Date of initial diagnosis of diabetes mellitus: List all medications including those taken related to the treatment of diabetes: …
| | OFFICE OF SUPERINTENDENT OF PUBLIC INSTRUCTION |
| |PUPIL TRANSPORTATION |
| |Old Capitol Building |
| |PO BOX 47200 |
| |Olympia WA 98504-7200 |
| | |
| | |
| |WASHINGTON STATE AUTHORIZED SCHOOL BUS DRIVER |
| |DIABETES EXEMPTION PROGRAM |
1 Driver Information
Last Name: First Name: MI:
Address:
City: State: ZIP code:
Telephone number: -
Employee or identification number if required by Employer:
2 School District or Employers Name:
3 Driver License and Motor Vehicle Record
Please attach a readable copy of your current, valid Washington State
Drivers
License indicating an Intrastate Medical Waiver for Diabetes or a
valid interstate exemption certificate for diabetes issued by the Federal
Motor Carrier Safety Administration FMCSA
4 Acknowledgement of Responsibility
I acknowledge that I have read and understand the requirements for an
insulin treated diabetic to maintain a Washington State school bus driver
authorization as contained in WAC 392-144-0209 In particular, I must
1 Possess a valid commercial driver license intrastate medical waiver
for diabetes from the Washington State Department of Licensing DOL
or a valid interstate exemption certificate for diabetes issued by the
FMCSA I understand that I must continue to maintain either the DOL
waiver or the FMCSA exemption certificate
2 Submit to the authorizing school districts or employer a copy of
this form completed within the required timelines for the respective
sections
3 Continue to self-monitor blood glucose and demonstrate conformance
with requirements more than 100mg/dl and less than 300 mg/dl within
one hour before duty transporting students and approximately every
four hours while on duty, using an
FDA approved device
4 Maintain a daily log of all blood glucose test results for the
previous six-month period and provide copies to the authorizing school
districts or employer, the examining licensed physician, and the
Office of Superintendent of Public Instruction upon request
Drivers Last Name: Drivers First Name:
5 Carry a source of readily absorbable/fast-acting glucose while on
duty
6 Submit to the authorizing school districts or employer, every six
months, the results of the HbA1c test indicating values more than 59
and less than 96 unless the medical examiner or licensed physician
indicates the event was incidental and not an indication of failure to
control glucose levels, using the appropriate section of this form
7 Submit to the authorizing school districts or employer, the results
of an annual examination unless required more often by an
ophthalmologist or optometrist to detect any peripheral neuropathy,
unstable diabetic retinopathy or clinically significant eye disease
that prevents me from meeting medical certificate vision standards, or
circulatory
insufficiency using the appropriate section of this
form
8 Provide a signed statement by my examining licensed physician
indicating that within the past three years I have completed
instructions to address diabetes management and driving safety, signs
and symptoms of hypoglycemia and hyperglycemia, and what procedures
must be followed if complications arise
9 Report immediately to my employer, any failure to meet the specific
glucose level requirements as listed in 3 and 6 of this
application, or any loss of consciousness or control
I understand that if I have a loss of consciousness or loss of control
cognitive function due to a diabetic event, I do not qualify for a school
bus driver authorization for one year, provided I have not had a recurrent
hypoglycemic reaction requiring the assistance of another person within the
previous five years Specifically, I understand that I must remove myself
from driving duties for any of the following:
1 Results of an HbA1c test indicating values less than 60 or greater
than 95 unless accompanied by the required medical opinion that the
event was incidental and not an indication
of failure to control
glucose levels
2 Results of self-monitoring indicate glucose levels less than 100 mg/dl
or greater than 300 mg/dl, until self-monitoring indicates compliance
with specifications
3 Experiencing a loss of consciousness or control relating to diabetic
condition
4 Failing to maintain the required records
I understand that falsification of records may result in permanent
revocation of my school bus driver authorization
I acknowledge and agree that it is my responsibility to comply with all the
self-monitoring, medical testing, and reporting requirements I accept
this responsibility in order to ensure the safety of the students I will be
transporting
Signature: Date:
Washington State Authorized School Bus Driver
Diabetes Exemption Program
Licensed Physician Evaluation Section
Driver Information
Last Name: First Name: MI:
Address:
City: State: ZIP code:
DOB MM/DD/YYYY: _______ / _______ / ________
This individual is applying for a Washington State school bus driver
diabetes exemption to be able to take insulin
while operating a school bus
