Attachment 2(H) - CSO Form 229.pdf

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Form CSO-229 Rev. 11/12 Page of Form CSO-229 Rev. 11/12 Page of Form CSO-229 Rev. 11/12 Page of U.S. Department of Justice United States Marshals Service Certificate of Medical Examination for Court Security Officers MEDICAL EXAM INSTRUCTIONS FOR COURT SECURITY OFFICER (CSO) APPLICANTS/INCUMBENTS:

1. Nothing to eat or drink (except water) for 12 hours prior to examination appointment time. Regularly scheduled medications may be taken, as directed, unless you are a diabetic. Diabetics must contact their treating physician regarding the procedure they should follow for fasting before having laboratory tests performed.

2. Eyeglass (including "over the counter" reading glasses) and contact lens wearers: you must wear or bring your glasses/contacts with you to the examination.

3. Hearing aid wearers: The hearing test must be performed without hearing aids.

INSTRUCTIONS FOR COMPLETION OF THIS FORM

1. Complete all fields. Incomplete forms will not be accepted.

2. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A". If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

3. Do not use "white out" or correction tape. Initial and date any changes made to the form.

4. All dates provided on this form must be in Month/Day/Year (mm/dd/yyyy) or Month/Year (mm/yyyy) format. Use numbers (1-12) to indicate months. For example, May 27, 1972 should be shown as 5/27/1972.

5. If you need additional space to complete this form, use the Supplemental Information page. Specify the question number for which you are providing additional details.

CHECKLIST FOR CLINIC STAFF

* If specimen is hemolyzed, lab test must be repeated.

* If specimen is hemolyzed, lab test must be repeated.

CSO must be positioned in such a way that he is unable to visually detect the administration of tones during testing.

PART I - IDENTIFICATION (To be completed by Applicant/Incumbent.)

3. Sex:

7. Select one:

PART II - RELEASE (To be completed by Applicant/Incumbent.)

10. I, , authorize my employer and an examining physician, , to release my medical examination records to the United States Marshals Service (USMS) for employment consideration as a Court Security Officer, with the stipulation that the released information be kept confidential and used solely for the purposes of determining my medical qualification. In addition, I hereby grant the USMS permission to release my medical records to the reviewing medical officials designated by the USMS.

PART III - REPORT OF MEDICAL HISTORY (To be completed by Applicant/Incumbent.)

1. List all medications currently used.

Name of Medication Diagnosis Dosage Taken Since

2. Provide history of hospitalizations.

Admission Date Reason for Admission Type of Treatment Outcome

3. Provide surgical history, including outpatient procedures.

Date of Surgery Diagnosis Type of Procedure Outcome

4. Answer each of the following questions:

NO YES If 'YES', explain:

a. Have you been refused employment or been unable to hold a job or stay in school because of:

i. Sensitivity to chemicals, dust, sunlight, etc.

ii. Inability to perform certain motions

iii. Inability to assume certain positions

iv. Other medical reasons (If 'YES', give reasons.)

b. Have you ever been denied life insurance? (If 'YES', give reason for denial and details.)

c. Have you been advised to have any operations not listed under Question #3 above (Surgical History)? (If 'YES', specify the type of procedure and when recommended.)

d. Have you ever been rejected for, or discharged from, military service because of physical, mental, or other reasons? (If 'YES', give date, reason, and type of discharge if any.)

e. Have you ever received or applied for disability compensation or disability pension? (If 'YES', specify what kind, granted by whom, amount, when and why.)

PART III - REPORT OF MEDICAL HISTORY (Continued) (To be completed by Applicant/Incumbent.)

PART IV - PHYSICAL EXAM (To be completed by Examining Physician.)

All items listed below as 'YES' (past or current) must be explained below.

