APPENDIX A - School Bus Driver Permit Medical Examiner's Certificate

APPENDIX A. School Bus Driver Permit Medical Examiner's Certificate

Part A

Medical Examiner's Preliminary Certification

NOTE: The medical examiner shall provide one completed and signed certificate to the applicant. A copy of the completed and signed certificate is to be forwarded by the medical examiner to the employing agency or organization of the applicant. One copy is to be retained by the medical examiner.

I certify that I have completed Part A of the school bus examination of ________________________________________ on ______________ in accordance with the provisions of 92 Ill. Adm. Code 1035.20 and, based upon that examination, find he/she is:

Qualified under the regulations

Qualified only when wearing corrective lenses

Qualified only when wearing a hearing aid

Not qualified under the regulations

_______________ __________________

Name of Medical Examiner Professional License Number of Medical Examiner

NOTE: COMPLETION OF PART A ONLY DOES NOT QUALIFY THE APPLICANT. TEST RESULTS MUST BE CERTIFIED IN PART B BEFORE THE APPLICANT CAN BE CONSIDERED QUALIFIED.

Part B

Final Medical Examiner's Certification

Date of TB Results:______________

Date of Drug Test Results:___________________

I certify that I have completed my examination, including my readings of the drug and TB test results, for ____________________________ on __________ in accordance with the provisions of 92 Ill. Adm. Code 1035.20. Based upon the results of drug and TB testing required by 92 Ill. Adm. Code 1035.20(j)(11) and (j)(13) and having no positive test results for infectious disease, or having determined that he/she is not contagious when performing the normal duties of a school bus driver, I find that he/she is:

Qualified under the regulations

Not qualified due to positive drug test

Not qualified due to positive tuberculosis test

_______________ __________________

Name of Medical Examiner Professional License Number of Medical Examiner

_______________ __________________

Phone Number of Medical Examiner Signature of Medical Examiner

_______________ __________________

Fax Number of Medical Examiner Date of Certification (Date the medical examiner has received all test results)

(Added at 40 Ill. Reg. 9646, effective July 1, 2016)

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