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FORM EB.001

SCHOOL BUS DRIVER’S APPLICATION FOR PHYSICIAN’S CERTIFICATE

Rev. 9-12

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

and Regulations of the Virginia Board of Education

APPLICANT NAME _____________________________________ SCHOOL DIVISION ______________________________________

APPLICANT SOCIAL SECURITY NO. ____________________

BIRTH DATE _____________________________________________

ADDRESS _______________________________________________________________________________________________________

Medical History (to be completed by the 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 symptoms

_____ High Blood Pressure

_____ Tuberculosis

_____ Brain Tumor

_____ Paralysis of any Type

_____ Back Injury

_____ Shoulder Injury

Have you every 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, identify the medication(s): __________________________________________________________________________

Do you have hay fever or other minor illnesses which require you to

take over the counter (nonprescription) medications at times?

_____ Yes

_____ No

If so, identify 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 of Applicant by Examining Physician/Nurse Practitioner:_____________________________________

____________________________________________________________________________________________________________

PHYSICAL QUALIFICATIONS FOR SCHOOL BUS DRIVERS

Has no known medical history or clinical diagnosis of

No person shall drive a school bus unless that person is

rheumatic, arthritic, orthopedic, muscular,

physically qualified to do so and has submitted a Certificate

neuromuscular, or vascular disease which would

signed by the applicant and the doctor for the applicable

interfere with the ability to control and operate a school

employment period.

bus safely without reasonable accommodations;

A person is physically qualified to drive a school bus if the

Has no known medical history or clinical diagnosis of

individual:

epilepsy or any other condition which is likely to cause

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

loss of consciousness or any loss of ability to control a

interferes with the ability to control and safely drive a

school bus without reasonable accommodations;

Has no known mental, nervous, organic, or functional

Has no impairment of the use of a foot, a leg, a hand,

disease or psychiatric disorder likely to interfere with the

finger, or an arm, and no other structural defect or

ability to drive a school bus safely without reasonable

limitation likely to interfere with the ability to control

accommodations;

and safely drive a school bus without reasonable

Has both distant and near visual acuity of at least 20/40

accommodations;

in each eye, and at least a field of 140 degrees of

Has no known medical history or clinical diagnosis of

horizontal vision or a comparable measurement that

diabetes mellitus currently requiring insulin for control

demonstrates a visual field within this range, and the

likely to interfere with the ability to control and safely

ability to recognize the colors of traffic signals and

drive a school bus without reasonable accommodations;

devices showing standard red, green, and amber;

Has no current clinical diagnosis of myocardial

First perceives a forced-whispered voice in the better ear

infarction, angina pectoris, coronary insufficiency,

at not less than 5 feet with or without the use of a

thrombosis, or any other cardiovascular disease of a

hearing aid or, if tested by use of an audiometric device,

variety known to be accompanied by syncope, dyspnea,

does not have an average hearing loss in the better ear

collapse, or congestive cardiac failure;

greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000

Has no known medical history or clinical diagnosis of a

Hz with or without a hearing aid when the audiometric

respiratory dysfunction likely to interfere with the ability

device is calibrated to American National Standard

to control and drive a school bus safely without

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

reasonable accommodations;

Does not use an amphetamine, narcotic, or any habit-

Has no known current clinical diagnosis of high blood

forming drug without appropriate physician supervision.

pressure likely to interfere with the ability to operate a

school bus safely without reasonable accommodations;

Form Eb.001 - School Bus Driver'S Application For Physician'S Certificate - Virginia Board Of Education

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