fd-945.pdf

FD-945 (Rev. 5-16-2008) 67 Number: _______________________

FBI Applicant Exam Authorization Form

TO:

FROM: FBI Field Office _______________________________________________________

Examinee: ______________________________________ D.O.B. ______________________

Job Position: ________________________________

Appointment Date: __________________ Time: ___________________

Bring all shot records (CDC – 731, International Certificate of Vaccination) If female bring pap results (within the last 6 months)

CPT Codes Required Core Components (lab) 80061 Required Lipid panel 80053 Required Blood metabolic panel 82977, 84550 Required GGT, Uric Acid 82955 Required G6PD 86900, 86901 Required Blood group & type 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, with interpretation by medical provider 92551 Required Audiometry 71020 Required Chest x-ray P/A & lateral 92120 Required Tonometry (IOT) 94010 Required Pulmonary function test 93000 Required Resting EKG 12 leads w/ interpretation 99172 Required Distant & near visual acuity w/ & w/o corrections 99172 Required Visual fields, strabismus 99172 Required Color vision 99385,86,87 Required History, PE, vitals (ht, wt, B/P, pulse, resp, temp) CPT codes If Indicated Supplemental Components 88141 Females If pap > 6 mos offer complete GYN exam 85660 If indicated Sickle cell trait – black or Mediterranean descent