GENERAL CONDITION

CHECK EACH ITEM

YES NOW

YES PAST

NO

1. Recent gain/loss of weight

2. Chronic or frequent colds

3. Skin diseases

4. Anemia

5. Leg cramps

6. Adverse reaction to serum drug or medicine

7. Tumor (Specify type/location below)

8. Growth (Specify type/location below)

9. Cyst (Specify type/location below)

10. Cancer (Specify type/location below)

11. Diabetes or sugar in urine

12. Stutter or stammer habitually

13. Excessive bleeding after injury or surgery

14. Do you wear glasses or contact lenses?

15. Blindness in one eye

16. Sleep apnea DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

HEAD, EYES, EARS, NOSE, THROAT (INCLUDING THYROID)

CHECK EACH ITEM

YES NOW

YES PAST

NO

17. Eye trouble or surgery (RK, PR, Lasik, other)

18. Ear, nose, throat, sinus trouble

19. Hearing loss

20. Severe tooth/gum trouble

21. Hay fever/allergies

22. Thyroid trouble

23. Wear a hearing aid DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

Applicant/Incumbent Comments (See example below. Use the Supplemental Information page if additional space is needed.):

Item # Diagnosis (if known) Date of onset Date of recovery (if resolved) Doctor's Comments: Please review comments in the area at left for completeness and add any additional clarifications in the unshaded area below.

Eczema (EXAMPLE) PART III - REPORT OF MEDICAL HISTORY (Continued) (To be completed by Applicant/Incumbent.)

PART IV - PHYSICAL EXAM (To be completed by Examining Physician.)

All items listed below as 'YES' (past or current) must be explained below.

CARDIORESPIRATORY

CHECK EACH ITEM

YES NOW

YES PAST

NO

24. Scarlet or rheumatic fever

25. Tuberculosis

26. Exposed to someone with tuberculosis

27. Coughed up blood

28. Asthma/emphysema/shortness of breath

29. Chest pain or pressure

30. Chronic cough/bronchitis

31. Palpitation/pounding heart

32. Heart disease or trouble

33. High or low blood pressure

34. Disease of the arteries

35. Abnormal chest x-ray

36. Increased cholesterol level

37. Abnormal ECG or stress test DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

GASTROINTESTINAL

CHECK EACH ITEM

YES NOW

YES PAST

NO

38. Frequent indigestion/reflux

39. Gallbladder trouble/stones

40. Jaundice or hepatitis

41. Hemorrhoids

42. Stomach, liver, intestinal trouble DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

GENITOURINARY/HERNIAS

CHECK EACH ITEM

YES NOW

YES PAST

NO

43. Rupture/hernias

44. Frequent or painful urination

45. Kidney stone or blood in urine

46. Protein in urine

47. Prostate trouble/surgery DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

Applicant/Incumbent Comments (See example below. Use the Supplemental Information page if additional space is needed.):

Item # Diagnosis (if known) Date of onset Date of recovery (if resolved) Doctor's Comments: Please review comments in the area at left for completeness and add any additional clarifications in the unshaded area below.

Hemmoroids (EXAMPLE) PART III - REPORT OF MEDICAL HISTORY (Continued) (To be completed by Applicant/Incumbent.)

PART IV - PHYSICAL EXAM (To be completed by Examining Physician.)

All items listed below as 'YES' (past or current) must be explained below.

NERVOUS SYSTEM

CHECK EACH ITEM

YES NOW

YES PAST

NO

48. Frequent or severe headache

49. Dizziness/vertigo

50. Fainting spells/syncope

51. Head injury

52. Stroke

53. Neuritis

54. Paralysis

55. Epilepsy or seizures

56. Frequent trouble sleeping

57. Depression, anxiety, excessive worry

58. Loss of memory or amnesia

59. Periods of unconsciousness

60. Psychiatric counseling

61. Learning disability

62. Treatment for mental condition

63. Attempted suicide DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

MUSCULOSKELETAL

CHECK EACH ITEM

YES NOW

YES PAST

NO

64. Wear a brace or back support

65. Swollen or painful joints

66. Broken bones

67. Arthritis, bursitis, tendonitis

68. Bone/joint or other deformity

69. Back pain/trouble

70. Painful or "trick" shoulder/elbow

71. "Trick" or locked knee

72. Gout

73. Loss of finger or toe

74. Foot pain or trouble DOCTOR'S COMMENTS - Check one and explain as necessary:

noted upon exam.

findings were noted:

Applicant/Incumbent Comments (See example below. Use the Supplemental Information page if additional space is needed.):

Item # Diagnosis (if known) Date of onset Date of recovery (if resolved) Doctor's Comments: Please review comments in the area at left for completeness and add any additional clarifications in the unshaded area below.

