SURNAME _______________________________ GIVEN NAMES ______________________________

 

PATIENT'S RELEASE: I hereby authorize release of this information to The Portage la Prairie School Division.

 

Signature ________________________________________________ Date ________________________

 

TO THE EXAMINING PHYSICIAN: This medical report is required by the School Division for the purpose noted. It is expected your examination will include the Medical Examination Requirements for all new employees plus the Class Two Licence Requirements for all Bus Drivers as listed on the reverse.

 

As a prerequisite to a job offer so as to assure the Division that this candidate is physically and medically capable of performing the responsibilities and duties associated with employment as __________________

This medical is at the request of your patient and is therefore at his/her expense.

 

As an annual requirement associated with maintaining a School Bus Driver's Certificate and Class 2 Driver's Licence. The medical standards for a class 2 licence are shown on the reverse. This medical is at the request of the School Division. Please bill the School Division directly.

 

PHYSICIAN'S STATEMENT: I hereby certify that the above named patient has been examined by me for the purpose stated. This patient is free from contagious disease and is is not physically and medically capable of performing the responsibilities and duties as a: School Bus Driver (class 2 licence) __________

other employment as noted above __________

Are there any restrictions or limitations on the duties this candidate can be expected to carry out?

yes no

If yes, explain: __________________________________________________________________________

 

Physician's Signature _______________________________________ Date ___________________

 

PLEASE PRINT: Physician's Name _________________________________________________________

 

Address _________________________________________________ Telephone_____________________

 

City _____________________________________________________ Postal Code____________________

 

THIS REPORT IS TO BE COMPLETED AND FORWARDED TO:

THE PERSONNEL DEPARTMENT

PORTAGE LA PRAIRIE SCHOOL DIVISION

535 - 3rd STREET N.W.

PORTAGE LA PRAIRIE, MANITOBA

R1N 2C4 TELEPHONE 857-8756

 

FOR DIVISION OFFICE USE: Accept ________ Reject ________ Second Opinion Req'd ___________

 

Signature _______________________________________________ Date __________________________

 

PG-04-99/03

 

 

MEDICAL STANDARDS - CLASS 2 LICENCES

 

VISION

- Best eye 20/30 or better, worst eye not less than 20/50 aided or unaided.

 

COLOUR RECOGNITION

- Must be able to accurately identify the colours red and green.

 

FIELD OF VISION

- Not less than 120 degrees in each eye.

 

DIPLOPIA

- Not acceptable.

 

MEDICAL STANDARDS

 

To the examining physician, please refer to your Medical Standards for Driving Manual for clarification or telephone the exclusive physician only line @ 204-945-5340.

 

PHYSICAL EXAMINATION REQUIREMENTS

 

1. Colour perception (Red, Yellow, Green) 9. Vascular system

2. Visual acuity 10. Blood pressure - Systolic, Diastolic

3. Hearing (conversational voice) 11. Respiratory system

4. Central Nervous System 12. Abdominal viscera

5. Coordination and muscle control 13. Hematopoietic system

6. Spine 14. Urine

7. Neck and extremities 15. Alcoholism, drug addiction

8. Heart 16. Psychiatric or mental disorders