in Washington State Part of the application process is an evaluation by a
licensed physician to determine if the individual has any medical problems
related to diabetes that might impair safe driving
PLEASE CHECK/FILL IN REQUESTED INFORMATION
1 I am a licensed physician
If not, do not continue your assessment Applicants must be evaluated by a
licensed physician
2 Office telephone number: ______ _____ - _________
3 Office fax number: ______ _____ - _________
4 Date of examination MM/DD/YYYY: _______ / _______ / ________
5 I am familiar with the patients medical history for the past five years
through a records review, treating the patient, or consultation with the
treating physician
check one YES NO
A review of the applicants five-year medical history is required If the
history is not available, please state the reason
Drivers Last Name: Drivers First Name:
6 Date of initial diagnosis of diabetes mellitus:
Treatment for diabetes mellitus prior to insulin use:
None Diet Oral agent
7 Insulin Usage:
Date insulin use began:
Type of insulins and current dosage now used:
If
patient uses insulin pump, current average daily dose:
Length of time on current dose:
8 Please use the Federal Motor Carrier Safety Administrations FMCSA
definition of a severe hypoglycemic reaction, as one that results in:
Seizure, or
Loss of consciousness, or
Requiring assistance of another person, or
Period of impaired cognitive function that occurred without warning
In the last five years, while being treated for diabetes, has the patient
had recurrent two or more severe hypoglycemic episodes? YES
NO
In the last 12 months, while being treated for diabetes, has the patient
had a severe hypoglycemic episode? YES
NO If no, proceed to 9 below
If yes, provide information on each hypoglycemic episode:
Dates:
Include additional information about each episode including symptoms of
hypoglycemic reaction, treatment, and suspected cause:
Was the patient hospitalized? YES NO
If yes, provide brief summary of hospitalization:
Has the patients treatment regimen changed since the last hypoglycemic
episode?
YES NO
Briefly explain changes:
Drivers Last Name: Drivers First Name:
9
Additional Information or History If none, write none:
10 List all medications including those taken related to the treatment of
diabetes:
Name of Medication Dose Reason for Taking the
Medication
11 In your medical opinion, does any one of the listed medications have
the potential to compromise the drivers ability to operate a school
bus safely? YES NO
If yes, which medications:
12 Associated Medical Conditions please check yes or no:
Renal Disease Renal insufficiency YES NO
Proteinuria YES
NO
Nephrotic Syndrome YES NO
Cardiovascular Coronary artery disease YES NO
Disease Hypertension YES NO
Transient ischemic attack YES
NO
Stroke YES
NO
Peripheral vascular disease YES NO
Neurological Disease Autonomic neuropathy YES NO
ie, cardiovascular GI, GU
Peripheral Neuropathy YES NO
Circle below
Sensory
Decreased sensation
Loss of vibratory sense
Loss of position sense
If the applicant has been or is currently being treated for any of the
above medical conditions, provide relevant additional information
consultation notes, special studies, follow-up reports, and hospital
records
Drivers Last Name: Drivers First Name:
13 Laboratory Reports/Stable Insulin Regimen:
A Background and criteria:
The individual should have stable control and no risk of hypoglycemia
and hyperglycemia while operating a school bus
30 day requirement: An individual diagnosed with diabetes mellitus who
had been previously treated with oral medication, and who now requires
insulin, should have at least a one-month period on insulin to
establish stable control
60 day requirement: An individual newly diagnosed with diabetes
mellitus, who is now starting insulin, should have at least a
two-month
period on insulin to establish stable control
Does this individual meet the appropriate waiting period required after
initial insulin treatment?
YES NO
If no, when will driver complete the waiting period? Date:
B Glycosylated hemoglobin A1c A1c test and blood glucose:
Review of A1c test and blood glucose testing provides evidence of the
drivers ability to manage his/her diabetes mellitus and drive safely
Newly diagnosed and treated drivers are required to provide an A1c test
within 30 days of the initial date of application and after the 60 day
requirement in 13 A is met Drivers with a long-term history must
provide an A1c test every six months
Please provide a copy of the following: Laboratory reports reflecting
A1c test results, to include lab reference normal range
Do the results of the HbA1c indicate values less than 60 or greater
than 95?
YES NO
If yes, in your medical opinion, was the event incidental and not an
indication of failure to control glucose levels?
YES NO
14 Glucose Measurements a driver should not have large fluctuations in
blood glucose levels:
A I have reviewed the patients daily glucose monitoring logs while
using insulin
YES NO
B Does the patient have any large fluctuations that may impact safe
driving?
