U.S. Department of Transportation Federal Aviation Administration

OPHTHALMOLOGICAL EVALUATION FOR GLAUCOMA
Privacy Act Statement
For Privacy Act Information go to next page.
Do not submit this cover sheet with the form

FAA Form 8500-14 (9-97) Supersedes Previous Edition NSN: 0052-00-694-4003

Page 1

OPHTHALMOLOGICAL EVALUATION FOR GLAUCOMA

PRIVACY ACT STATEMENT: This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a: The authority for collecting this information is contained in 49 U.S.C. §§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6
7. The principal purpose for which the information is intended to be used is to identify and evaluate your qualifications and eligibility for the issuance of an airman certificate and/or rating. Submission of the data is mandatory, except for the Social Security Number, which is voluntary. Failure to provide all required information will result in our being unable to issue you a certificate and/or rating. The information collected on this form will be included in a Privacy Act System of Records known as DOT/FAA 847, titled “Aviation Records on Individuals” and will be subject to the rou- tine uses published in the System of Records Notice (SORN) for DOT/FAA 847 (see www.dot.gov/privacy/privacyactnotices), including:
(a) Providing basic airmen certification and qualification information to the public upon request; examples of basic information include:
• The type of certificates and ratings held, limitations, date of issuance and certificate number;
• The status of the airman’s certificate (i.e., whether it is current or has been amended, modified, suspended or revoked for any reason);
• The airman’s home address, unless requested by the airman to be withheld from public disclosure per 49 U.S.C. 44703(c);
• Information relating to an airman’s physical status or condition used to determine statistically the validity of FAA medical standards; and the date, class, and restrictions of the latest physical
• Information relating to an individual’s eligibility for medical certification, requests for special issuance, and requests for review of certificate denials.
(b) Using contact information to inform airmen of meetings and seminars conducted by the FAA regarding aviation safety.
(c) Disclosing information to the National Transportation Safety Board (NTSB) in connection with its investigation responsibilities.
(d) Providing information about airmen to Federal, State, local and tribal law enforcement agencies when engaged in an official investigation in which an airman is involved.
(e) Providing information about enforcement actions, or orders issued thereunder, to Federal agencies, the aviation industry, and the public upon request.
(f) Making records of delinquent civil penalties owed to the FAA available to the U.S. Department of the Treasury and the U.S. Department of Justice (DOJ) for collection pursuant to 31 U.S.C. 3711(g).
(g) Making records of effective orders against the certificates of airmen available to their employers if the airmen use the affected certificates to perform job responsibilities for those employers.
(h) Making airmen records available to users of FAA’s Safety Performance Analysis System (SPAS), including the Department of Defense Commercial Airlift Division’s Air Carrier Analysis Support System (ACAS) for its use in identifying safety hazards and risk areas, targeting inspection efforts for certificate holders of greatest risk, and monitoring the effectiveness of targeted oversight actions.
(i) Making records of an individual’s positive drug test result, alcohol test result of 0.04 or greater breath alcohol concentration, or refusal to submit to testing required under a DOT-required testing program, available to third parties, including current and prospective employers of such individuals. Such records also contain the names and titles of indi- viduals who, in their commercial capacity, administer the drug and alcohol testing programs of aviation entities.
(j) Providing information about airmen through the Civil Aviation Registry’s Comprehensive Airmen Information System to the Department of Health and Human Services, Office of Child Support Enforcement, and the Federal Parent Locator Service that locates noncustodial parents who owe child support. Records in this system are used to identify airmen to the child support agencies nationwide in enforcing child support obligations, establishing paternity, establishing and modifying support orders and location of obligors. Records listed within the section on Categories of Records are retrieved using Connect: Direct through the Social Security Administration’s secure environment.
(k) Making personally identifiable information about airmen available to other Federal agencies for the purpose of verifying the accuracy and completeness of medical information provided to FAA in connection with applications for airmen medical certification.
(l) Making records of past airman medical certification history data available to Aviation Medical Examiners (AMEs) on a routine basis so that AMEs may render the best medical certification decision.
(m) Making airman, aircraft and operator record elements available to users of FAA’s Skywatch system, including the Department of Defense (DoD), the Department of Homeland Security (DHS), DOJ and other authorized Federal agencies, for their use in managing, tracking and reporting aviation-related security events.
(n) Other possible routine uses published in the Federal Register (see Prefatory Statement of General Routine Uses for additional uses (65 F.R. 19477-78) For example, a record from this system of records may be disclosed to the United States Coast Guard (Coast Guard) and to the Transportation Security Administration (TSA) if information from this system was shared with either agency when that agency was a component of the Department of Transportation (DOT) before its transfer to DHS and such disclosure is necessary to
accomplish a DOT, TSA or Coast Guard function related to this system of records.

