fd-965.pdf
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- Solicitation number
- RFP0215156
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FORM
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Text version
FD-965 (Rev. 5-16-2008) 67 Number: _______________________
FBI Hazardous Device School Exam
To: __________________________________________________________________________
From: FBI Field Office
Examinee: _________________________________________ D.O.B. ___________________
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 & 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
45999 Males > 40 - offer Digital rectal exam
94010 Req unless PE < 1 yr Pulmonary Function test
FD-899, FD-900 Required Completion of Respiratory clearance & questionnaire
85025 Required Complete Blood Count w differential
93000 Req unless PE < 1 yr EKG
Review required Review Basic Immunization Series
90658 Update as required Influenza, annually
90700
Update as required Tdap: tetanus/diphtheria/pertussis every 10 years
90718 Update as required Tetanus/diphtheria every 10 years
| personnel file number: |
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| examinee: |
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| appointment date: |
| time: |
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