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 use by law enforcement agencies during the police officer certification process. The form serves as documentation that applicants for police certification have completed a psychological evaluation conducted by a licensed psychologist or psychiatrist qualified in the psychiatric or psychological field. The examining professional must certify whether the applicant is qualified or not qualified for certification under Tennessee Code Annotated Sections 38-8-106 and/or 8-8-102, based on whether the applicant is free from any mental health impairment as defined in the current Diagnostic and Statistical Manual of Mental Disorders (DSM) that would affect their ability to perform essential job functions. The form requires the examining professional to provide their license number, state of licensure, contact information, and the date of the psychological examination, and must be completed and returned to the employing law enforcement agency, which then submits it with the Application for Certification to the POST Commission. A copy of the confidential evaluation results is retained by the agency but not forwarded to the POST Commission.
The form includes a perjury warning pursuant to Tennessee Code Annotated Section 39-16-702, emphasizing that any false statements made with intent to deceive constitute a criminal offense. This confirmation of psychological evaluation is a mandatory administrative requirement in Tennessee's police officer certification process and establishes documentation that proper mental health screening has been conducted prior to an individual being certified as a peace officer.
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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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