Fillable Printable School Bus Driver Health Certificate: SDE Annual Physical Form - Oklahoma

School Bus Driver Health Certificate: SDE Annual Physical Form - Oklahoma

This form may be duplicated. Revised 8/09

Oklahoma State Department of Education (SDE) - 2500 North LincolnBoulevard - Oklahoma City,Oklahoma73105-4599

Student Transportation Section (405) 521-3472

Oklahoma School Bus Driver Health Certificate: SDE Annual Physical Form

The Oklahoma State Boardof Education requires each school bus driver to pass a physical examination. Oklahoma regulation

requires (1) anannual physical using this form; or(2) a physical every two years using a Department of Transportation (DOT) form.

Schools must keep completed health certificate forms on file for one year at the district for theirRegional Accreditation Officer.

*A person taking insulin by injection does not meet Oklahoma SDE qualifications to drive a school bus.

**A school bus driver’s vision must be 20/40 or better; corrective lenses are acceptable.

County Name ______________________Employing School District _______________________________

School Bus DriverName (PRINT)_______________________________________ Birth Date___________

1. Is this applicant Diabetic? No/ Yes: Controlled by diet and/or oral medication only? Yes

*Is this applicant dependent on insulin by injection?No / Yes

2. **Vision (Snellen Test): Left Eye 20/_____ Right Eye 20/ _____ Using Both Eyes 20/ _____

Are Corrective Lenses required to drive? No/ Yes Comments:________________________

3. Hearing Test Results: Acceptable / Not Acceptable Hearing Aid(s) Required Yes / No

Comments________________________________________________________________________

4. Deformities or missing limb?No/ YesSpecify: ______________________________________

5. Seizures (past/present) No/ YesSpecify: ___________________________________________

6. Paralysis (past/present) No/ YesSpecify: ___________________________________________

7. Tuberculosis (past/present) No

/ YesSpecify:________________________________________

8. Alcohol addiction (past/present) No/ YesSpecify:____________________________________

9. Drug addiction (past/present) No/ YesSpecify:______________________________________

10. Heart disorder/disease (past/present) No/ YesSpecify:________________________________

11. Normal Loco-motor: No/ YesSpecify Limits:______________________________________

12. Arthritis: No/ YesSpecify:______________________________________________________

13. Blood Pressure: _____ / _____ BP within normal limits? Yes/ NoControlled by Rx?________

14. Emotional disorders (past/present): No/ YesSpecify:_________________________________

15. List all prescription medications:

_____________________________________________________________________________________

“I certify that the above information I provided is correct and true to the best of my knowledge.”

Signature of Bus Driver Applicant:________________________________________ Date _________________

Oklahoma Licensed Physician (PRINT Name) M.D. / D.O. / D.C.

AddressCity Zip Phone

“Based on the history provided byapplicant, and my medical examination on this date, the above applicant

IS /IS NOT physically and emotionally competent to drive a school bus to haul students.”

Signature of Physician:Date: Year: