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, applicable to law enforcement agencies conducting psychological evaluations for police officer certification applicants. The form serves as official documentation that a licensed psychologist or psychiatrist has evaluated a prospective officer and determined whether the applicant meets mental fitness standards required under Tennessee Code Annotated Sections 38-8-106 and 8-8-102. The examining professional must assess whether the applicant is free from any impairment, as defined in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association, that would affect the applicant's ability to perform essential job functions with or without reasonable accommodation. The evaluator must indicate qualification status by checking either "Qualified" or "Not Qualified" and sign the form with their license number, state of license, and examination date. A copy of the report and confidential evaluation results must be retained by the employing agency; the confidential evaluation results must not be forwarded to the POST Commission, only this confirmation form.
The psychological evaluation is a mandatory prerequisite for police officer certification in Tennessee and is conducted at the expense of the employing law enforcement agency. This confirmation form establishes an official record that the evaluation was performed by a qualified mental health professional licensed in Tennessee and documents the examiner's professional judgment regarding the applicant's psychological fitness for law enforcement duties. False statements on this document constitute perjury under Tennessee law, establishing the legal significance of the certification process.
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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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