YES NO
Drivers Last Name: Drivers First Name:
Note: The applicant must participate in a diabetes education program at
least every three years to apply for and remain in the diabetes exemption
program
15 Since beginning insulin use, has the patient received education in
the management of diabetes that includes diet, monitoring, recognition
and treatment of hypoglycemia and hyperglycemia? YES NO
If yes, please provide last education date MM/YYYY: ______/_________
16 I hereby certify that in my medical opinion, the applicant understands
how to individually manage and monitor his/her diabetes mellitus
YES NO
17 I hereby certify that in my medical opinion, the applicant has
demonstrated the ability and
willingness to properly monitor and manage
his/her diabetes mellitus YES NO
18 I hereby certify that in my medical opinion, the applicants medical
condition allows them to safely operate a school bus, while using
insulin for the control of diabetes mellitus YES
NO
19 The following restrictions/conditions apply:
20 Licensed Physicians Identification:
please print
Last name: First Name:
Signature: Date:
Medical license number: State of issue:
Washington State Authorized School Bus Driver
Diabetes Exemption Program
Vision Evaluation Section
Driver Information
Last Name: First Name: MI:
Address:
City: State: ZIP code:
DOB MM/DD/YYYY: _______ / _______ / ________
This individual is applying for an original or continuing to maintain a
Washington State school bus driver diabetes exemption to be able to take
insulin while operating a school bus in Washington State Part of the
application process is an eye examination required on an annual basis by
an ophthalmologist
or optometrist to determine if the individual has any
vision problem that might impair safe driving Note: If the applicant has
retinopathy, an ophthalmologist examination is required
PLEASE CHECK/FILL IN REQUESTED INFORMATION
1 I am an ophthalmologist I am an optometrist
2 Date of most recent examination: _________________________________
3 Distant visual acuity please provide both if applicable:
UNCORRECTED CORRECTED
Glasses
Contact Lens
Right eye: 20/_____ 20/_____
Left eye: 20/_____ 20/_____
4 Field of vision FOV:
Right eye: ___________degrees a quantitative evaluation is required
Left eye: ___________degrees a quantitative evaluation is required
Test used to determine: _________________________________________
Note: If the patient has received laser treatment, and in your medical
opinion you believe the patients FOV is compromised, Federal Motor Carrier
Safety Administration FMCSA recommends formal perimetry to determine if
the driver meets the FOV standard
5 Color Vision:
Is the patient able to identify
correctly the standard red, green, and
amber traffic control signal colors? YES NO
Drivers Last Name: Drivers First Name:
Note: If color testing results are inconclusive, it is discretionary
whether to administer a controlled test using an actual traffic signal to
determine the individuals ability to recognize red, green, and amber
An applicant with diabetic retinopathy must be evaluated by an
ophthalmologist The vision examination must occur AFTER any eye
surgery/procedures postoperatively
6 Does the patient have diabetic retinopathy? YES NO
If yes: Proliferative
Stable Unstable
Nonproliferative
Stable Unstable
Treatment:
Date diagnosed:
Surgery/procedures:
Requires recheck in ____ months
7 Does the patient have macular edema? YES NO
8 Does the patient have cataracts? YES NO
9 Does the patient have any other medical diagnosis related to vision?
YES NO
If yes, what?
10 If yes
to any of the conditions listed above, are any unstable?
YES NO
If yes, which conditions?
11 In your medical opinion, is monitoring required more often than
annually?
YES NO
If yes, how often?
12 In your medical opinion, does the patient possess any vision problem
that might impair safe driving?
YES NO
If yes, please explain
13 I hereby certify that in my medical opinion, the applicants medical
condition allows them to safely operate a school bus, while using
insulin for the control of diabetes mellitus
YES NO
Drivers Last Name: Drivers First Name:
14 Ophthalmologist or Optometrist Identification:
please print
Last name: First Name:
Signature: Date:
Medical license number: State of issue:
Washington State Authorized School Bus Driver
Diabetes Exemption Program
HbA1c Report Section
Driver Information
Last Name:
First Name: MI:
Address:
City: State: ZIP code:
DOB MM/DD/YYYY: _______ / _______ / ________
This individual is fulfilling requirements to maintain a Washington State
school bus driver diabetes exemption to be able to take insulin while
operating a school bus in Washington State Washington Administrative Code
WAC 392-144-0209dvi requires the driver to provide to the
authorizing school districts or employer, medical examiner or physician
signed results of a Glycosylated hemoglobin A1c A1c test
Review of A1c test and blood glucose testing provides evidence of the
drivers ability to manage his/her diabetes mellitus and drive safely
Please provide a copy of the following: Laboratory reports reflecting
A1c test results, to include lab reference normal range
Do the results of the HbA1c indicate values less than 60 or greater
than 95?
YES NO
If YES: In your medical opinion, was the event incidental and not an
indication of failure to control glucose levels?
YES NO
Date of HbA1c
Medical Examiners or
Physicians Signature:
Medical license number: State of issue:
Source:acacamps.org
