Form F-11 Psychological Evaluation Form - Alaska

Form F-11 is a Alaska Department of Public Safety form also known as the "Psychological Evaluation Form". The latest edition of the form was released in January 4, 2017 and is available for digital filing.

Download a PDF version of the Form F-11 down below or find it on Alaska Department of Public Safety Forms website.

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Alaska Police
Standards Council
PO Box 111200
F-11
ALASKA POLICE STANDARDS COUNCIL
Juneau, AK 99811-1200
Phone: 907 465-4378
PSYCHOLOGICAL EVALUATION FORM
This form is filled out after an officer is hired. It must be submitted to APSC no later than 30 days after hiring.
Last Name, First, Middle
Date of Birth
Agency
Position
Date of Psychological Exam
Police
Corrections
Probation/Parole
13 AAC 85.010(a)(6) requires that a person hired as a police officer "is certified by a licensed psychiatrist or
psychologist to be mentally capable of performing the essential functions of the job of police officer and is free
from any emotional disorder that may adversely affect the person's performance as a police officer."
13 AAC 85.210(a)(6) requires that a person hired a probation, parole, or correctional officer "has taken
the Department of Correction's psychological screening examination and is mentally capable of performing the
essential functions of the job of probation, parole, or correctional officer and is free from any emotional disorder
that may adversely affect the person's performance as a probation, parole, or correctional officer."
I, the undersigned, certify that I have completed a psychological exam for _____________________________
Officer Name
on ______________________.
Date of Exam
At the time of the examination:
I certify the above police officer meets the requirements of 13 AAC 85.010(a)(6).
I certify the above probation, parole, or correctional officer meets the requirements of 13 AAC
85.210(a)(6).
At this time and for the position marked above, the applicant does not meet the requirements of 13 AAC
85.010(a)(6) or 13 AAC 85.210(a)(6).
Comments:
Examiner's signature
Address
Printed Name
Phone
Date
License Type
License # and State
Information contained in this form will be used by the council for purposes of determinining the applicant's eligibility for employment and certification.
APSC 01/04/2017
Alaska Police
Standards Council
PO Box 111200
F-11
ALASKA POLICE STANDARDS COUNCIL
Juneau, AK 99811-1200
Phone: 907 465-4378
PSYCHOLOGICAL EVALUATION FORM
This form is filled out after an officer is hired. It must be submitted to APSC no later than 30 days after hiring.
Last Name, First, Middle
Date of Birth
Agency
Position
Date of Psychological Exam
Police
Corrections
Probation/Parole
13 AAC 85.010(a)(6) requires that a person hired as a police officer "is certified by a licensed psychiatrist or
psychologist to be mentally capable of performing the essential functions of the job of police officer and is free
from any emotional disorder that may adversely affect the person's performance as a police officer."
13 AAC 85.210(a)(6) requires that a person hired a probation, parole, or correctional officer "has taken
the Department of Correction's psychological screening examination and is mentally capable of performing the
essential functions of the job of probation, parole, or correctional officer and is free from any emotional disorder
that may adversely affect the person's performance as a probation, parole, or correctional officer."
I, the undersigned, certify that I have completed a psychological exam for _____________________________
Officer Name
on ______________________.
Date of Exam
At the time of the examination:
I certify the above police officer meets the requirements of 13 AAC 85.010(a)(6).
I certify the above probation, parole, or correctional officer meets the requirements of 13 AAC
85.210(a)(6).
At this time and for the position marked above, the applicant does not meet the requirements of 13 AAC
85.010(a)(6) or 13 AAC 85.210(a)(6).
Comments:
Examiner's signature
Address
Printed Name
Phone
Date
License Type
License # and State
Information contained in this form will be used by the council for purposes of determinining the applicant's eligibility for employment and certification.
APSC 01/04/2017
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