Broken left arm (EXAMPLE) Is there any other medical disorder or physical impairment that has not been documented on the previous pages which could interfere with the full performance of the duties listed on page 10?

If 'YES', explain below.

SUPPLEMENTAL INFORMATION PAGE

APPLICANT/INCUMBENT'S SIGNATURE AND CERTIFICATION STATEMENT

Read the following carefully before signing this certification. A false answer to any question in this statement may be grounds for disqualification and may be punishable by fine or imprisonment (U.S. Code Title 18, Section 1001).

I have completed this statement with the knowledge and understanding that any or all items contained herein may be subject to investigation and I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies, to duly accredited investigators, and other authorized employees of the Federal Government for that purpose.

CERTIFICATION: I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

PART V - PHYSICAL MEASUREMENTS (To be completed by Examining Physician or clinic staff.)

VITAL SIGNS

Height:

Blood Pressure:

VISION/ACUITY

Both Right Left Both Right Left Uncorrected Near:

Uncorrected Far:

Corrected Near:

Corrected Far:

VISION - COLOR

Testing MUST be done with Ishihara (or comparable) Pseudo=Isochromatic Plates. A MINIMUM OF FOURTEEN PLATES must be reported.

Type of test:

VISION - PERIPHERAL

Is the peripheral vision normal?

VISION - DEPTH PERCEPTION

HEARING

Hearing testing must be done with an AUDIOMETER IN A SOUND CONTROLLED ROOM OR BOOTH. Each ear must be tested separately at 500, 1000, 2000, 3000, and 4000 Hz. HEARING AIDS MAY NOT BE USED DURING TESTING. Attach audiometer printout to this form.

Results:

Right ear Left ear PART VI - EXAMINATION SUMMARY (To be completed by Examining Physician.)

Please be advised that the COURT SECURITY OFFICER (CSO) IS A WEAPONS BEARING SECURITY POSITION. The range of duties that the officer must be constantly prepared to perform include INTENSE PHYSICAL EXERTION, USE OF FIREARMS AND PHYSICAL CONFRONTATION. Emergency situations requiring such activities MAY ARISE WITHOUT WARNING and require maximum performance with no opportunity for preparation. Any condition that can subtly or suddenly compromise the CSO's ability to perform the full range of duties may result in INJURY or DEATH to the officer, co-workers or members of the public.

Detailed description of the essential job functions of the Court Security Officer position may be found on page 10.

Are there any contraindications to the performance of aggressive security activities?

Please affirm the following three statements and sign below.

NOTE: The designated physician must co-sign all examinations performed by Physician Assistants or Nurse Practitioners.

The following must be attached to this exam form:

Attending Physician: Return this completed form in a sealed envelope to the Court Security Officer.

COURT SECURITY OFFICER JOB FUNCTIONS

The primary functions of the Court Security Officer include physical security for federal court facilities and perimeters, checkpoint security for court facilities and courtroom entry points, courtroom monitoring, and a rapid response to emergencies and alarms within facility where federal court proceedings are held.

Essential duties require Court Security Officers to be able to:

