Attachment%20B%20Psychological%20Evaluation.pdf
PDF 232 KB Posted
- 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 form for psychological evaluations required by the Tennessee Peace Officer Standards and Training (POST) Commission, utilized by Tennessee law enforcement agencies conducting psychological assessments of police officer applicants. The form serves as the official documentation submitted by licensed psychologists or psychiatrists to confirm that applicants meet Tennessee Code Annotated Sections 38-8-106 and 8-8-102 requirements by being free from any mental impairment that would affect job performance. The examining professional must evaluate the applicant using tests and clinical assessment, then certify the applicant as either QUALIFIED or NOT QUALIFIED for police officer certification. Upon completion, the psychologist/psychiatrist returns the signed confirmation to the employing law enforcement agency, which then submits it with the Application for Certification to the POST Commission, while maintaining a copy and the confidential evaluation results in the agency's personnel file. The form explicitly prohibits submission of confidential psychological evaluation reports to the POST Commission.
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. All parties involved in the certification process are warned that false statements on the document constitute perjury under Tennessee Code Annotated Section 39-16-702. The form is designed to ensure standardized psychological clearance procedures across Tennessee law enforcement agencies and establishes accountability for the examining mental health professional conducting the evaluation.
View the file
Other files for this state and local contract opportunity
Show all 50
Facility Protection Services - UPDATED has more files on GovTribe.
On GovTribe
Work with this file on GovTribe
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 |
File details come from the government source that posted it. Updated .