Physical Fitness Certificate Template printable pdf download

***Sample***

Updated May 2014

(Insert employer name or place on letterhead / Return to employer when complete)

Physical Fitness Certificate

School Bus Driver

Special Purpose Bus Operator (special purpose bus capacity greater than 15 passengers)

School Bus Monitor (not required)

Indiana Code 20-27-8-1, in part states, (a) an individual may not drive a school bus for the transportation of students or be

employed as a school bus monitor unless the individual satisfies the following requirements:

(7) Possess the following required physical characteristics:

(A) Sufficient physical ability to be a school bus driver, as determined by the state school committee. (Title 575 IAC 1-8)

(B) Possession and full normal use of both hands, both arms, both feet, both legs, both eyes, and both ears.

(i) may be transmitted through airborne or droplet means; or

(ii) requires isolation of the infected person under 410 IAC 1-2.3.

(D) Freedom from any mental, nervous, organic, or functional disease which might impair the person’s ability to properly operate

a school bus.

(E) Visual acuity, with or without glasses, of at least 20/40 in each eye and a field of vision with 150 degree minimum and with

depth perception of at least 80%.

Indiana Code 20-27-9-5(c)(1), in part , states if the special purpose bus has a capacity of more than fifteen passengers, the

operator meet the requirements for a school bus driver set forth in I.C. 20-27-8-4

Physical Fitness Certificate Requirement

An individual who is or intends to become a school bus driver must obtain a physical examination certificate stating that the

individual possesses the physical characteristics required by section 1(a)(7) of this chapter. The certificate shall be made by an

individual who is registered in the Federal Motor Carrier Safety Administration's National Registry of Certified Medical

Examiners after the certified medical examiner has conducted a physical examination of the school bus driver or prospective

school bus driver. The school corporation shall determine how the certified medical examiner who is to conduct the physical

examination is chosen and who must pay for the physical examination.. (I.C. 20-27-8-4)

I certify that _________________________________possesses the physical characteristics required by I.C. 20-27-8-1 to be a

school bus driver, school bus monitor, or special purpose bus operator. The certificate of examination shall be filed with the

school corporation or employer not more than seven days after the examination. (I.C. 20-27-8-5)

______________________________________________

Certified medical examiner signature

_______________________________________________________________________________

Printed name

_______________________________________________

Certified medical examiner national registry ID number

________________________________________

Date of examination

This physical examination expires 24 months from the above date. (I. C. 20-27-8-5)

_________________________________________________________________________________________________________

Certified medical examiner’s address and telephone number

Physical Fitness Certificate Template