Form T-1A "Physician's Medical Release Form" - Kentucky

What Is Form T-1A?

This is a legal form that was released by the Kentucky Law Enforcement Council - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the Kentucky Law Enforcement Council;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form T-1A by clicking the link below or browse more documents and templates provided by the Kentucky Law Enforcement Council.

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Download Form T-1A "Physician's Medical Release Form" - Kentucky

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Rate (4.8 / 5) 20 votes
 
 
 
Office Use Only
Form T-1a
Kentucky Law Enforcement Council
P
M
R
F
HYSICIAN
S
EDICAL
ELEASE
ORM
 
Mail:
Kentucky Law Enforcement Council
INSTRUCTIONS:
This form must be completed by a physician,
Funderburk Building
physician assistant or Nurse Practitioner, prior to the applicant
521 Lancaster Ave.
Richmond, KY 40475-3102
participating in the physical ability, IF the applicant checks “yes” on any
Phone: 859-622-6218
Fax: 859-622-5943
question between numbers 1-11 on the Form T-1. If this form is
required and not completed, the applicant will be sent home.
 
 
NAME:
 
Date of Birth
SS#
 
 
Peace officers in the Commonwealth of Kentucky are required to perform a variety of
essential physically demanding tasks including the following:
Walking for extended periods
o
Short sprints
o
Long pursuit running lasting over 2 minutes
o
Jumping over and around obstacles
o
Lifting and carrying objects sometimes up and down stairs
o
Using hands and feet in use of force situations
o
Using force in short and long term (greater than 2 minutes) efforts
o
Bending and reaching
o
Dragging people and objects as in extracting victims from vehicles
o
 
To measure an individual’s capacity to perform these critical tasks all applicants must
undergo a physical ability test consisting of the following items:
1.5 mile run to measure aerobic power
o
300 meter sprint to measure anaerobic power
o
Sit ups to measure abdominal muscular endurance
o
Push ups to measure upper body muscular endurance
o
Free weight bench press to measure upper body absolute strength
o
 
Your professional opinion is requested as to whether the individual can safely participate in
physical ability testing.
 
PLEASE CHECK ONE:
There are no contraindications to the individual either 1) being capable of performing
the essential physical tasks or 2) being capable of undergoing the physical ability test
items.
There are contraindications and it is recommended that the individual not participate in the
physical ability test items.
 
 
I hereby verify that the above information is true and accurate.
 
Signed this
day of
, 20_
.
 
 
Signature of Physician, Physician Assistant or Nurse Practitioner
 
 
 
Printed Name of Physician, Physician Assistant or Nurse Practitioner
 
 
 
 
 
Revised June 2014
 
 
 
Office Use Only
Form T-1a
Kentucky Law Enforcement Council
P
M
R
F
HYSICIAN
S
EDICAL
ELEASE
ORM
 
Mail:
Kentucky Law Enforcement Council
INSTRUCTIONS:
This form must be completed by a physician,
Funderburk Building
physician assistant or Nurse Practitioner, prior to the applicant
521 Lancaster Ave.
Richmond, KY 40475-3102
participating in the physical ability, IF the applicant checks “yes” on any
Phone: 859-622-6218
Fax: 859-622-5943
question between numbers 1-11 on the Form T-1. If this form is
required and not completed, the applicant will be sent home.
 
 
NAME:
 
Date of Birth
SS#
 
 
Peace officers in the Commonwealth of Kentucky are required to perform a variety of
essential physically demanding tasks including the following:
Walking for extended periods
o
Short sprints
o
Long pursuit running lasting over 2 minutes
o
Jumping over and around obstacles
o
Lifting and carrying objects sometimes up and down stairs
o
Using hands and feet in use of force situations
o
Using force in short and long term (greater than 2 minutes) efforts
o
Bending and reaching
o
Dragging people and objects as in extracting victims from vehicles
o
 
To measure an individual’s capacity to perform these critical tasks all applicants must
undergo a physical ability test consisting of the following items:
1.5 mile run to measure aerobic power
o
300 meter sprint to measure anaerobic power
o
Sit ups to measure abdominal muscular endurance
o
Push ups to measure upper body muscular endurance
o
Free weight bench press to measure upper body absolute strength
o
 
Your professional opinion is requested as to whether the individual can safely participate in
physical ability testing.
 
PLEASE CHECK ONE:
There are no contraindications to the individual either 1) being capable of performing
the essential physical tasks or 2) being capable of undergoing the physical ability test
items.
There are contraindications and it is recommended that the individual not participate in the
physical ability test items.
 
 
I hereby verify that the above information is true and accurate.
 
Signed this
day of
, 20_
.
 
 
Signature of Physician, Physician Assistant or Nurse Practitioner
 
 
 
Printed Name of Physician, Physician Assistant or Nurse Practitioner
 
 
 
 
 
Revised June 2014