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)

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