Attachment%20B%20Psychological%20Evaluation.pdf
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- Attached to
- Facility Protection Services - UPDATED State and local contract opportunity
- Solicitation number
- RFP 32110-22726
- Issued by
- Davidson County, Tennessee
About this file
This is a Confirmation of Psychological Evaluation form issued by the Tennessee Peace Officer Standards and Training (POST) Commission for law enforcement agencies conducting psychological assessments of police officer certification applicants. The form serves as an official confirmation document that a licensed psychologist or psychiatrist has completed a psychological evaluation of an applicant in compliance with Tennessee Code Annotated Sections 38-8-106 and 8-8-102. The examining professional must certify whether the applicant is qualified or not qualified for police officer certification based on whether the applicant is free from any impairment as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) that would affect the applicant's ability to perform essential job functions, with or without reasonable accommodation. Upon completion, the form must be signed by the examining professional, returned to the employing law enforcement agency, and attached to the Application for Certification submission to the POST Commission.
The form requires the examining psychologist or psychiatrist to provide specific information including their name, license number, state of license, street address, zip code, telephone number, and the date of the psychological examination. A copy of the completed confirmation form and the confidential evaluation results are to be retained in the agency's file, with explicit instruction that confidential evaluation materials are not to be sent to the POST Commission. The form includes a perjury statement warning that any false statements made with intent to deceive constitute a criminal offense under T.C.A. 39-16-702. This standardized form (RDA #1494 IN-1779) was last updated on October 4, 2013.
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Text version
TENNESSEE
PEACE OFFICER STANDARDS AND TRAINING COMMISSION
CONFIRMATION OF PSYCHOLOGICAL EVALUATION
APPLICANT:___________________________________AGENCY:_ ___________________________________________
TO THE HEAD OF LAW ENFORCEMENT AGENCY
This form should be presented to the psychologist/psychiatrist providing psychological evaluation for the purpose of police officer certification.
Upon completion of psychological evaluation, the examining professional should check the appropriate confirmation statement and sign this form in the space provided. This form should then be forwarded to the law enforcement agency. This form should then be attached to the Application for Certification – Police Officer, and should be forwarded to the POST Commission. A copy of this report and the confidential results of the evaluation should be kept in the agency’s file. DO NOT SEND CONFIDENTIAL EVALUATION TO THE POST COMMISSION.
TO THE EXAMINING PSYCHOLOGIST/PSYCHIATRIST
Pursuant to Tennessee Code Annotated, Section 38-8-106 and/or Section 8-8-102, applicants for police certification must have been certified by a
Tennessee licensed health care provider qualified in the psychiatric or psychological field as being free from any impairment, as set forth in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association at the time of the examination, that would, in the professional judgment of the examiner, affect the applicant's ability to perform an essential function of the job, with or without a reasonable accommodation. Upon completion of evaluation, please sign the appropriate statement and return this document to the law enforcement agency.
CONFIRMATION STATEMENT BY THE EXAMINING PROFESSIONAL
I have evaluated tests administered to the referenced individual and find that this officer is:
QUALIFIED NOT QUALIFIED
to be certified under the provisions of Tennessee Code Annotated, Section 38-8-106 and/or Section 8-8-102. The results of my evaluation are being forwarded to the employing agency.
Any person who, with the intent to deceive, makes any false statement on this document commits the offense of perjury pursuant to T.C.A. § 39-16-702.
(Signature of Psychologist/Psychiatrist)
(License Number) (State of License)
(Name of Psychologist/Psychiatrist – Please Print)
(Street Address) (ZIP) (Telephone)
(Date of Psychological Examination) (Today’s Date)
RDA #1494
IN-1779 10/4/13
| APPLICANT: |
| Name of PsychologistPsychiatrist Please Print: |
| Street Address: |
| Date of Psychological Examination: |
| License Number: |
| State of License: |
| ZIP: |
| Telephone: |
| Todays Date: |
| AGENCY: |
| QUALIFIED: Off |
| NOT QUALIFIED: Off |
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