fd-947.pdf

FD-947 (Rev. 5-16-2008) 67 Number:

FBI Hazardous Material Response Team - Periodic

TO:

FROM: FBI Field Office Examinee: _________________________________________ D.O.B. ____________________________ Job Position: ___________________________________ Appointment Date: _________________ Time: ________________

Bring all shots record (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 82480 Required Plasma cholinesterase, one draw 82482 Required RBC cholinesterase, one draw 82955 Required G6PD (omit if already on record) 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 94010 Required Pulmonary function test 99172 Required Distant & near visual acuity w/ & w/o corrections 99172 Required Visual fields, strabismus 99172 Required Color vision 99395, 96, 97 Required History, PE, vitals (ht, wt, B/P, pulse, resp, temp), written summary of findings FD-899, FD-900 Required Completion of FD-899, FD-900 CPT codes If Indicated Supplemental Components 84153 Males >40 years Prostate specific antigen 45999 Males > 40 Digital rectal exam 88141 Females If pap > 6 mos offer complete Gyn exam 77057 Females > 40 years 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 83655 If indicated Blood lead 84202 If indicated ZPP 93015 Required at age 40, 44,48, 50, 52, 54, & 56 Exercise stress test Bruce protocol

92120 > 40 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 CPT Codes Per Instructions Vaccinations 90632 Update as required Hepatitis A vaccine, basic series 90746 Update as required Hepatitis B vaccine – basic 90636 Approval required Twinvax 90690 or 90691 Update as required Typhoid (injection Q 2 yrs or oral Q 5) 90707 Update as required MMR (once as adult) 90713 Update as required Inactive polio (IPV) one dose as an adult 90658 Update as required Influenza, annually 90718 Update as required Tetanus/diphtheria q 10 years 90715 Update as required Tdap, tetanus/diphtheria/pertussis q 10 years 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 – special series 90675 Approval required Rabies – special series 90749 As available Smallpox – special series