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 issued by the Tennessee Peace Officer Standards and Training (POST) Commission for law enforcement agencies conducting police officer certification evaluations. The form serves as official documentation that a licensed psychologist or psychiatrist has completed a psychological evaluation of a police officer applicant to determine fitness for certification under 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 an assessment of mental health using the current Diagnostic and Statistical Manual of Mental Disorders (DSM), specifically determining whether any impairment would affect the applicant's ability to perform essential job functions with or without reasonable accommodation. The form requires the examining professional to provide their license number, state of licensure, street address, telephone number, and the dates of both the psychological examination and form completion, and must be forwarded to the employing law enforcement agency, attached to the Application for Certification, and submitted to the POST Commission, with a copy and confidential results retained in the agency's file.
The form includes mandatory perjury language warning that false statements constitute an offense under T.C.A. 39-16-702, emphasizing the legal significance of the psychological evaluation confirmation in the police officer certification process. Confidential evaluation results are explicitly prohibited from being sent to the POST Commission, maintaining the privacy of detailed psychological findings while ensuring the certification determination reaches the appropriate regulatory body. This document serves as a critical screening mechanism to ensure that individuals certified as peace officers in Tennessee meet established psychological fitness standards for law enforcement service.
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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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