CERTIFICATE OF MEDICAL EXAMINATION FOR INSULIN-TREATED DIABETES MELLITUS and manage the applicant’s diabetes, understands what procedures should be …
DEPARTMENT OF EDUCATION
PO Box 83720
BOISE, IDAHO 83720-0027
Pupil Transportation Section
CERTIFICATE OF MEDICAL EXAMINATION FOR INSULIN-TREATED DIABETES MELLITUS
Physician: The applicant identified below is subject to the provisions of
33-1509 of Idaho Code and Administrative Rules of the Idaho State Board
of Education IDAPA 080202150-190 The applicant has applied for an
exemption from Idaho physical requirements ITDM specific to driving a
school bus in the State of Idaho Granting of such an exemption is
contingent upon the applicant submitting annual and quarterly medical
statements to the State Department of Education Your cooperation in this
matter is appreciated
Name of Applicant: _________________________________________________ DOB:
___________________
Address of Applicant:
_________________________________________________________________________
Street City State
ZIP
REPORT OF EXAMINATION AND MEDICAL HISTORY BY ENDOCRINOLOGIST
TODAYS DATE:
| |Description of Query and
Certification |YES |NO |
|1 |I am familiar with the applicants medical history for the past | | |
| |five 5 years through actual treatment or through consultation | | |
| |with a physician who has treated the applicant | | |
|2 |I have conducted a complete and thorough medical examination | | |
| |including a comprehensive evaluation of the applicants medical | | |
| |history and current status OR I am aware of, and have access to, a| | |
| |report of the applicants medical examination and comprehensive | | |
| |evaluation through consultation with the physician who conducted | | |
| |the medical examination and evaluation | | |
|3 |The medical examination, evaluation and subsequent report include:| | |
| |a the date insulin use began; b diabetes diagnosis and disease | | |
| |history; c hospitalization records; d consultation notes for | | |
| |diagnostic examinations; e special studies pertaining to the | | |
| |diabetes; f all follow-up reports; g reports of any hypoglycemic| |
|
| |insulin reactions within the last five years; h two 2 measures | | |
| |of glycosylated hemoglobin, the first ninety days before the last | | |
| |and current measure; i insulin dosage and types, diet utilized | | |
| |for control and any significant factors such as smoking, alcohol | | |
| |use, and other medications or drugs taken; and j examinations to | | |
| |detect any peripheral neuropathy or circulatory insufficiency of | | |
| |the extremities | | |
| |Query and Certification Continues On Next Page | | |
| |Description of Query and Certification |YES |NO |
|4 |The applicant has been educated in diabetes and its management, | | |
| |has been thoroughly informed of and understands the procedures | | |
| |which must be followed to monitor and manage the applicants | | |
| |diabetes, understands what procedures should be followed if | | |
| |complications arise and has the ability to recognize the early | | |
| |symptoms of hypoglycemia such as
sweating, anxiety, forceful | | |
| |heartbeat and lightheadedness | | |
|5 |The applicant has the ability and has demonstrated a willingness | | |
| |to properly monitor and manage the applicants diabetes | | |
|6 |The applicant understands the importance of maintaining and | | |
| |maintains appropriate medical supplies for glucose management | | |
| |while preparing for the operation of a commercial motor vehicle | | |
| |and during its operation including: a an acceptable glucose | | |
| |monitor with memory; b supplies needed to obtain adequate blood | | |
| |samples and to measure blood glucose; c Insulin to be used as | | |
| |necessary; and d an amount of rapidly absorbable glucose to be | | |
| |used as necessary | | |
|7 |The applicant has been educated in the procedures which must be | | |
| |followed to monitor and manage the applicants blood glucose levels| | |
| |and agrees prior to driving and while driving to: a check glucose| | |
|
|before starting to drive and take corrective action if necessary -| | |
| |if glucose is less than 100 milligrams per deciliter mg/dl, take| | |
| |glucose or food and recheck in 30 minutes - do not drive if | | |
| |glucose is less than 100 mg/dl - and repeat the process until | | |
| |glucose is greater than 100 mg/dl; b while driving check glucose | | |
| |every two to four hours and take appropriate action to maintain it| | |
| |in the range of 100 to 400 mg/dl; c have food available at all | | |
| |times when driving - if glucose is less than 100 mg/dl, stop | | |
| |driving and eat - recheck in 30 minutes and repeat procedure until| | |
| |glucose is greater than 100 mg/dl; and d if glucose is greater | | |
| |than 400 mg/dl, stop driving until glucose returns to the 100 to | | |
| |400 mg/dl range - if more than two hours after last insulin | | |
| |injection and eating, take additional insulin - recheck blood | | |
| |glucose in 30 minutes - do not resume driving until glucose is | | |
| |less than 400 mg/dl
| | |
|8 |I am aware of the make and model of the glucose monitoring device | | |
| |with memory that is currently used by the applicant | | |
|9 |I am aware of the applicants blood glucose measurements and the | | |
| |applicants glycosylated hemoglobin are generally in an adequate | | |
| |range based on daily glucose measurements taken with the glucose | | |
| |monitoring device and correlated with the daily records of driving| | |
| |time and a current measurement of glycosylated hemoglobin | | |
|10 |The applicant has provided me with a copy of the applicants | | |
| |Application for Exemption and/or Application for Exemption Renewal| | |
| |and I concur with the applicants declarations regarding the | | |
| |applicants ITDM status as documented in the Application for | | |
| |Exemption and/or Application for Exemption Renewal and the date of| | |
| |the Application for Exemption and/or Application for Exemption | | |
| |Renewal reasonably corresponds to the date of this medical | | |
|
|certification | | |
|11 |It is my professional opinion that the applicant has not had a | | |
| |recent history of a hypoglycemic reaction that resulted in any | | |
| |change in mental status that would have been detrimental to safe | | |
| |driving | | |
|12 |It is my professional opinion that the applicants diabetic | | |
| |condition will not adversely affect the applicants ability to | | |
| |operate a school bus | | |
| |Signature and Certification On Next Page | | |
Physician: Please provide additional comments related to your examination
of the applicant, any recommended driving restrictions, recommended Insulin-
Treated Diabetes Mellitus blood-sugar monitoring sequence,
etc
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CERTIFICATION OF ENDOCRINOLOGIST
I, print full name _____________________________________________, being a
board-certified or board-eligible endocrinologist, certify that I have
personally examined the individual named above on this date, or have
consulted with the aforementioned individuals personal physician this
date, and that this is a true and complete report of medical examination
and comprehensive evaluation or that this is a true and complete report
based on a thorough and comprehensive
physician to physician consultation
as documented in my professional records and according to the declarations
herein made
____________________________________________________________
___________________________
Signature of Endocrinologist
Date
______________________
_________________________________________________________________
Phone Street Address City
State Zip
PLEASE RETURN THE ABOVE COMPLETED MEDICAL REPORT CERTIFICATION TO:
Supervisor of Transportation Services
Idaho State Department of Education
Pupil Transportation Section
PO Box 83720
Boise, Idaho 83720-0027
———————–
DR MARILYN HOWARD
STATE SUPERINTENDENT
PUBLIC INSTRUCTION
Source:ashfordstpeters.nhs.uk
