Attachment 13 FLETC Form 500-14-04.pdf
PDF 3 MB Posted
- Attached to
- ENTERPRISE HEALTH UNIT SERVICES
- Solicitation number
- 70LGLY26RGLB00005
About this file
This is a medical restriction form used by the Federal Law Enforcement Training Centers (FLETC) under the Department of Homeland Security to document trainee health status and program modifications. The form is completed exclusively by Health Unit Staff and serves as the official record of medical clearance or necessary training restrictions for trainees attending FLETC programs.
The form identifies the trainee, agency, and class number, then indicates whether the individual is fully medically cleared or requires program modifications and restrictions. Available restrictions span physical activities (no running, climbing, swimming, grappling), equipment operation (no motor vehicles, firearms), environmental exposures (no sun/heat/cold, gas/fume, pepper spray), upper and lower extremity limitations (with right/left/bilateral designations), sedentary-only participation, virtual attendance from dormitory, LED screen restrictions, and other occupational or non-occupational limitations. The form includes sections for explanation of body parts or systems affected, estimated length of restriction, recheck date, service provider identification, and trainee signature. A determination by the training agency or FLETC is required. Contact information is provided for FLETC locations at Glynco (912-267-2385), Charleston (843-746-0802), and Artesia (575-748-8090) for clarification requests from instructors or coordinators.
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Text version
DEPARTMENT OF HOMELAND SECURITY
FEDERAL LAW ENFORCEMENT TRAINING CENTERS
TRAINEE RESTRICTION STATUS
This form is to be filled out by Health Unit Staff only. Date:
Trainee of [Agency/Class No.] has been examined and is able to participate fully in all training programs (medically cleared).
consultation with the Health Services Staff reveals the following program modifications/restrictions are necessary for subject staff/student
Modification/Restriction Modification/Restriction Explanation/Body Part/System Affected
Isolation No Operation of Motor Vehicles or Equipment (including boats)
Sick in Quarters No use of Firearms
May Attend Class Virtually From Dorm
No Use of LED Screens (Phones, Laptops, Monitors)
Participation in Sedentary Classroom Activities Only
Avoid Sun/Heat/Cold Exposure
No Excessive Walking (May Walk to Class & Dining Hall Only)
No Gas or Fume Exposure No Pepper Spray Exposure
No Running (Walking Permitted)
No Use of Upper Extremity
R L Bilateral
Must Keep Leg Elevated No Above Shoulder Activity
R L Bilateral No Lifting, Pushing, Pulling, Carrying
Must Wear Brace/Splint
Lower Extremity
Upper Extremity
R L Bilateral
No Swimming
OTHER ACTIVITIES/COMMENTS:
Date:Trainee Signature:
Estimated Length of Restriction: Recheck Date: Time Out:
Service Provider:
Training Decision required by Agency and or FLETC.
Instructor/Coordinator: Please contact the Health Unit for clarification, if necessary.
Glynco: 912-267-2385 Charleston: 843-746-0802 Artesia: 575-748-8090
FLETC Form 500-14-04 (12/2024) Page 1 of 1
No Climbing Steps/Ladders
No Squatting/Kneeling/Crawling Occupational (Workers' Comp) Nonoccupational (Private)
No Grappling or Contact Sports
Health Services Contract Part 9, Attachment 13
Table 1
| Button2: |
| Group20: Off |
| Date1_af_date: |
| Sun/Heat/Cold Exposure: Off |
| Staff Member/Trainee: |
| of [Agency/Division/Class No: |
| ]: |
| Body Part Affected: |
| Other activities/comments: |
| No running walking permitted: Off |
| Must keep leg elevated: Off |
| Driving: Off |
| Firearms/Rifle, Pistol, Shotgun: Off |
| Simmunition: Off |
| No Use of Upper Extremity: Off |
| No Above Shoulder activity: Off |
| Must wear Brace/Splint: Off |
| upper body physical activity: Off |
| lower body physical activity: Off |
| boxing: Off |
| swimming: Off |
| CPR: Off |
| Date2_af_date: |
| Text3: |
| Text5: |
| no operation: Off |
| Date9_af_date: |
| No lifting, pushing, pulling, carrying: Off |
| No Swimming: Off |
| Group21: Off |
| No Squatting: Off |
| No Grappling or Contact Sports: Off |
File details come from the government source that posted it. Updated .