Attachment 2(K) - CSO Form 012.pdf

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Form CSO-012 Rev. 11/12 Page of Form CSO-012 Rev. 11/12 Page of Form CSO-012 Rev. 11/12 Page of U.S. Department of Justice United States Marshals Service Request to Reevaluate Court Security Officer's Medical Qualification ATTENTION CONTRACTOR: Use of this form is required when a Court Security Officer is returning to perform security services after recovering from an injury, extended illness, and/or outpatient or inpatient surgery, including such procedures as LASIK. This form must be completed by the Court Security Officer's attending physician and submitted to the Office of Court Security (OCS), Judicial Services Division for a qualification determination. A Court Security Officer may not resume security services until OCS has provided written approval for the individual to resume performing under the applicable contract.

NOTE TO ATTENDING PHYSICIAN

The individual listed below is seeking to resume work as an armed Court Security Officer. It is imperative that you consider the individual's condition along with the life-threatening situation that a Court Security Officer may encounter. Court Security Officer duties may include physical exertion, use of firearms, and physical confrontation. These requirements may arise without warning and under adverse weather/environmental conditions. Inability to safely perform such duties may result in injury or death to the individual or others. Please review the Court Security Officer contract requirements listed on page 4, consider your medical assessment of the individual's medical condition, and provide a written response to each of the questions listed below.

8. Does the individual have any physical or mental restrictions or limitations?

b. Are the restrictions or limitations temporary or permanent?

10. Will the treatment affect the individual's ability to perform any of the Court Security Officer duties identified on page 4?

If 'YES', please explain in detail below:

12. Can the individual return to full, unrestricted security duties as outlined on page 4?

Does the individual have the ability to:

a. Safely use and retain a handgun?

b. Physically subdue an attacker(s)?

c. Physically control violent or unruly crowds?

d. Climb two flights of stairs in pursuit or in an emergency?

e. Sit or stand in one position for at least two hours?

ATTENDING PHYSICIAN'S CERTIFICATION

I hereby certify that my assessment and responses to the questions listed on this form are true, complete, and accurate to the best of my knowledge and ability.

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

CONTRACTOR'S CERTIFICATION

Based on the company's personal observation and the information provided herein, it is the company's opinion that this individual meets all of the Court Security Officer medical standards.

Contractor: Send by fax (703) 603-2023 or FedEx to:

US Marshals Service JSD - Office of Court Security 2604 Jefferson Davis Hwy Alexandria, VA 22301-1025

Retain a copy for your records.

U.S. MARSHALS SERVICE

DESIGNATED MEDICAL REVIEWING OFFICIAL'S CERTIFICATION

I agree / disagree with the attending physician's recommendation regarding the individual's ability to safely perform Court Security Officer duties.

Additional documentation regarding my decision is attached/ not attached.

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

INSTRUCTIONS FOR COMPLETION OF THIS FORM

1. Complete all fields below. All fields are required. 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. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.

4. All telephone numbers must include area codes.

5. 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.

6. If you need additional space to complete this form, please use a separate blank sheet of paper. Include the patient's name and date of birth on each sheet. Specify the question number for which you are providing additional details.

PURPOSE OF THE FORM

Completion of Form CSO-012 is required when a Court Security Officer is returning to perform security services after recovering from an injury, extended illness, and/or outpatient or inpatient surgery, including such procedures as LASIK. This form must be completed by the Court Security Officer's attending physician and submitted to the Office of Court Security, Judicial Services Division, U.S. Marshals Service for a qualification determination. A Court Security Officer may not resume security services until Federal Occupational Health has provided written approval for the individual to resume performing under the applicable contract.

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, 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.

9.0.0.2.20101008.1.734229