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 psychological evaluation confirmation form from the Tennessee Peace Officer Standards and Training (POST) Commission used by law enforcement agencies to document the mental fitness assessment of police officer applicants. The form serves as an official confirmation that a licensed psychologist or psychiatrist has evaluated an applicant and determined whether the individual is qualified or not qualified for police certification under Tennessee Code Annotated Sections 38-8-106 and 8-8-102. The examining professional must certify that the applicant is free from any impairment as defined in the current edition of the Diagnostic and Statistical Manual of Mental Disorders that would affect the applicant's ability to perform essential job functions, with or without reasonable accommodation. The form requires the psychologist or psychiatrist to provide their license number, state of license, name, address, telephone number, and the date of examination, and must be signed by the examining professional under penalty of perjury. A copy of the confidential evaluation results remains with the employing agency, while only this confirmation form is forwarded to the POST Commission attached to the Application for Certification.
This document is a standard administrative form (RDA #1494 IN-1779, effective October 4, 2013) that establishes a uniform procedure for psychological fitness determinations across Tennessee law enforcement agencies. The form does not address pricing, funding, or procurement terms, as it functions solely as a certification document rather than a solicitation or contract instrument. It establishes that qualified mental health professionals must conduct evaluations prior to any officer certification, ensuring compliance with state statutory requirements and protecting public safety by screening for psychological conditions that could impair job performance.
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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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