Attachment%20G%20Medical%20Examination.pdf

TENNESSEE

PEACE OFFICER STANDARDS AND TRAINING COMMISSION

CONFIRMATION OF MEDICAL EXAMINATION

(To be completed by a licensed medical examiner)

OFFICER:______________________________________________________SSN:____________________

AGENCY:______________________________________________________________________________

TO THE HEAD OF LAW ENFORCEMENT AGENCY

This form should be presented to the medical examiner for the purpose of police officer certification. Upon completion of physical evaluation, the examiner should sign the appropriate statement and this form should be returned 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.

TO THE MEDICAL EXAMINER

Pursuant to Tennessee Code Annotated, Section 38-8-106, applicants for police certification must have passed a physical examination by a licensed physician or a nurse practitioner or physician assistant, so long as the task is expressly included in the written protocol developed jointly by the supervising physician and the nurse practitioner or physician assistant, whichever is applicable, setting forth the range of services that may be performed by the nurse practitioner or physician assistant. Upon completion of evaluation, please sign the appropriate statement and return this document to the law enforcement agency.

CONFIRMATION STATEMENT OF ATTENDING PHYSICIAN

I have performed a medical examination and find that this officer is:

PHYSICALLY FIT – This person is physically fit within reasonable degree of medical certainty.

NOT PHYSICALLY FIT – This person is not physically fit for the following reasons:

Comment:

(Signature of Medical Examiner) (Street Address)

(Date) (Telephone) (City/State)

RDA #1494

IN-1778 10/4/13