FLETC Form 500-14-04: Trainee Restriction Status

This is a medical restriction form used by the Department of Homeland Security's Federal Law Enforcement Training Centers (FLETC) to document training program modifications and restrictions for trainees based on health conditions. The form is completed exclusively by Health Unit Staff and documents the trainee's agency affiliation and class number, along with an initial determination of whether the trainee is medically cleared to participate fully in all training programs or requires specific modifications.

The form provides a comprehensive checklist of restriction options across multiple categories including isolation, sedentary activities, equipment operation prohibitions (motor vehicles, firearms, LED screens), environmental exposure limitations (sun, heat, cold, gas, fumes, pepper spray), physical activity restrictions (running, climbing, grappling, swimming, excessive walking), and body-part-specific limitations (upper extremity, lower extremity, shoulder activity, leg elevation, braces/splints). Health Services Staff must indicate the explanation and affected body parts or systems for any selected restrictions. The form requires documentation of the restriction duration, recheck date, trainee signature, service provider identification, and classification of the restriction as occupational (Workers' Compensation) or nonoccupational (private). Contact information is provided for three FLETC locations: Glynco (912-267-2385), Charleston (843-746-0802), and Artesia (575-748-8090). The form notes that training decisions must be coordinated between the trainee's agency and FLETC, with instructors directed to contact the Health Unit for clarification when necessary.