"Law Enforcement Applicant Medical History Form" - Oregon

Law Enforcement Applicant Medical History Form is a legal document that was released by the Oregon Department of Public Safety Standards and Training - a government authority operating within Oregon.

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Law Enforcement Applicant Medical History
Employing Agency Information Only
Physical Standards and Critical & Essential tasks are derived from a discipline specific Job Task Analysis (JTA) for Law
Enforcement Officers. Each JTA meets the Americans with Disabilities Act (ADA) criteria to identify the Essential
Functions/Tasks of the position. A physician developed the medical standards based upon the essential tasks.
Critical and Essential Tasks are found at www.oregon.gov/dpsst/SC/pages/cjforms.aspx
Employing agencies can utilize this form if they do not have their own Medical Examination sheet. This is not a required document.
The F2a Final Medical Report and optional waiver are the only forms DPSST requires.
To be completed by applicant
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
1. Do you have any current medical conditions?
Yes
No
If so, please list:
2. Have you had any prior medical conditions that required treatment?
Yes
No
If so, please list:
3. Have you ever had surgery?
Yes
No
If so, please list (include year of surgery):
4. Are you currently taking any medications? (prescribed or over the counter)
Yes
No
If so, please list:
Check if you have had any of the following.
Physician Comments
Headaches requiring treatment
Concussion or loss of consciousness
Seizures
Stroke
Other neurological conditions
Dizziness / balance problems
Memory problems
Depression / anxiety or other psychological conditions
Vision problems
. Currently wear glasses or contacts
Law Enforcement Applicant Medical History
Employing Agency Information Only
Physical Standards and Critical & Essential tasks are derived from a discipline specific Job Task Analysis (JTA) for Law
Enforcement Officers. Each JTA meets the Americans with Disabilities Act (ADA) criteria to identify the Essential
Functions/Tasks of the position. A physician developed the medical standards based upon the essential tasks.
Critical and Essential Tasks are found at www.oregon.gov/dpsst/SC/pages/cjforms.aspx
Employing agencies can utilize this form if they do not have their own Medical Examination sheet. This is not a required document.
The F2a Final Medical Report and optional waiver are the only forms DPSST requires.
To be completed by applicant
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
1. Do you have any current medical conditions?
Yes
No
If so, please list:
2. Have you had any prior medical conditions that required treatment?
Yes
No
If so, please list:
3. Have you ever had surgery?
Yes
No
If so, please list (include year of surgery):
4. Are you currently taking any medications? (prescribed or over the counter)
Yes
No
If so, please list:
Check if you have had any of the following.
Physician Comments
Headaches requiring treatment
Concussion or loss of consciousness
Seizures
Stroke
Other neurological conditions
Dizziness / balance problems
Memory problems
Depression / anxiety or other psychological conditions
Vision problems
. Currently wear glasses or contacts
Law Enforcement Applicant Medical History
Employing Agency Information Only
Applicant Name (Last, First Middle)
Date of Birth (MM/DD/YYYY)
DPSST No.:
Check if you have had any of the following.
Physician Comments
. Eye surgery
. Difficulty driving or seeing at night
. Hearing loss / use of hearing aids
. Ringing in the ears
. Chest pain
. Heart attack
. Irregular / abnormal heart beats
. Heart murmurs
. Unusual shortness of breath
. Persistent diarrhea or constipation
. Blood in your stool
. Blood in your urine
. Coughing up blood
. Liver problems
. Kidney or bladder problems
. Unusual vaginal bleeding (if applicable)
. Hernia(s)
. Anemia
. Frequent bloody noses
. Easy bruising
. Cancer
. Unexplained weight changes
. Chronic fatigue
. Thyroid problems
. Diabetes
. Back or neck pain / injuries
. Muscle / ligament / joint injuries
. Broken bones
. Arthritis
. Illegal drug use
. Alcohol use
. Conviction(s) of driving under the influence
. Attended drug or alcohol rehabilitation
Law Enforcement Medical Examination
Employing Agency Information Only Do Not Send to DPSST
Applicant Name: (Last, First Middle)
DOB: (MM/DD/YYYY)
DPSST No.:
Height:_________ ft. ________in.
