z Lung disease, incl. emphysema, asthma,

z z Chronic, severe low back pain

Loss of or altered consciousness

. . Eye / vision disorders (not incl. corrective lenses)

z z Sleep disorders, daytime sleepiness,

z z Muscular disease

chronic bronchitis, or pleurisy

. . Ear disorders, loss of hearing or balance

, z Diabetes controlled by: z diet

or severe snoring

Narcotic / habit forming drug use

z oral medication

z insulin

Heart attack/disease/other heart problems:

Stroke or paralysis

Regular or frequent alcohol use

For any YES answer, indicate onset date, diagnosis, medication, treating physician, any current limitations; also, list any other medications used

regularly:

_________________________________________________________________________________________________________________________

I certify that the above information is complete and true. I understand that inaccurate, false or misleading information may invalidate the examination and

my Medical Examiner's Certificate.

____________________________________________________

_______________

Driver or Attendant's Signature

Date

3. VISION Must be at least 20/40 in each eye with or without correction and at least 70 degrees of horizontal meridian in each eye to pass;

See the reverse side, section 8, "Certification", for more details.

ACUITY UNCORRECTED CORRECTED HORIZONTAL MERIDIAN

Able to recognize/distinguish

Yes

Depth Perception

Yes

Right eye

20/_____

_______degrees

standard red, green, yellow?

Normal.

Left eye

20/_____

_______degrees

4. HEARING Must hear whispered voice > 5 ft. in either ear , with hearing aid if needed; or average hearing in better ear greater than <

40db, i.e. the driver only needs one good ear.

Record distance from patient at which

Right ear

Left Ear

If audiometer is used,

Right Ear: 500hz

1000hz

2000hz Average

Left Ear: 500hz 1000hz 2000hz

Average

whispered voice can be heard.

record in decibels and

_____ft

_____ft. average the three #'s.

_____

______

_____

5. BLOOD PRESSURE/PULSE RATE

GUIDELINES FOR BLOOD PRESSURE EVALUATION:

Systolic/Diastolic = ________/_______

If BP high on initial exam:

Within 3 Months:

Thereafter, certify at this interval:

Driver qualified for 2 years if < 160/90; take at least 2

If 161-180 and /or 91-104,

If < 160/90, certify for 1 yr.

Certify annually if acceptable

readings if initial is high and consider using larger cuff.

certify for 3 mos. only.

blood pressure is maintained.

Pulse Rate = ________

If >180 and/or >104, don't

If < 160/90, certify

Certify every 6 months if acceptable

Regular

certify until reduced to <181/105;

for 6 mos.

blood pressure is maintained.

q describe:___________________________

Irregular

then certify for 3 mos. only.

6. LABORATORY AND OTHER TEST FINDINGS Urinalysis: Sp. Gr._______Protein_____Blood_____Sugar_____Micro(if indicated)_______________

All other lab, xray, and EKG are optional, and should be performed if indicated to clarify whether or not the driver/attendant qualifies. Record findings here:

________________________________________________________________________________________________________________________________________________________________

7. PHYSICAL EXAMINATION

Height = _____ft._____inches

Weight = _________lbs.

Check YES or NO to the question, "Is the Driver's ability to safely operate the bus affected?" or "Is the Attendant's ability to safely perform affected?"

BODY SYSTEM

CHECK FOR:

YES*

BODY SYSTEM

CHECK FOR:

YES*

1. General Appearance

Marked overweight, tremor, signs of alco-

8. Vascular System

Abnormal pulse/amplitude,bruits,

holism or drug abuse.

or vericose veins.

2. Eyes

Pupil equality, reaction to light, accom-

9. Genito-urinary

Hernias

modation, ocular muscle imbalance,

10. Extremities

Loss or impairment of all/portion

catarcts, other eye problems

of extremitiy, deformities, edema;

3. Ears

Middle ear disease, perforated eardrums,

insufficient grasp/prehension to

occlusion of external canal.

maintain grip; insufficient mobility/

4. Mouth and Throat

Irremediable deformities likely to inter-

strength in lower limb to operrate

fere with breathing or swallowing.

pedals properly.

5. Heart

Murmurs, enlarged heart, pacemaker.

11. Spine and other

Previous surgery, deformities, limit-

6. Lungs/chest

Wheeze, rales, dypsnea, cyanosis;

ation of motion, tenderness.

abnormal findings may require PFT's

12. Neurological

Impaired equilibrium/coordination;

and/or CXR for further evaluation.

asymmetric DTR's.

7. Abdomen and Viscera

Organomegaly, masses, bruits,

13. Psychiatric

Depression, anxiety, panic attacks,

hernia, abdominal wall weakness

psychosis.

*COMMENTS: The presence of a condition may not necessarily be disqualifying, particularly if the condition is controlled, not likely to worsen or is readily amenable to

treatment. However, the following conditions are disqualifying for all bus drivers and attendants in New Mexico: insulin-dependent diabetes; epilepsy; paralysis; or

any condition likely to interfere with safe driving or attending. This may also include limitations of strength or movement, certain medications, substances, cardiac

conditions and poor general health (see reverse side for more details). Describe any abnormality in detail:

__________________________________________________________________________________________________________________________________________________________________

Medical Examination For School Bus Drivers And Attendants

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