Attachment 10 FLETC Form 500-14-01.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

HEALTH QUESTIONNAIRE

Full Name (Last, First, Middle) Age DOB Class Agency Date

Address Work Email Phone Number

1. Check each item listed with a yes or no response:

Yes No Yes No

Diabetes Pulmonary Disease (Emphysema) Height High Blood Pressure Asthma

Heart Disease Alcohol (Drinks/Day) Weight Rhabdomyolysis Tobacco Use (Packs/Day) Sex Male Female HIV (AIDS) CNS (Neurological Disease: stroke, seizures, migraines) Hepatitis Orthopedic Problems (bone, joint, muscle, tendon) Positive TB Skin Test Gastrointestinal Disorders (ulcers, etc.) Other:

If any of the following apply to you, respond with a brief explanation that includes the year of occurrence. Every item must have a response. If the item does not apply, respond N/A in the space provided. 11. Eye problems (any type) (i.e. prior complicated OC spray exposure Yes No

2. Type of exercise performed on a regular basis and frequency or allergy, & Lasik surgery and date)

3. Unusual shortness of breath on exertion (or exercise) Yes No 12. Physical activity/Exercise restriction (any type) Yes No

4. Joint problem (any kind) past or present (Provide part of your body Yes No 13. Heat Illness/heat exhaustion Problem (how often & date of last Yes Nofeeling pain/swelling, or has had dislocation, broken bones, sprains) event)(month/year occurrence)

5. Back Problems (any kind) (month/year occurrence) Yes No 14. Other medical problems or deformities (any kind)

15. List medication(s) currently taking (prescription, over the counter,

6. Frequent dizziness or unconsciousness Yes No supplements) Medication Name, Dosage, Frequency

7. Heart problems (i.e. chest pain, racing heart/skipped beats, abnormal Yes No 16. List any allergic reactions or sensitivities to medications, food or insect bitesEKG, enlarged heart, heart murmur, family history of sudden cardiac death)

8. Recent infections, serious illnesses or hospitalizations (head injury, urinary Yes No problems, viral or bacterial infections, etc.)

9. Surgery (Include month/year, type) Yes No

17. Gynecological problems (specify)

18. Are you pregnant? Yes No10. Abnormal blood test, past or present (i.e. mononucleosis, anemia) Yes No

19. Have you attended a FLETC training program prior to this training? Yes No

PRIVACY ACT NOTICE

The following information is provided in accordance with the Privacy Act of 1974 (5) U.S. C. 552a(e)(3): Authority for the collection of this information is 5 U.S.C. 301, 5 U.S.C. 4101 et seq., Executive Order No. 11348 and the DHS Delegation Number 7950. The primary use of this information is to evaluate fitness to participate in training activities conducted at the FLETC and provide historical health information necessary to plan and deliver treatment while on the FLETC. Routine uses of this information as established and published in accordance with 5 U.S.C .a (3)(4) (D), include transfer of this information to officials of the FLETC and your agency. Disclosure of this information is voluntary. However, it may not be possible for you to receive training at the FLETC if the information is not provided. Under penalty of perjury, I swear or affirm that the information which I have provided is true to the best of my knowledge.

Health Unit Staff Use ONLY Below this Line Trainee Signature

CLEARED FOR TRAINING Blood Pressure: /

NOT CLEARED FOR TRAINING: Provider Name:

Comments:

FLETC Form 500-14-01 (11/22) Page 1 of 1

Health Services Contract Part 9, Attachment 10