fd-963.pdf

FD-963 (Rev. 5-16-2008) 67 Number:_____________________

FBI Pilot Exam

To:

From: FBI Field Office

Examinee: ____________________________________________ D.O.B. __________________

Employee’s Name: _________________________ Employee’s Job Position: ___________________

Appointment Date: ______________ Time: _____________

Bring all shot records (CDC –731, International Certificate of Vaccination)

CPT Codes Required Core Components 81001 Required Urinalysis

82270 Offer Stool for occult blood X 3

92551 Required Audiometry

99172 Required Distant, intermediate & 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

71020 Needs FBIHQ approval Chest x-ray, P/A & lateral

93000 Required EKG w/ interpretation

45999 Males > 40 - offer Digital rectal exam

90658 Update as required Influenza, annually

90718 Update as required Tetanus/diphtheria every 10 years

90700 Update as required Tdap: tetanus/diphtheria/pertussis every 10 years

PROVIDER As required – FAA Class 2 FAA Class 2 Medical Certification**, PE entered into FAA database

PROVIDER Or as required – FAA Class 1**

FAA Class 1 Medical Certification**. If required by applicant age, electronically transmit EKG to FAA

** Pilots designated by Special Flight Operations Unit-CIRG for Required Crewmember Duty on overseas operations of FBI aircraft are required to maintain a current Class I FAA Medical Certificate.