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FD-945 (Rev. 12/31/2010)
FBI Applicant Exam Authorization Form
TO: ___________________________ _____________ _________ _________
FROM: FBI Field Office ____________________ __________ __________ ____________ Examinee: _______________________________________ DOB: _____________________ 67 Number: _______________________ Job Position: ________________________________ Appointment Date: __________________ Time: ___________________
Bring all shot records (CDC – 731, International Certificate of Vaccination) If female, bring pap results (within the last 12 months)
| CPT Codes |
| Required |
| Core Components (lab) |
| 80061 |
| Required |
| Lipid panel |
| 80053 |
| Required |
| Comprehensive metabolic panel |
| 81001 |
| Required |
| Urinalysis |
| 85025 |
| Required |
| Complete blood count with differential |
| CPT Codes |
| Required |
| Core Components (Screening Tests) |
| 99172 |
| Required |
| Distant & near visual acuity with and without correction |
| 99172 |
| Required |
| Visual fields, strabismus |
| 99172 |
| Required |
| Color vision – must include test used, number of plates used and number correct |
| 92551 |
| Required |
| Audiometry |
| 71020 |
| Required |
| Chest x-ray P/A & lateral |
| 94010 |
| Required |
| Pulmonary function test |
| 93000 |
| Required |
| Resting EKG 12 leads with interpretation |
| 86580 |
| Required |
| Mantoux TB test, unless prior hx of conversion, with interpretation by medical provider |
| 99385,86,87 |
| Required |
| History, PE, vitals (ht, wt, B/P, pulse, temp) |
| 88141 |
| Required |
| Female – IF PAP > 12 months offer complete GYN EXAM – applicant can use PCP |
| CPT codes |
| If Indicated |
| Supplemental Components |
| 82270 |
| Offer |
| Stool for occult blood X 3 |
| 88141 |
| Offer |
| If pap >12 months offer complete GYN exam |
| 85660 |
| If Indicated |
| Sickle cell trait – black or Mediterranean descent by history |
| 92002 |
| If Indicated |
| Ophthalmological services and completion of FAA form 8500-7 |
