APPENDIX “A”

Arkansas Division of Academic Facilities & Transportation SCHOOL BUS DRIVER PHYSICAL EXAMINATION FORM

NAME OF DRIVER _______

ADDRESS_______

PHYSICAL FITNESS:

1. EYES:

VISUAL ACUITY___ RIGHT LEFT __

GLASSES PROPERLY FITTED: YES _ NO ___

FIELD OF VISION: (Minimum of 70%) YES _ NO ___

COLOR BLIND (RED-GREEN-AMBER) PASS _ FAIL ___

2. HEARING: PASS _ FAIL ___

(Must perceive forced whispered voice ≥ 5ft. with or without hearing aid, or average hearing loss in better ear ≤ 40db.)

3. INDICATIONS OF CARDIOVASCULAR DISEASE THAT WOULD INTERFERE WITH DRIVING A SCHOOL BUS: YES _ NO ___

4. ABNORMALITIES OF THE LUNGS THAT WOULD INTERFERE WITH DRIVING A SCHOOL BUS: YES _ NO ___

5. BLOOD PRESSURE: (WITHIN NORMAL LIMITS) YES _ NO ___

6. AMPUTATION OF MEMBER: ARM_ HAND LEG__ FOOT_____

7. EVIDENCE OF EPILEPSY OR SEIZURES: YES _ NO ___

8. CLINICAL DIAGNOSIS OF ALCOHOLISM: YES _ NO ___

9. USE OF DRUGS OTHER THAN THOSE PRESCRIBED BY A PHYSICIAN: YES _ NO ___

10. DIABETES (INSULIN DEPENDENT): YES _ NO ___

11. ELIGIBILITY TO DRIVE A BUS: QUALIFIED _____

DISQUALIFIED _____

PHYSICIAN OR APRN

DATE

*

The following is intended to provide guidelines that will assist the physician in determining whether the driver is physically qualified to drive a school bus.

1. Eyes – Visual Acuity – must be at least 20/40 with or without corrective lenses. Glasses – must be properly fitted. Field of Vision – if answer is no, then not qualified to drive a school bus. Color Blind – if answer is fail, then not qualified to drive a school bus.

2. Hearing – if answer is “fail,” then not qualified to drive a school bus.

3. Cardiovascular Disease – if answer is yes, then not qualified to drive a school bus.

4. Lung Abnormalities – if answer is yes, then not qualified to drive a school bus.

5. Blood Pressure – must be within normal limits.

6. Amputation – if answer is yes to any, the examining official may approve the examinee if the amputation does not affect their ability to drive a school bus.

7. Epilepsy/Seizures – if answer is yes, then not qualified to drive a school bus.

8. Alcoholism – if answer is yes, then not qualified to drive a school bus.

9. Drug Use – if answer is yes, then not qualified to drive a school bus.

10. Diabetes – if insulin dependent, then not qualified to drive a school bus.

(Exception: If physician has controlled diabetes for a minimum of six (6) months with the use of insulin, the driver may be approved to drive).