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GBE-E MEDICAL EXAMINATION OF SCHOOL EMPLOYEES This is to
certify I have examined and find
him/her free of communicable disease and any physical or mental disabilities
that might interfere with performing his or her duties, except as follows: TB Test Results: Date of Test: , M.D. Date of Examination Signature |
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(To
be used by drivers employed by the School Department -- Not for contracted
drivers) STATE
OF DEPARTMENT
OF SAFETY DIVISION
OF MOTOR VEHICLES SCHOOL
BUS DRIVER PHYSICAL EXAMINATION FORM Name Address
Have you ever had: Heart trouble? Epilepsy? Fainting spells? Diabetes? Tuberculosis? If
"Yes" to any of the above , explain: Signature
of driver: Date:
Visual acuity (if individual
wears glasses, test and record acuity with and without glasses.) Without glasses R 20/ L 20/ B 20/ With glasses R
20/ L
20/ B
20/ Field
of vision degrees Depth
perception Color perception
Muscular
anomalies Hearing
without hearing aid: Right Left
Heart
sounds: At apex murmur At base murmur Rhythm Enlargement
Indicated Pulse
Rate Regularity Blood
pressure: Systolic Diastolic Condition
of arteries: Sclerosis Pulsations Lungs:
Rales Breath Sounds Chest X-Ray Weight Height Extremities: Deformities
Routine
office urinalysis: Evidence
of infectious disease, mental disability, emotional instability, or drug
addiction: Remarks regarding any condition
not within normal limits:
After
examination, I find that is is not free from any ailment, disease or
defect that might affect his or her ability to safely operate a school bus. Licensed Physician Date Adoption Date: School Board Review: April 9, 2009 |