Attmt 24 Mental Health Screener Decision Template.pdf
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- Solicitation number
- 70B06C26R00000017
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This is a template document for psychiatric screening evaluations used by the Department of Homeland Security's US Customs and Border Protection (CBP) to assess mental health qualifications of applicants and contractors.
The template is designed to document psychiatric screening consultation results through four primary sections. Section 1 requires documentation of relevant medical history facts pertaining to the applicant's medical qualification for the position. Section 2 mandates listing all diagnoses—including traumatic brain injury (TBI) and insomnia—along with medications and conditions identified through personal records, pre-employment medical examinations, online assessments, and provider interviews. Section 3 addresses medical status summary and impact, divided into two categories: applicants who meet Minimum Medical Qualifications (MMMQ) must demonstrate that issues are resolved, in remission, or unlikely to affect job duties, with rationale explaining why the issues do not pose threats or prevent job performance; conversely, applicants requiring further evaluation must have documented current active symptoms, lack of stability, or high recurrence risk, with documented opinions on significant risk of substantial harm to themselves, coworkers, or the public. Section 4 contains the psychiatric specialist's recommendation, with distinct language tracks for Border Patrol Agent (BPA) applicants (referencing the Psychiatric Disorders Standard) and all other positions (referencing health and safety requirements), including hybrid language for applicants evaluated for both BPA and other positions. The template requires signature and credentials of the evaluating psychiatric specialist.
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Attachment 24 Mental Health Screener Decision Template [Date]
Department of Homeland Security US Customs and Border Protection [Addressee Office] [Addressee Street Address, Room/Suite #] [Addressee City, State, Zip Code] Attn.: [Addressee Unit], [COR]
Name: ________________________ Applicant ID(s): [#######] Vendor ID(s): [#######] Position(s): _____________________ Consult request date: _____________ Revision date (if applicable): ________________ Consult type: Psychiatric Screening
1. Medical Findings Overview: [Documentation of important/relevant facts from the applicant’s medical history that are being reviewed in relation to medical qualification for the position].
2. Diagnosis/diagnoses: list all diagnoses (including TBI and insomnia), medications, and conditions as indicated by the individual’s personal records, the pre-employment medical exam, online assessments, and provider interview.
3. Medical Status Summary/Impact:
a. Meets Minimum Medical Qualifications (MMMQ)
i. If an issue is cleared, indicate if it is because the issue is resolved, in remission, or unlikely to affect job duties.
ii. Provide rationale regarding why the issue does not pose a threat to the applicant or others.
iii. Provide rationale regarding why the issue does not prohibit the applicant from performing essential functions of the job.
b. Further Evaluation is Recommended
i. If any issue is NOT cleared, indicate if it is because the issue has current and active symptoms, a lack of documented stability, or if there is a high risk of recurrence.
ii. Based on your initial assessment of the applicant’s current status, duration of the risk of their condition, the nature and severity of the harm, and the likelihood the harm will occur, document your opinion of why their condition could pose a significant risk of substantial harm to themselves, their coworkers, or the public.
4. Recommendation:
For BPA applicants:
[Applicant name] meets Psychiatric Disorders Standard for BPA or Additional information and a current comprehensive evaluation are recommended.
For all other positions:
[Applicant name] meets health and safety requirements or Additional information and a current comprehensive evaluation are recommended.
If an applicant’s file is being reviewed for BPA and another position:
[Applicant name] meets Psychiatric Disorders Standard for BPA and meets health and safety requirements for [Position] or Additional information and a current comprehensive evaluation are recommended.
[Psychiatric Specialist Signature] [Name and Credentials]
File details come from the government source that posted it. Updated .