FD-1126.pdf

FD-1126

12/11/2025

FEDERAL BUREAU OF INVESTIGATION

AUTHORIZATION FOR EXAMS AND MEDICAL SURVEILLANCE

Initial Request

Case closed by vendor. Updated FD-1126provided.

Revised FD-1126

Resending FD-1126 due to:

Please only use CAPITAL letters when filling out the section below:

EXAMINEE'S DIVISION LOCATION AND RA IF APPLICABLE ORDERING DIVISION:

LAST NAME: FIRST NAME: POC NAME:

POSITION TITLE:

Employee Applicant

POC EMAIL:

DATE OF BIRTH: POC PHONE:

067#: POC FAX:

EXAMINEE PHONE (DESK/CELL):

EXAMINEE EMAIL (UNCLASS):

POC RETURN ADDRESS:

Authorization forms to be faxed Toll Free to #877-507-3190 or Local DID to #909-610-2647

Employee Occupational Health Exam (includes all components from both columns)

FD-1093 Report of Medical Exam Form (in its entirety) FD-1065 Medical History Form FD-1125 Tuberculosis Exposure Risk Assessment

Tuberculosis Skin Test (if indicated by FD-1125) Resting EKG (12 lead with interpretation)

Applicant Occupational Health Exam (includes all components from both columns)

FD-1093A Report of Medical Exam Form (in its entirety) FD-1065 Medical History Form FD-1125 Tuberculosis Exposure Risk Assessment

FD-967 New Agent Physical Activities (SA an PO applicants only) Tuberculosis Skin Test (unless contraindicated) Resting EKG (12 lead with interpretation)

Department of State Health Exam (includes all components from both columns)

DS-1843 Medical History Exam FD-1125 Tuberculosis Exposure Risk Assessment Tuberculosis Skin Test (unless contraindicated) Complete Blood Count with Differential Complete Metabolic Panel with ALT

HIV I and HIV II Hepatitis B Surface Antigen Hepatitis C Antibody Rapid Plasma Reagin (syphilis)

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LAST NAME: FIRST NAME: DATE OF BIRTH:

Dive Exam (includes allcomponents)

FD-1065A FBI Diving Medical History Addendum FD-899 FBI Respiratory Clearance and Hazardous Materials Response Medical Report FD-900 Hazardous Materials Response Respiratory Medical EvaluationQuestionnaire

Hazmat Exam/Respiratory Exam (includes allcomponents)

FD-899 FBI Respiratory Clearance and Hazardous Materials Response Medical Report FD-900 Hazardous Materials Response Respiratory Medical Evaluation Questionnaire

Federal Aviation Administration Exam(FAA) Class I Class II Class III

US Department of Transportation Exam (DOT)

Travel Medicine Review Exam / Immunizations

Ad Hoc Immunizations (employees only)

Anthrax Seasonal Influenza

Hepatitis A #1 #2 Tetanus Diphtheria (Td)

Hepatitis B #1 #2 #3 Tetanus, Diphtheria, Pertussis (Tdap)

Inactivated Polio Vaccine (4 childhood or 3 adult doses) Typhoid Vaccine

Japanese Encephalitis Vaccine #1 #2 Booster Twinrix (Hepatitis A and B combination) #1 #2 #3

Meningitis ACWY Vaccine Varicella #1 #2

MMR #1 #2 Yellow Fever

Rabies Vaccine #1 #2 Review and Update Required Vaccines According toSOW.

Travel Review Medications

Malaria prophylaxis (Atovquone/Proguanil) Traveler’s diarrhea prophylaxis (Azithromycin- first line drug)

Malaria prophylaxis (Doxycycline) Traveler’s diarrhea prophylaxis (Ciprofloxacin- if allergic to Azithromycin) Malaria prophylaxis (Primaquine)

Forms

DS-6570 ESCAPE Posts (specific countries only- www.state.gov)

FD-1125 Tuberculosis ExposureRisk Assessment

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www.state.gov

LAST NAME: FIRST NAME: DATE OF BIRTH:

Testing

Audiogram HIV I/ HIV II

Blood Lead IGRA (MORU Travel Team only)

Chest X-ray (PA and Lateral) Intraocular Pressure

Complete Blood Count with Differential Lipid Panel

Complete Metabolic Panel with ALT Plasma and RBC Cholinesterase level (One Draw)

ECG- Resting 12 lead with interpretation Pulmonary Function Test (Spirometry)

Field of Vision/Strabismus Rapid Plasma Reagin (Syphilis)

Glucose-6-phosphate-dehydrogenase (G6PD) Tuberculosis Skin Test

Hemoglobin A1c Urinalysis

Hepatitis B Surface Antigen Zinc Protoporphyrin (ZPP)

Hepatitis C Antibody

Signature of FBI Requestor:

(OHN/FFDC/Applicant Coordinator)

Date:

Requestor should refer to the COMPLETION INFORMATION SHEET and STATEMENT OF WORK. Only those items requested will be completed by the vendor.

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