Faa Form 8500 14 PDF Details

Ensuring the safety and proficiency of pilots is a multidimensional effort that involves rigorous health screening, among which, the assessment for vision-related conditions like glaucoma is critical. The FAA Form 8500-14, titled 'Ophthalmological Evaluation for Glaucoma,' is a specialized document used by the Federal Aviation Administration (FAA) to gather essential information concerning an applicant's ocular health, specifically related to glaucoma. This form is mandated under the authority of Title 49 of the United States Code and is integrated within the medical standards and certification process outlined in Title 14 of the Code of Federal Regulations, Part 67. The objective behind collecting this data is not just to evaluate if an applicant possesses the visual standards necessary for operating safely as an airman, but also to assist in the ongoing improvement of certification procedures and medical criteria. Moreover, the information submitted becomes part of a protected system of records, emphasizing the privacy and importance of the data provided. The comprehensive nature of the form, which includes sections for detailing the history, diagnosis, treatment, and control of the condition, underscores the FAA's commitment to maintaining a high standard of health and operational ability among airmen, ensuring that those with glaucoma are appropriately evaluated and monitored to safeguard not only their own well-being but also that of the public.

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Form NameFaa Form 8500 14
Form Length3 pages
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Avg. time to fill out45 sec
Other names8500 14, faa 8500 8 pdf, 850014, form 8500 14

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U.S. Department

of Transportation

Federal Aviation

Administration

INFORMATION FOR APPLICANT

OPHTHALMOLOGICAL EVALUATION FOR

GLAUCOMA

Privacy Act Statement

Information requested on this form is solicited under the authority of Title 49 of the United States Code (Transportation) sections 109(9), 40113(a), 44701-44703, and 44709 (1994) formerly codified in the Federal Aviation Act of 1958, as amended, and Title 14 of the Code of Federal Regulations (CFR), Part 67, Medical Standards and Certification. Submission of this information is mandatory and incomplete submission will result in delay of consideration of or denial of application for an airman medical certificate.

The purpose of this information is to determine whether an applicant meets Federal Aviation Administration medical requirements to hold an airman medical certificate for further consideration under 14 CFR 11.53 and 67.401. It is also used to depict airman population patterns and to update certification procedures and medical standards. The information collected on this form becomes a part of the Privacy Act System of Records DOT/ FAA 847, General Air Transportation Records on individuals, and is provided the protection outlined in the system's description as published in the Federal Register.

Paperwork Reduction Act Statement: Applicants with glaucoma must submit FAA Form 8500-14, Ophthalmological Evaluation for Glaucoma. Information on this form enables FAA medical personnel to evaluate and determine the permissible operational activities of applicants that are commensurate with their medical condition and public safety. Submission of information is mandatory.

The purpose of this information is to determine whether an applicant meets FAA medical requirements to hold an airman medical certificate for further consideration under Title 14 of the Code of Federal Regulations (CFR) 11.53 and 67.401. Any person who is denied a medical certificate by an aviation medical examiner may appeal to the Federal Air Surgeon under 14 CFR 67.409, Denial of medical certificate. This information is also used to depict airman population patterns and to update certification procedures and medical standards.

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information collection is 2120-0034. Public reporting for this collection of information is estimated to be approximately 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, completing and reviewing the collection of information. All responses to this collection of information are required to obtain a certificate under the authority of 14 CFR Parts 61 and 67. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177.

Tear off this cover sheet before submitting this form

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

NSN: 0052-00-694-4003

Form Approved OMB No.

2120-0034 Expiration Date 03/31/21

 

OPHTHALMOLOGICAL EVALUATION FOR GLAUCOMA

1. DATE

 

 

 

 

 

U S. DEPARTMENT OF TRANSPORTATION

 

 

 

 

FEDERAL AVIATION ADMINISTRATION

 

 

 

 

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, Wide 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)

 

TEST METHOD USED

UNCORRECTED

 

 

CORRECTED

 

A. DISTANT

 

O. D.

O.S.

O. U.

O. D.

 

O.S.

 

O. U.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST METHOD USED

UNCORRECTED

 

 

CORRECTED

 

 

 

 

 

 

 

 

 

 

B. NEAR

 

O.D.

O.S.

O.U.

O.D.

 

O.S.

 

O.U.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST METHOD USED

UNCORRECTED

 

 

CORRECTED

 

 

 

 

 

 

 

 

 

 

C. INTERMEDIATE

 

O.D.

O.S.

O.U.

O.D.

 

O.S.

 

O.U.

(32 INCHES)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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?

O.D.

O.S.

 

 

SPHERE-CYLINDER AXIS

SPHERE CYLINDER AXIS

GLASSES

CONTACT LENSES

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 -- D ESCRIBE 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

NSN: 0052-00-667-4002

PAGE 2

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2. The subsequent stage is usually to submit these particular blank fields: SURGERY, A IF SURGERY HAS BEEN PERFORMED, B IS SURGERY ANTICIPATED WITHIN, YES PROBABLE, NO NOT LIKELY, INITIAL RESPONSE TO THERAPY, PRESENT TREATMENT Indicate exact, ADEQUACY OF CONTROL, A DESCRIBE PRIOR CONTROL INCLUDING, B MAXIMUM INTRAOCULAR PRESSURES IN, C INTRACOCULAR PRESSURE, TEST METHOD USED, TIME SINCE LAST MEDICATION, and NOTE Pressures should NOT be.

Part no. 2 of completing faa 8500 14

3. In this step, examine A DID EXAMINEE WEAR GLASSES OR, B SIZE OF TEST OBJECT USED WITH, TEST Specify which, SCREEN, VISUAL ACUITY Record Use Snellen, A DISTANT, B NEAR, C INTERMEDIATE, INCHES, TEST METHOD USED, UNCORRECTED, CORRECTED, O D, O U, and O D. These will need to be completed with highest accuracy.

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SLIT LAMP  Record results of slit, FAA FORM   Supersedes Previous, and disease process healed or active inside faa 8500 14

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