Ill. Admin. Code tit. 92, pt. 1035, app A
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)
Ill. Admin. Code tit. 92, pt. 1035, app A