School Bus Drivers Application For Physicians Certificate printable pdf download

SCHOOL BUS DRIVER’S

Form EB.001

APPLICATION FOR PHYSICIAN’S CERTIFICATE

Revised 4-95

This form is required under the provision of Section 22.1-178 of the

Code of Virginia and Regulations of the Board of Education

APPLICANT NAME ___________________________________

SCHOOL DIVISION _______________________

APPLICANT’S SOCIAL SECURITY NO. _______________________

BIRTH DATE _______________________

ADDRESS____________________________________________________________________________________________

Medical History (to be completed by 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 symptom _____

High Blood Pressure

_____

Tuberculosis

_____

Brain Tumor

_____

Paralysis of any type

_____

Back Injury

_____

Shoulder Injury

_____

Have you ever 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, which medication is it? ________________________________________________

Do you have hay fever or other minor illness which require you to take over the counter (non-prescription) medications at times?

Yes ___ No ___

If so, please list 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 by Examining Physician: _______________________________________________________________

______________________________________________________________________________________________________

Physical Qualifications for School Bus Drivers

1. No person shall drive a school bus unless that person is physically

g. Has no known medical history or clinical diagnosis of rheumatic,

qualified to do so and has submitted a School Bus Driver’s Application

arthritic, orthopedic, muscular, neuromuscular, or vascular disease which

For Physician’s Certificate signed by the applicant and the doctor for

would interfere with the ability to control and operate a school bus safely

for the applicable employment period.

without reasonable accommodations;

h. Has no known medical history or clinical diagnosis of epilepsy or any

2. A person is physically qualified to drive a school bus if the individual:

other condition which is likely to cause loss of consciousness or any loss of

a. Has no loss of a foot, a leg, a hand, or an arm which interferes with

of ability to control a school bus without reasonable accommodations;

the ability to control and safely drive a school bus without reasonable

i. Has no known mental, nervous, organic or functional disease or

accommodations;

psychiatric disorder likely to interfere with the ability to drive a school bus

b. Has no impairment of the use of a foot, a leg, a hand, finger, or an

safely without reasonable accommodations;

arm, and no other structural defect or limitation likely to interfere with

j. Has both distant and near visual acuity of at least 20/40 (Snellen) in

the ability to control and safely drive a school bus without reasonable

each eye with or without corrective lenses, and field of vision of at least

accommodations;

70 degrees in the horizontal meridian in each eye, and the ability to

c. Has no known medical history or clinical diagnosis of diabetes

recognize the colors of traffic signals and devices showing standard red,

nellitus currently requiring insulin for control likely to interfere with

green and amber;

the ability to control and safely drive a school bus without reasonable

k. First perceives a forced-whispered voice in the better ear at not less

accommodations;

than 5 feet with or without the use of a hearing aid or, if tested by use of an

d. Has no current clinical diagnosis of myocardial infarction, angina

audiometric device, does not have an average hearing loss in the better ear

pectoris, coronary insufficiency, thrombosis, or any other cardiovascular

greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without

disease of a variety known to be accompanied by syncope, dyspnea,

a hearing aid when the audiometric device is calibrated to American

collapse, or congestive cardiac failure;

National Standard (formerly ASA Standard) Z24.5-1951; and

e. Has no known medical history or clinical diagnosis of a respiratory

l. Does not use an amphetamine, narcotic, or any habit-forming drug

dysfunction likely to interfere with the ability to control and drive a

without appropriate physician supervision.

school bus safely without reasonable accommodations;

Has no known current clinical diagnosis of high blood pressure to

interfere with the ability to operate a school bus safely without reasonable

accommodations;

School Bus Drivers Application For Physicians Certificate

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