fd-964.pdf
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- Solicitation number
- RFP0215156
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FORM
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Text version
FD-964 (Rev. 5-16-2008) 67 Number: _________________________
FBI Commercial Driver Exam
To: _____________________________________________________________
From: FBI Field Office _____________________________________________
Examinee: ___________________________________ D.O.B. _____________
Job Position: _________________________
Bring all shot records (CDC –731, International Certificate of Vaccination)
Appointment Date: _______________________ Time: __________________
CPT Codes Required Core Components
81001 Required Urinalysis
82270 Offer Stool for occult blood X 3
92551 Required Audiometry
99172 Required Distant & near visual acuity w/ & w/o corrections
99172 Required Visual fields, strabismus
99172 Required Color vision
99391, 92, 93 Required Written summary of findings
99395, 96, 97 Required History, PE, vitals (ht, wt, B/P, pulse, resp, temp)
71020 Needs FBIHQ approval Chest x-ray P/A & lateral
45999 Males > 40 - offer Digital rectal exam
90658 Update as required Influenza, annually
90718 Update as required Tetanus/diphtheria q 10 years
PROVIDER Please read CFR 391.41 Physical Qualifications for Drivers
| personnel file number: |
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| examinee: |
| DOB: |
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