Work Environment

1. Work extended hours

2. Work in adverse weather

3. Work alone while armed

4. Work under stress

5. Stop, question or detain individuals

6. Encounter individuals who display a violent or irrational temperament

7. Provide armed escort

Weapons

8. Use handgun with weak (non-dominant) hand

9. Use handcuffs

10. Use handgun

11. Confiscate weapon from person in pat down

Cardiovascular and Musculoskeletal

12. Must have the ability to physically subdue attacker(s)

13. Must have the ability to physically control violent or unruly crowds

14. Must have the ability to subdue after running in pursuit

15. Must have the ability to respond to emergency with unplanned strenuous physical activity

16. Must have the ability to climb stairs in pursuit or in emergency

17. Must have the ability to sit or stand in one position for at least 2 hours

Vision

18. Use distant vision to monitor front checkpoint and to monitor courtroom

19. Use distant vision to monitor garage/vehicles

20. Use distant vision to detect if individual has weapon

21. Use near vision to read x-ray monitor

22. Recognize basic colors

23. Visually detect peripheral movement/ID threat

Hearing

24. Comprehend speech during face-to-face conversations

25. Comprehend speech during telephone conversations

26. Comprehend speech during radio transmissions

27. Comprehend speech when you can't see another CSO

28. Hear sounds that require investigation

29. Determine location of sound

PURPOSE OF THE FORM

Completion of Form CSO 229 is required to ensure that all applicant and incumbent Court Security Officers meet the medical standards as outlined in the Statement of Work and are medically qualified to perform all Court Security Officer duties. This form must be completed by the applicant or incumbent Court Security Officer and the designated examining physician and submitted to the Office of Court Security, Judicial Services Division, U.S. Marshals Service for a medical qualification determination.

AUTHORITY TO REQUEST THIS INFORMATION

The authority for collection of this information is set forth in 28 U.S.C 561; 28 U.S.C. 566; and 5 U.S.C. 3301.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

The disclosure of this information is VOLUNTARY. However, Failure to provide information requested on this form may result in the government's inability to determine your eligibility for the position applied for or occupied, and may affect your prospects for employment or continued employment under a government contract, or at a Federal facility, or with a government license. Your Social Security number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

PRIVACY ACT ROUTINE USES

In accordance with Justice/USM-010, Judicial Facility Security Index System, 72 Fed.Reg. 33515, 26 (June 18, 2007), records or information may be disclosed:

(a) To any criminal, civil, or regulatory law enforcement authority (whether federal, state, territorial, local, tribal, or foreign) where the information is relevant to the recipient entity's law enforcement responsibilities;

(b) In an appropriate proceeding before a court, grand jury, or administrative or adjudicative body, when the Department of Justice determines that the records are arguably relevant to the proceeding; or in an appropriate proceeding before an administrative or adjudicative body when the adjudicator determines the records to be relevant to the proceeding;

(c) To the news media and the public, including disclosures pursuant to 28 CFR 50.2, unless it is determined that release of the specific information in the context of a particular case would constitute an unwarranted invasion of personal privacy;

(d) To a Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of, and at the request of, the individual who is the subject of the record;

(e) To the National Archives and Records Administration for purposes of records management inspections conducted under the authority of 44 U.S.C. 2904 and 2906;

(f) To an actual or potential party to litigation or the party's authorized representative for the purpose of negotiation or discussion of such matters as settlement, plea bargaining, or in informal discovery proceedings;

(g) To appropriate officials and employees of a federal agency or entity which requires information relevant to a decision concerning the hiring, appointment, or retention of an employee; the issuance, renewal, suspension, or revocation of a security clearance; the execution of a security or suitability investigation; the letting of a contract; or the issuance of a grant or benefit;

(h) A record may be disclosed to designated officers and employees of state, territorial, local (including the District of Columbia), or tribal law enforcement or detention agencies in connection with the hiring or continued employment of an employee or contractor, where the employee or contractor would occupy or occupies a position of public trust as a law enforcement officer or detention officer having direct contact with the public or with prisoners or detainees, to the extent that the information is relevant and necessary to the recipient agency's decision;

(i) To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government, when necessary to accomplish an agency function related to this system of records;

(j) To a former employee of the Department for purposes of: responding to an official inquiry by a federal, state, territorial, or local government entity or professional licensing authority, in accordance with applicable Department regulations; or facilitating communications with a former employee that may be necessary for personnel-related or other official purposes where the Department requires information and/or consultation assistance from the former employee regarding a matter within that person's former area of responsibility;

(k) To appropriate agencies, entities, and persons when (1) the Department suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; (2) the Department has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by the Department or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with the Department's efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response for the patient, and 60 minutes for the examining physician, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to U.S. Marshals Service, Attn: JSD-Office of Court Security, 2604 Jefferson Davis Highway, Alexandria, VA 22301. Do not return this document to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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