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

 

 

 

 


(To be used by drivers employed by the School Department -- Not for contracted drivers)

 

STATE OF NEW HAMPSHIRE

DEPARTMENT OF SAFETY

DIVISION OF MOTOR VEHICLES

JAMES H HAYS SAFETY BUILDING

HAZEN DRIVE, CONCORD, N.H.  03305

 

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:           April 8, 1993

School Board Review: April 9, 2009