Appendix B_.pdf

December 8, 2020 VHA DIRECTIVE 0730(1)

APPENDIX B

POLICE OFFICER EVALUATION GUIDE

Evaluation Type: Applicant Periodic J Directed/Special Examination

Applicant/Employee Name:

Last 4 of Social Security Number:

Employing VA Medical Facility:

Date of Evaluation:

Date of Report:

Evaluated by:

REFERRAL INFORMATION

Reason for Referral:

Indicate if (choose one): pre-employment, periodic/annual, or fitness-for-duty (directed or special examination).

[If the evaluation is a directed or snecial examination, include a description of events or behaviors that prompted the evafuation. Veterans Health Administration (VHA) Human Resources must provide a written summary articulating the reason that the employee's ability has come into question and articulate the reason to the employee when ordering the exam. If the findings suggest that the Police Officer is not capable of performing the functional requirements of a Department of Veterans Affairs (VA) Police Officer, the evaluation must include objective evidence that would indicate the employee is not capable of performing the functional requirements, and what evidence suggests that this impairment in functioning is due to an emotional or psychological condition.]

Referral Question:

Is the individual psychologically fit to perform the functional requirements of a Police Officer for VA?

For Directed or Special Examinations Only: Employee's perception of events of concern:

HISTORY REVIEW

NOTE: Only information pertinent to the findings of this evaluation will be provided in the report. Information should be included in recurring evaluations only when it is determined that the employee does not meet the functional requirements for a VA Police Officer.

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December 8, 2020 VHA DIRECTIVE 0730(1)

APPENDIX B

Education:

Employment history:

Military history:

Marital status:

Legal history:

Financial status:

Medical history:

Mental health history:

Other information pertinent to referral question:

Background or collateral information received from sources other than employee:

MENTAL STATUS ASSESSMENT

INTERVIEW RESULTS - Summarize

PSYCHOLOGICAL TESTING

Tests administered:

Testing validity:

Test findings:

SIGNIFICANT FINDINGS

See Appendix C for the evaluation dimensions for VA Police Officers.

Discussion of any psychological dimensions in which applicant was determined to be "Unsuitable":

LIMITATIONS TO FINDINGS

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