Attachment J.9 Certification of Physical Qualification.pdf
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- Attached to
- Supplier Information Request (SIR): Central Service Area Contract Armed Security Officer Services
- Solicitation number
- 693KA8-26-R-00003
About this file
ATTACHMENT J.9: CERTIFICATION OF PHYSICAL QUALIFICATIONS FOR FEDERAL AVIATION ADMINISTRATION SECURITY OFFICERS
This document is a certification form for evaluating the physical qualifications of Federal Aviation Administration (FAA) security officers under Solicitation for Information (SIR) No. 693KA8-26-R-00003. The form requires a physician to certify that prospective security officer employees meet specific physical and medical standards necessary to perform guard duties. Required certifications include: drug testing and screening results; general physical fitness and good health without physical defects or abnormalities; binocular vision correctable to 20/30 (Snellen) without color blindness; ability to hear normal conversation at 20 feet and whispered conversation at 10 feet without a hearing aid; and specific hearing thresholds at designated frequencies (500, 1000, 2000, and 3000 Hz at ≤25 decibels; 4000 and 5000 Hz at ≤45 decibels). The form also requires certification that hearing is not affected by an ear disorder impacting equilibrium.
The form requires signature and date certification from both the examining physician (including typed or printed name, license number, address, and phone number) and a contractor representative (including printed or typed name and phone number). The document serves as a standardized template for contractors to document compliance with FAA security officer physical qualification standards during the personnel screening process.
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Text version
SIR No. 693KA8-26-R-00003 Part III - List of Documents, Exhibits, and Other Attachments
Section J – Attachments
ATTACHMENT J.9
CERTIFICATION OF PHYSICAL QUALIFICATIONS
FEDERAL AVIATION ADMINISTRATION SECURITY OFFICERS
EMPLOYEE NAME: _____________________ DATE OF BIRTH: __________________
ADDRESS:
CONTRACTOR:
CONTRACT NUMBER:
// YES // NO The individual named above has submitted to drug testing and screening. The results will be sent to the Contractor via separate correspondence.
// YES // NO The individual named above is physically fit to perform guard duties and is in good general health without any physical defects or abnormalities.
// YES // NO The individual named above possesses binocular vision correctable to 20/30 (Snellen) and is not color blind.
// YES // NO The individual named above has the ability to hear normal conversation at 20 feet and whispered conversation at 10 feet without the benefit of a hearing aid.
// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) at 500, 1000, 2000, and 3000 Hertz (Hz) at a level that is less than or equal to 25 decibels.
// YES // NO The individual named above possesses hearing (corrected by a hearing aid or uncorrected) at 4000 and 5000 Hz at a level that is less than or equal to 45 decibels.
// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) that is not affected by an ear disorder that affects equilibrium
SIR No. 693KA8-26-R-00003 Part III - List of Documents, Exhibits, and Other Attachments
Section J – Attachments
ATTACHMENT J.9
Physician’s Typed or Printed Name
Physician’s Signature Date
License Number
Address
Phone Number
CERTIFIED BY:
Contractor’ Representative’ Signature Date
Printed or Typed Name
Phone Number
CERTIFIED BY:
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