FAA Form 8500-14 (9-97) Supersedes Previous Edition Page 2

OPHTHALMOLOGICAL EVALUATION FOR GLAUCOMA

Form Approved OMB No. 2120-0034 Expiration Date 08/31/2014

U S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION 1. DATE
2A. NAME OF AIRMAN (Last, First, Middle) 2B. DATE OF BIRTH (Month, Day, Year) 2C. SEX (M or F)
3. ADDRESS OF AIRMAN (No. Street, City, State, Zip Code)
4. HISTORY -- Record pertinent history, past and present, concerning general health and visual problems.
5. FAMILY HISTORY OF GLAUCOMA
6. Diagnosis
A. TYPE (Check One) Simple, W ide Angle, Open Closed Angle, Narrow Angle. Angle Closure
B. DISCOVER -- e.g., routine examination, FAA physical examination, acute symptoms, reduction in visual acuity, etc.
C. CONFIRMATION -- Tonometric readings, gonioscopy visual fields, tonography, or provocative tests. GIVE METHODS, RESULTS AND DATE CONFIRMED
7. SURGERY
A. IF SURGERY HAS BEEN PERFORMED, INDICATE WHICH EYE AND TYPE OF SURGERY.
B. IS SURGERY ANTICIPATED WITHIN 24 MONTHS?
YES, PROBABLE NO, NOT LIKELY
8. INITIAL RESPONSE TO THERAPY -- Indicate results including strength, frequency and type of medication used at that time.
9. PRESENT TREATMENT -- Indicate exact type, strength, frequency, and name of medication being used.
10. ADEQUACY OF CONTROL
A. DESCRIBE PRIOR CONTROL, INCLUDING SERIAL TONOMETRIC FINDINGS, CHANGES IN VISUAL FIELDS, ETC.
B. MAXIMUM INTRAOCULAR PRESSURES IN RELATIONSHIP TO DAILY MEDICATION (If known).
C. INTRACOCULAR PRESSURE
O.D. O.S. TEST METHOD USED TIME SINCE LAST MEDICATION
NOTE -- Pressures should NOT be taken within 2 hours after use of medication unless 10.B. is completed.

FAA FORM 8500-14 (9-97) Supersedes Previous Edition NSN: 0052-00-667-4002 Page 1

11. FIELD OF VISION -- Record physiological and any pathological peripheral or central visual field losses from a perimeter and/or tangent screen using white test object -- SUBMIT OR ATTACH CHARTS
A. DID EXAMINEE WEAR GLASSES OR CONTACT LENSES DURING
TEST? (Specify which) B. SIZE OF TEST OBJECT USED WITH TANGENT SCREEN
12. VISUAL ACUITY -- Record (Use Snellen linear values)

A. DISTANT TEST METHOD USED UNCORRECTED CORRECTED
O. D. O.S. O. U. O. D. O.S. O. U.

B. NEAR TEST METHOD USED UNCORRECTED CORRECTED
O.D. O.S. O.U. O.D. O.S. O.U.

C. INTERMEDIATE
(32 INCHES) TEST METHOD USED UNCORRECTED CORRECTED
O.D. O.S. O.U. O.D. O.S. O.U.
D. IMPORTANT -- If correction is needed and there is inability to correct either eye to 20/20 or better, give reasons.
13. PRESENT CORRECTION
DOES AIRMAN WEAR?

GLASSES CONTACT LENSES O.D. O.S.
SPHERE-CYLINDER AXIS SPHERE CYLINDER AXIS
14. PUPILS -- Statement of relative size and reaction of the pupils to accommodation and light, with special reference to any disease process, healed or active
15. OPHTHALMOSCOPIC -- Describe any variations from normal in either eye on funduscopic examinations, with special reference to any disease process, healed or active.
16. SLIT LAMP -- Record results of slit lamp examination of each eye where indicated.
17. FUSION --Estimate fusion ability and state methods used in examination
18A. TYPED NAME AND ADDRESS OF EYE SPECIALIST 18B. SIGNATURE OF EYE SPECIALIST

FAA FORM 8500-14 (9-97) Supersedes Previous Edition

from katrine elizabeth sackett32463 whitelady 5'21/2 5'3
7101 n ih 35 austin tx by burger king
donated old bldg to use for apt use not incomplete working order of a building for seniors homeless ssi reciepts wheel chair combined or other people
today is oct 31 2018

Views: 
1304
Post type: 
Author: 
training time
Business or Product name: 
Address: 
7101 North Interstate Highway 35
Austin, TX 78752
United States