FD-946-Respiratory REVISION 12312010.doc
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FD-946 (Rev. 12/31/2010) FBI Respiratory Protection Program- Baseline Exam for Professional Staff ONLY
TO:
FROM: FBI Field Office
Examinee:
D.O.B.
67 Number:
Job Position:
Appointment Date: ______________ Time: _____________
| CPT Codes |
| Required |
| Core Components |
| 71020 |
| Required |
| Chest x-ray P/A & lateral |
| 94010 |
| Required |
| Pulmonary function test |
| 99385,86,87 |
| Required |
| History – FD-1065 |
| FD 900 |
| Required |
| Completion of respiratory questionnaire |
| FD 899 |
| Required |
| Completion of respirator use form |
| 99172 |
| Required |
| Distant visual acuity with and without correction |
| 99385,86,87 |
| Required |
| Focused physical exam SF- 88, Section 17, eval a-n, Height/weight/BP/heart rate/temp; SEE SOW |
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