Weight: _________ lbs. / _________ kg.
Eyes and Vision
Eye Exam (EOM, Pupils, etc.):
Normal:
Yes
No
1. Visual Acuity Standards
1.1. Monocular vision must be at least 20/30 (Snellen) corrected in each eye and not worse than 20/100 (Snellen)
uncorrected in either eye.
1.2. Binocular vision must be at least 20/20 (Snellen) corrected.
1.3. Applicant whose uncorrected vision is worse than 20/100 must wear soft contact lenses to meet the corrected
vision requirement.
Right
Left
Both
Uncorrected
R20 /
L20 /
B20 /
Corrected
R20 /
L20 /
B20 /
2. Color Vision Standards
2.1. Applicant must be able to distinguish red, green, blue, and yellow, as determined by the HRR Test, 4th Edition.
2.2. Red or green deficiencies may be acceptable, providing the applicant can read at least nine of the first 13 plates of
the Ishihara Test.
2.3. Applicant who fails to meet the color vision standard may meet this standard by demonstrating they can correctly
discriminate colors via a field test conducted by the employer as approved by the examining physician/surgeon.
HRR Test, 4
th
Ed.:
Ishihara (if applicable):
Field Test (if applicable):
3. Depth Perception Standards
3.1. Random Stereo Test equal to 60 seconds of arc or better.
Seconds of Arc:
4. Peripheral Vision Standards
4.1. Visual Field Performance must be 140 degrees in the horizontal meridian combined.
Peripheral Vision
Right
Left
Total
Horizontal
Comments:
Law Enforcement Medical Examination
Employing Agency Information Only Do Not Send to DPSST
Applicant Name:
DOB:
Hearing
Ear Exam (External Canal, Tympanic Membrane, etc.)
Normal:
Yes
No
5. Hearing Acuity Standards
5.1. Applicant must have no average hearing loss greater than 25 (db.) at the 500, 1,000, 2,000 and 3,000-Hertz levels
in either ear with no single loss in excess of 40 db.
5.2. Amplification devices may be used to meet the above hearing requirement.
500 Hz
1000 Hz
2000 Hz
3000 Hz
4000 Hz*
6000 Hz*
Average*
Right
Left
*Average does NOT include 4000 or 6000 Hz.
Comments:
6. Cardiovascular Standard
Resting blood pressure must be less than or equal to 160 mmHg systolic and 100 mmHg diastolic.
Applicant who fails to meet the cardiovascular standards must be examined by a general practitioner to address
the issue.
Applicant who has a history of organic cardiovascular disease will necessitate further medical evaluation.
Heart Rate:
_____________
Normal:
Yes
No
Sounds & Rhythm:
Normal:
Yes
No
Blood Pressure:
___ /
_______
Comments:
7. Pulmonary Function Standard
Applicant with obstructive or restrictive spirogram (FVC or FEV1 less than 80% or FVC/FEV1 ratio of less than 70%) require
further evaluation.
Pulmonary Function Test: _____________
Comments:
Law Enforcement Medical Examination
Employing Agency Information Only Do Not Send to DPSST
Applicant Name:
DOB:
8. Medications Standard
The side effects of any prescribed medication must not interfere with the ability of the applicant to perform the critical
and essential tasks of the job.
Comments:
Head/Throat/Neck
Comments:
Abdominal
Comments:
Musculoskeletal
Test flexibility by bending, stooping, squatting; also by head, arm and finger motions. Perform more in-depth exam of
previously injured area.
Comments*
Normal
Spine
Yes
No
Yes
No
Upper Extremities
Yes
No
Lower Extremities
* Note any deformities, amputations, loss of motion, weakness, instability, limited function, etc.
Comments:
Neurological
Normal
Reflexes (including pathologic reflexes)
Yes
No
Cerebellar and Cranial Nerves
Yes
No
Comments:
Skin
Comments:
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