fd-943.pdf

FD-943 (Rev 5-16-2008) 67 Number: _____________________________

FBI Fitness for Duty Periodic Exam Form

To: __________________________________________________________________________________ From: FBI Field Office __________________________________________________________________ Examinee: ___________________________________________ D.O.B. ___________________________ Job Position: ___________________________________ Appointment Date: _________________________ Time: ______________________ Treadmill Appt: __________________________

BRING ALL SHOT RECORDS (CDC-731, INTERNATIONAL CERTIFICATE OF VACCINATION)

CPT Codes Required Core Components (lab) 80061 Required Lipid panel 80053 Required Complete Metabolic Panel 82977, 84550 Required GGT, Uric Acid 81001 Required Urinalysis 82270 Offer Stool for occult blood X 3 85025 Required Complete blood count /w differential CPT Codes Required Core Components (Screening Tests) 86580 Required Mantoux TB test, unless prior hx of conversion 92551 Required Audiometry 93000 Required Resting EKG 12 leads w/ interpretation 99172 Required Distant & near visual acuity w/ & w/o corrections 99172 Required Visual fields, strabismus, color vision (if not previously recorded) 99395, 96, 97 Required History, PE, vitals (ht, wt, B/P, pulse, resp, temp), written summary of findings CPT Codes If Indicated 84153 Males >40 years Prostate specific antigen 45999 Males > 40 years Digital Rectal Exam 88141 Females- offer If PAP > 6 months offer complete GYN exam 77057 Females > 40 offer Mammography, offer if > 40 years, in conjunction with GYN Breast Exam performed within 1 year, on record 71020 If indicated Chest X-ray P/A & lateral 94010 If indicated Pulmonary function test 93015 Required at age 40, 44,48,50, 52, 54, & 56 Exercise stress test Bruce protocol

92120 > 40 years Tonometry 93015, 78465, 78478, 78480, A9505, A9502

Requires approval Thallium stress test – follows abnormal screening

93350, 93015 Requires approval Stress Echo – preferred – follows abnormal screen 86900,86901 If indicated Blood group & type 85660 If indicated Sickle Cell (Black/Mediterranean descent) 83655, 84202 If indicated Lead & ZPP (if authorized by HQ) 82955 If indicated G6PD (If none previously recorded) CPT Codes Per Instructions Vaccinations 90632 Update as required Hepatitis A vaccine, basic series 90746 Update as required Hepatitis B vaccine – basic series 90636 Update as required Twinrix – basic series 90690 or 90691 Update as required Typhoid (injection Q 2 yrs, oral Q 5) 90707 Update as required MMR (once as adult) 90713 Update as required Inactivate polio (IPV) one dose as adult 90658 Update as required Influenza, annually 90718 Update as required Tetanus/diphtheria q 10 years 90715 Update as required Tdap Tetanus/Diphtheria/Pertussis 90717 Update as required Yellow fever q 10 years 90733 or 90734 Update as required Meningococcal vaccine – per manufacturers recommended frequency 4120F Screening dose Mefloquine trial, one dose & record reaction 90471 As requested Administration of vaccine – FBI supplied 90581 As available Anthrax, FBI supplied 90675 Update as required Rabies 90749 As available Small Pox