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FD-965 (12/31/2010)
FBI Hazardous Device School Exam
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 |
| 81001 |
| Required |
| Urinalysis |
| 85025 |
| Required |
| Complete Blood Count w differential |
| 92551 |
| Required |
| Audiometry |
| 93000 |
| Req unless PE < 1 yr |
| EKG |
| 94010 |
| Req unless PE < 1 yr |
| Pulmonary Function test |
| FD-899 |
| Required |
| Completion of Respiratory Clearance |
| FD-900 |
| Required |
| Review of Respiratory Questionnaire |
| 99172 |
| Required |
| Distant & near visual acuity with and without corrections |
| 99172 |
| Required |
| Visual fields, strabismus |
| 99172 |
| Required |
| Color vision |
| 99385, 86, 87 |
| Required |
| History, PE, vitals (ht, wt, B/P, pulse, temp), written summary of findings |
| 71020 |
| Needs FBIHQ approval |
| Chest x-ray, P/A & lateral |
| 82270 |
| Offer |
| Stool for occult blood X 3 |
| 45999 |
| Offer |
| Digital rectal exam Males >40 years |
| Review required |
| Review Basic Immunization Series |
| 90658 |
| Update as needed |
| Influenza, annually |
90700
| Update as needed |
| Tdap: tetanus/diphtheria/pertussis every 10 years OR |
| 90718 |
| Update as needed |
| Tetanus/diphtheria every 10 years |
