FD-1093.pdf

FD-1093

01/02/2026

FEDERAL BUREAU OF INVESTIGATION

REPORT OF MEDICAL EXAMINATION

(FOR EMPLOYEES WITH AN FFD REQUIREMENT)

67#: DATE OF EXAM:

This information is for official, confidential use only and will not be released to unauthorized persons.

1. Name of examinee: - Official Bureau Name: (LAST, FIRST, MIDDLE) 2. Date of Birth 3. Age

4. Division 5. Field Office

6. Examining Facility

6a. Street Address of Examining Facility 6b. City 6c. State 6d. Zip Code

7. Rating or Speciality of Examiner 8. Purpose of Examination

9. Sex 10. Race

The remainder of this form is to be completed by Examining Facility Medical staff and Providers Only

11. Height: (inches) without shoes 12. Weight: (lbs) 13. Blood Pressure: Sitting

14. Pulse: Sitting 15. Temperature: (method of measure)

16. Distant Vision -

WITHOUT

Correction

Left: 20/

Right: 20/ With Correction (if needed)

Left: 20/

Right: 20/

17. NEAR Vision –

WITHOUT

Correction

Left: 20/

Right: 20/

With Correction (if needed)

Left: 20/

Right: 20/

18. Field of Vision Left:

Right:

19. CLINICAL EVALUATION

Check each item in appropriate column, enter “NE” if not evaluated, “NA” if not applicable or “PD” if patient declined.

Normal Abnormal Normal Abnormal

HEAD, FACE, NECK

AND SCALP

VASCULAR SYSTEM

(Varicosities, etc.)

EARS- GENERAL

(INTERNAL CANALS)

(Auditory acuity under items 21)

ABDOMEN AND VISCERA

(Include hernia)

TESTICULAR

Drums (Perforation) ENDORCRINE SYSTEM

NOSE G-U SYSTEM

SINUSES UPPER EXTREMITIES

(Strength, range of motion)

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FEDERAL BUREAU OF INVESTIGATION

REPORT OF MEDICAL EXAMINATION

(FOR EMPLOYEES WITH AN FFD REQUIREMENT)

Normal Abnormal Normal Abnormal

MOUTH AND THROAT LOWER EXTREMITIES

(Except feet) (Strength, range of motion)

EYES – GENERAL (Visual acuity under 17 and 18)

FEET

OPTHALMOSCOPIC SPINE, OTHER

MUSCULOSKELETAL

PUPILS (Equality and reaction) SKIN, LYMPHATICS

OCULAR MOTILITY

(Associated parallel movements nystagmus)

IDENTIFYING BODY

MARKS, SCARS,

TATTOOS

LUNGS AND CHEST NEUROLOGIC

HEART (Thrust, size, rhythm, sounds)

PSYCHIATRIC (Specify any personality deviation)

20. Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 23 and use additional sheets if necessary.

20a. Please Comment on the following:

Alcohol History/Usage:

Tobacco History/Usage:

Dietary Habits:

Level of Exercise:

Travel History:

Immunization Status:

I consider the examinee’s present weight to be Satisfactory Excessive Deficient

Under proper medical supervision, employee should Lose lbs Gain lbs

21: A. For all Special Agents and Police Officers:

1. Does examinee have any defects restricting or prohibiting their participation in defensive tactics and dangerous assignments which might entail the practical use of firearms?

YES NO

2. Does examinee demonstrate uncorrected visual acuity no worse than 20/100 (Snellen) in each eye, with correction to 20/20 in one eye and no worse than 20/40 in the other eye?

YES NO

B. For employees for positions other than listed in A, above:

1. Does examinee demonstrate distant vision no worse than 20/20 in one eye and 20/40 in the other,corrected or uncorrected?

YES NO

2. Does examinee have any defects prohibiting safe operation of motor vehicles (20/40 in one eye and 20/100 in the other eye, corrected or uncorrected)?

YES NO

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FEDERAL BUREAU OF INVESTIGATION

REPORT OF MEDICAL EXAMINATION

(FOR EMPLOYEES WITH AN FFD REQUIREMENT)

22. RECOMMENDATIONS – FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

23. The EMPLOYEE is:

Fit for Duty

Not Fit for Duty PENDING FBIHQ Review

23a. If not Fit for Duty, list Disqualifying Defects by Item Number

24. Typed or Printed Name of Physician Signature of Physician Date

25. Typed or Printed Name of Reviewing Officer or Approving Authority

Signature of Reviewing Officer or Approving Authority

Date

Privacy Act Statement: The collection of the information on this form, which is authorized by 5 U.S.C. § 301 and 5 U.S.C. § 3301, is relevant and necessary to provide appropriate medical care and to determine eligibility and/or fitness for duty. Completion of this form is voluntary; however, your failure to supply all the information requested on this form may impede or preclude agency action regarding medical care or continued employment. This information is maintained in your medical file in the FBI Central Records System, Justice/FBI-002, a description of which can be found at https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx. This information may be disclosed in accordance with the routine uses referenced in this notice.

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https://go.fbinet.fbi/DO/OGC/LTB/PCLU/Pages/PCLULibraryMenu.aspx