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FD-943 (Rev 12/31/2010)
FBI Fitness for Duty Periodic Exam Form
TO:
FROM: FBI Field Office:
Examinee: ___________________________________________ DOB: ___________________________ 67 Number: _____________________________ Job Position: ___________________________________ Date of Physical: __________________Time: _________________ Treadmill Appt: ___________________
BRING ALL SHOT RECORDS (CDC-731, INTERNATIONAL CERTIFICATE OF VACCINATION)
| 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) |
| 86580 |
| Required |
| Mantoux TB test, unless prior hx of conversion |
| 92551 |
| Required |
| Audiometry |
| 93000 |
| Required |
| Resting EKG 12 leads with interpretation |
| 99172 |
| Required |
| Distant & near visual acuity with and without corrections |
| 99172 |
| Required |
| Visual fields and strabismus |
| 99385, 86, 87 |
| Required |
| History, PE, vitals (ht, wt, B/P, pulse, temp), written summary of findings |
| CPT Codes |
| If Indicated |
| AGE/GENDER SPECIFIC or ADDITIONAL COMPONENTS |
| 82270 |
| Offer |
| Stool for occult blood X 3 |
| 99172 |
| If not previously recorded |
| Color Vision – note test used, number of plates used and number correct |
| 84153 |
| Required |
| Prostate specific antigen – Males > 40 years |
| 45999 |
| Offer |
| Digital Rectal Exam Males > 40 years |
| 88141 |
| Offer |
| If PAP > 12 months offer complete GYN exam - Female |
| 77057 |
| Offer |
| Mammography, offer if female > 40 years, in conjunction with GYN Breast Exam performed within 1 year, on record |
| 93015 |
| Required |
| Exercise stress test Bruce protocol at age 40, 44, 48, 50, 52, 54 & 56 |
| 78465 |
| Requires approval |
| Thallium stress test – follows abnormal screening |
93350
| Requires approval |
| Stress Echo – preferred – follows abnormal screen |
| 71020 |
| If indicated |
| Chest X-ray P/A & lateral – based on exam findings or HCPU approval |
| 94010 |
| If indicated |
| Pulmonary function test – based on exam findings or HCPU approval |
| 92120 |
| Offer |
| Tonometry if > 40 years |
| 86900,86901 |
| If indicated |
| Blood group & type |
| 85660 |
| If indicated |
| Sickle Cell (Black/Mediterranean descent by history) |
| 83655, 84202 |
| If indicated |
| Lead & ZPP (requires division or HCPU approval) |
| 82955 |
| If indicated |
| G6PD (If none previously recorded) |
| CPT Codes |
| Per Instructions |
| Vaccinations |
| 90632 |
| Update as required |
| Hepatitis A vaccine, basic series |
| 90746 |
| Update as required |
| Hepatitis B vaccine – basic series |
| 90636 |
| Update as required |
| Twinrix – basic series |
| 90690 or 90691 |
| Update as required |
| Typhoid (injection Q 2 yrs, oral Q 5) |
| 90707 |
| Update as required |
| MMR (once as adult) |
| 90713 |
| Update as required |
| Inactivate polio (IPV) one dose as adult |
| 90658 |
| Update as required |
| Influenza, annually |
| 90718 |
| Update as required |
| Tetanus/diphtheria q 10 years OR |
| 90715 |
| Update as required |
| Tdap Tetanus/Diphtheria/Pertussis q 10 years |
| 90717 |
| Update as required |
| Yellow fever q 10 years |
| 90733 or 90734 |
| Update as required |
| Meningococcal vaccine – per manufacturers recommended frequency |
| 4120F |
| Screening dose |
| Mefloquine trial, one dose & record reaction |
| 90581 |
| As available |
| Anthrax, FBI supplied |
| 90675 |
| Update as required |
| Rabies |
| 90749 |
| As available |
| Small Pox |
| 99401,02,03,04 |
| As requested |
| Travel Medicine Consultation |
