Section 1035.APPENDIX A School Bus Driver Permit Medical Examiner's Certificate

Section 1035.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)