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 evaluation issued by the Tennessee Peace Officer Standards and Training (POST) Commission, used by law enforcement agencies to certify that police officer applicants have been evaluated by licensed psychiatric or psychological professionals. The form requires the examining psychologist or psychiatrist to confirm whether applicants are qualified or not qualified for police certification based on their mental fitness to perform essential job functions, in accordance with Tennessee Code Annotated Sections 38-8-106 and 8-8-102 and the Diagnostic and Statistical Manual of Mental Disorders (DSM) standards. The examining professional must document their license number, state of license, credentials, examination date, and current date, then return the completed form to the employing law enforcement agency for attachment to the Application for Certification - Police Officer before submission to the POST Commission. The form emphasizes that confidential evaluation results remain with the employing agency and are not transmitted to the POST Commission, and warns that any false statements constitute perjury under T.C.A. 39-16-702.
This document serves as a supplemental requirement within the context of Tennessee's Facility Protection Services RFP 32110-22726, which requires armed Facility Protection Officers and related personnel across multiple state regions. The psychological evaluation confirmation form would be a necessary credential document for FPO applicants, as the RFP mandates that all contractor-employed personnel meet extensive training requirements and documented qualifications, though the RFP does not explicitly reference this specific POST Commission form. The form ensures that personnel hired for sensitive facility protection roles have undergone appropriate mental health screening to verify fitness for duty in a security context requiring sound judgment and psychological stability.
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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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