Fillable Medical Examination For School Bus Drivers And Attendants (Page 2 of 2) in pdf

8. CERTIFICATION All applicants will be qualified for Interstate/DOT . Maximum length of certification will be on a two year cycle. Examinations

completed after June 1 of any particular year will expire on July 31, 2 years from that particular year. Examinations completed before June 1 of any

particular year will expire July 31, 1 year from that particular year; i.e. a medical examination qualifying a 2 year certificate, completed between June 1,

2000 and May 31 2001 will expire July 31 2002. Therefore, the best time to get a medical examination for a 2 year certificate is between

June 1 and July 31.

The examiner may specify a shorter duration of certification for any reason he/she feels is appropriate; this will be done usually because of the blood

pressure protocols or other conditions amenable to treatment (i.e. to see evidence of better control of non-insulin dependent diabetes with adjustment

of medications and diet). Certificates for shorter duration will be staggered and will be exceptions to the above 2 year cycle and not required expiring

July 31.

9. MEDICAL REQUIREMENTS The Driver/Attendant must be in good physical and mental health, be able-bodied, and be free from communicable

diseases. In addition to the specifics on vision, hearing, and blood pressure on the reverse side of this form, any abnormalities of laboratory or

physical examination must be documented and described, and the condition must be controlled, not likely to worsen, or is amenable to treatment.

Conditions must not affect the ability of the Driver to safely operate the bus, or the ability of the Attendant to safely attend.

10. DISQUALIFYING CONDITIONS (The applicant may be required to pay for additional studies/consults, depending on local school district policy).

xInsulin Dependent Diabetes; Non-Insulin Dependent Diabetes is OK if reasonably controlled and applicant is having no hypoglycemic episodes.

xEpilepsy; Non-epileptic seizure or loss of consciousness with subsequent normal EEG and recommendation by a Neurologist who feels the applicant will drive/attend

safely, may allow an applicant, who is not taking anticonvulsant, to qualify if he/she is seizure-free for 3 years.

xLoss of foot, leg or hand; Loss of fingers or toes may possibly be allowed if the applicant demonstrates adequate ability to drive/perform safely, with or without a

prosthesis.

xParalysis of extremity; also Limitation of movement or strength which interferes significantly with the ability to drive / perform.

xCardiac Condition likely to interfere with safe driving / job performance; EKG and/or stress test may be required per examiner's request if indicated.

xUse of Medication or Substance likely to interfere with safe driving/attending; includes addiction by medical determination to use of narcotics, habit-forming drugs, or

the excessive use of alcohol.

xPoor General Health as determined by the medical examiner.

xAny other Mental/Physical Condition likely to interfere with safe driving/attending.

11. OTHER REQUIREMENTS / INFORMATION

xMedical Examination shall be conducted by a licensed Medical Doctor, Doctor of Osteopathy, Doctors of Chiropractic, Certified Nurse Practitioner, or a Physician

Assistant.

xA Medical Examination is required for Drivers and Attendants at least every 2 years. Certifications for 2 years will expire July 31 (See section 8, Certification). Additional

medical examinations may be required at any time at the request of the employer, local school district and / or the State Transportation Director.

xThe original Medical Examination form must be completed, signed and dated and be on file at the place of employment before students are transported by the Driver or

attended by the Attendant. A notarized copy will be forwarded to the local school district upon request.

xThese forms must be retained for a minimum of 5 years after employment ends.

xA tuberculosis test is required only on new or current school bus drivers or attendants who do not have a tuberculosis test on file in the school district office. If a test is

positive, State Health Department procedures are to be followed.

xThe employer, local school district and/or the State Transportation Director has the right to require re-examination or verification by a licensed physician in a specialized

field as a condition of employment.

xA Medical Examiner's Certificate will be issued to each certified Driver/Attendant. It shall be kept with the Driver / Attendant when on duty.

COMPLETE THIS SECTION IF THE DRIVER OR ATTENDANT DOES NOT QUALIFY

___ Does not meet standards; disqualified because

_____________________________________________________________________________.

___ Temporarily disqualified due to

__________________________________________________________________________________________.

Return to medical examiner's office for follow up on______________(If approved on follow-up exam, the section below will be completed at that

time).

CERTIFICATION: COMPLETE THIS SECTION IF THE DRIVER OR ATTENDANT QUALIFIES

I certify that I have examined ______________________________________________________________________________________, in

accordance with state and Federal regulations, and with knowledge of the bus driver's/attendant's duties, I find this person is qualified under the

regulations as:

z BUS DRIVER or z BUS ATTENDANT

INTERSTATE/DOT bus/activities

;

for a period of: z 2 YEARS, or because of _____________________________________________ only for a period of z 1 YEAR z 6 MOS. z 3

MOS

and, if applicable, only when: ........................ z wearing CORRECTIVE or CONTACT LENSES..................... or.................... z wearing HEARING AID

The information I have provided regarding this medical examination is true and complete.

SIGNATURE OF MEDICAL EXAMINER

MED. EXAMINER'S TELEPHONE

DATE OF EXAM

______________________________________________________________

_____________________________

_________________

PRINTED NAME OF EXAMINER

__________________________________________________________________________________________________

MD_____ DO____

CNP____ PA-C____

MEDICAL EXAMINER'S ADDRESS