Post-Offer & Annual Physical Examination -Template
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2Georgia Department of Education
Post-Offer and Annual Physical Examination
For School Bus Drivers
To the examining physician:
The purpose of this examination is to detect the presence of defects of such character and extent as to affect the applicant's ability to safely
operate a school bus. The person being examined is required to sign the statement regarding the accuracy of his or her medical and occupational
history and to authorize the release of the examination results to the designated local board of education. Please mail this form to the board of
education specified by the applicant.
As a minimum, the applicant shall have no mental, nervous, organic, or functional disease or condition that would interfere with safe driving; he
or she shall have no loss of foot or hand; his or her visual acuity in each eye shall be at least 20/40, or correctable to 20/40 with glasses, and
visual form field shall not be less than 140 degrees in horizontal meridian, and ability to distinguish red, green, and yellow colors; his or her
hearing shall be such that a forced whispered voice is first perceived, in the better ear, at not less than 5 feet with or without the use of a hearing
aid (hearing acuity at least 25dB or less in the speech range [500, 1000 and 2000 Hz in the better ear with or without a hearing aid]); the
minimum age to qualify as a school bus driver is 18 years. Each driver shall be required to have an annual physical examination prior to the
beginning of the school year and as often thereafter as the local board of education may deem advisable.
Driver's Name
Age
Sex ____________
Date of Birth
Social Security Number_____________________________________________________
Address _____________________________________________________________________________________________________________________________
To be completed by examining physician (Please comment in each space. Enter O for negative.)
Medical History
(Present state of health)
Illnesses
Asthma
Stomach Ulcer
Seizures
Tuberculosis
Diabetes
Convulsions Fainting
Chronic Cough
Cancer
Emotional Illnesses
Shortness of Breath
Kidney Diseases
Muscular Diseases
Cardiovascular Diseases
Rheumatic Fever
Allergies
Injuries and Broken Bones
Head
Neck
Back
Arms
Legs
Other
___________________________________
Operations
____________________________________________________________________________________________________________________
Occupational History
(Exposure -- duration and time)
Dusts
Fumes
Radiation
Other
_
The above information to the best of my knowledge is accurately recorded with no pertinent medical data omitted, and I hereby authorize the
release of the information listed above and the results of the examination to the officials of the _________________________________________
Board of Education.
_______________________________________________________
_______________________
Signature of Applicant
Date
DE Form 0514, Revised May 2012
(continued on reverse side)
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