fd-866.pdf

FD-866

Revised

05-16-2008

FEDERAL BUREAU OF INVESTIGATION

FITNESS FOR DUTY (FFD) EXAMINATION

Date of FFD Exam _______________________ FIELD OFFICE/RA: ________________________________ Clinic or location: ___________________________________

1. Were you greeted courteously? □ Excellent □ Good □ Fair □ Poor

2. Was there a suitable changing facility for □ Excellent □ Good □ Fair □ Poor examination preparation?

3. Were your screening tests in preparation for physician □ Excellent □ Good □ Fair □ Poor examination conducted in a complete and professional manner (blood draw, blood pressure, pulse, height, weight, eye pressures, vision and hearing testing, electrocardiogram)?

4. Did the physician conducting the examination perform an □ Excellent □ Good □ Fair □ Poor appropriate review of your medical history, including questions regarding alcohol use, medications, operations, allergies, accidents, and hospitalization?

5. Was the physician examination performed in a courteous, □ Excellent □ Good □ Fair □ Poor professional manner and were the results discussed with you, answering questions to your satisfaction?

6. Was the physical examination thorough, covering all □ Excellent □ Good □ Fair □ Poor important body areas?

7. Please rate the following:

Overall Quality of Service □ Excellent □ Good □ Fair □ Poor Examining Physician □ Excellent □ Good □ Fair □ Poor Nursing /Support Staff □ Excellent □ Good □ Fair □ Poor Facility Hygiene/Cleanliness □ Excellent □ Good □ Fair □ Poor

8. What was your waiting time for examination? □ 10 min □ 10-20 min □ 20 min or more

May we contact you for clarification or additional information? □ Yes □ No

Name: (optional)________________________________ Telephone Number: (optional)______________________

Comment: (Please comment if rating is fair or poor)

PLEASE RETURN FORM TO YOUR NURSE OR FIT FOR DUTY COORDINATOR WHO WILL FORWARD IT TO THE

REGIONAL NURSE.

(FORM TO BE USED FOR ON BOARD PHYSICALS ONLY)