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FD-944 (Rev. 12/31/2010) FBI Hazardous Material Response Team – Initial or Pre-Employment
TO:
FROM: FBI Field Office
Examinee: ____________________________________ DOB: _________________________ 67 Number:
Job Position: _________________________
Appointment Date: __________________ Time: ________________ 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 |
| 82480 |
| Required |
| Plasma cholinesterase ( 2 separate draws) – draw 1 |
| 82480 |
| Required |
| Plasma cholinesterase - draw 2 at least 24 hours after draw 1 |
| 82482 |
| Required |
| RBC cholinesterase (2 separate draws) – draw 1 |
| 82482 |
| Required |
| RBC cholinesterase-draw 2 at least 24 hours after draw 1 |
| 83655 |
| Required |
| Blood lead |
| 84202 |
| Required |
| Zinc Protoporphyrin (ZPP) |
| 85025 |
| Required |
| Complete blood count with differential |
| 86900, 86901 |
| Required |
| Blood group & type |
| CPT Codes |
| Required |
| Core Components (Screening Tests) |
| 71020 |
| Required |
| Chest x-ray P/A& lateral |
| 86580 |
| Required |
| Mantoux TB test, unless prior hx of conversion |
| 92551 |
| Required |
| Audiometry |
| 93000 |
| Required |
| Resting EKG 12 leads with interpretation |
| 94010 |
| Required |
| Pulmonary function test |
| 99172 |
| Required |
| Distant & near visual acuity with and without correction |
| 99172 |
| Required |
| Visual fields, strabismus |
| 99172 |
| Required |
| Color vision |
| 99420 |
| Required |
| Written summary of findings |
| 99385, 86, 87 |
| Required |
| History, PE, vitals (ht, wt, B/P, pulse, temp) |
| FD-899, FD-900 |
| Required |
| Completion of FD-899, FD-900 |
| CPT Codes |
| If Indicated |
| Supplemental Components |
| 84153 |
| Required |
| Prostate specific antigen Males over 40 years |
| 45999 |
| Offer |
| Digital rectal exam Males over 40 years |
| 88141 |
| Offer |
| If pap > 12 months offer complete GYN exam Females |
| 77057 |
| Offer |
| Mammography, offer if > 40 years, in conjunction with GYN Breast Exam performed within 1 year, on record - Females |
| 82270 |
| Offer |
| Stool for Occult Blood X 3 |
| 93015 |
| Required-age specific |
| Exercise stress test Bruce protocol – (ages 40, 44, 48, 50, 52, 54 & 56) |
| 92120 |
| Offer |
| Tonometry – over 40 years |
| 93350 |
| Requires Approval |
| Stress Echo-preferred test-following abnormal screening |
| 78465 |
| Requires Approval |
| Thallium stress test-follows abnormal screening |
| CPT Codes |
| Per Instructions |
| Vaccinations – Physician should review and UPDATE AS NEEDED |
| 90632 |
| Update as needed |
| Hepatitis A vaccine, basic series |
| 90746 |
| Update as needed |
| Hepatitis B vaccine – basic series |
| 90636 |
| Update as needed |
| Twinrix |
| 90690 or 90691 |
| Update as needed |
| Typhoid (injection Q 2 yrs or oral Q 5) - basic |
| 90707 |
| Update as needed |
| MMR (once as adult) |
| 90713 |
| Update as needed |
| Inactive polio (IPV) one does as adult |
| 90658 |
| Update as needed |
| Influenza, annually |
| 90718 |
| Update as needed |
| Tetanus/diphtheria q 10 years OR |
| 90715 |
| Update as needed |
| Tdap- tetanus/diphtheria/pertussis q 10 yrs. |
| 90717 |
| Update as needed |
| Yellow fever q 10 years |
| 90733 or 90734 |
| Update as needed |
| Meningococcal vaccine – per manufacturers recommended frequency |
| 4120F |
| Screening dose |
| Mefloquine trial, one dose & record reaction |
| 90581 |
| As available |
| Anthrax, FBI supplied |
| 90675 |
| Approval required |
| Rabies |
| 90749 |
| As available |
| Smallpox |
| 99401,02,03,04 |
| As requested |
| Travel Medicine Consultation |
