Attachment 2(H) - CSO-229.pdf

Date of Examination:

Purpose of Examination:

New Applicant Exam

Annual Medical Exam

(Privacy Act Protected) Form CSO-229 Rev. 06/07

Certificate of Medical Examination for Court Security Officers

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.

Signature (sign in ink) Date

Name:

District:

Medical Facility Completing Examination:

CSO-229 INSTRUCTIONS

-- 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.

-- ALL ITALICIZED AREAS are to be completed in ink by contractor's employee/applicant and reviewed by Examining Physician. Use the Supplemental Information page (p. 8) if additional space is needed.

-- Provide details where necessary. Do not leave any question blank. Do not use "white out" or correction tape. Additional information must be documented on the attached "Supplemental Information" sheet.

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

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

-- All certification statements must be signed and dated.

-- Corrections/alterations to documentation must be legible and signed or initialed by staff member.

-- "White out"/correction tape must not be used.

-- All test results and report forms must be legible and clearly identified with the CSO's name and the date the test was performed.

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

___ Fasting Chemistry panel to include fasting glucose, electrolytes, liver & renal function tests.*

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

___ Fasting Lipid Panel

___ CBC with WBC differential & Platelet Count*

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

___ Urinalysis (Test results for Specific Gravity, Glucose, Protein, & Blood in the urine must be documented)

___ 12 lead resting EKG (Lead placement must be verified by physician)

___ Hearing test - pure tone air conduction audiogram results (Attach printout or record results on page 10.)

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

___ Vision test results

-2-

CSO (INCUMBENTS)/APPLICANTS:

EXAMINING CLINIC STAFF:

CHECKLIST FOR CLINIC STAFF:

NAME (Last, First, Middle-Type or print): Soc. Sec. No.: Sex: Date of Birth:

M F

Circuit: District: Applicant Incumbent Years in Position: Date of Exam:

-3-

NAME (Last, First, Middle): Social Security #:

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.

DATESIGNATURE

DATEWITNESS

PART I. COURT SECURITY OFFICER IDENTIFICATION

PART II. COURT SECURITY OFFICER MEDICAL RELEASE FORM

STATEMENT OF MEDICATIONS CURRENTLY USED:

NOTE: CHECK HERE IF MEDICATIONS ARE NOT CURRENTLY USED

(Use the supplemental information page located at the end of the exam form if additional space is needed)

STATEMENT OF HOSPITALIZATION HISTORY:

NOTE: CHECK HERE IF NEVER HOSPITALIZED

PART III. REPORT OF MEDICAL HISTORY

Name of Medication Diagnosis Dosage Taken Since

Admission Date Reason for Admission Type of Treatment Outcome

-4-

NAME (Last, First, Middle): Social Security #:

STATEMENT OF SURGICAL HISTORY INCLUDING OUTPATIENT PROCEDURES:

NOTE: CHECK HERE IF NO PRIOR HISTORY OF SURGERY

YES NO EXPLANATION

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

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

B. Inability to perform certain motions C. Inability to assume certain positions D. Other medical reasons (If yes, give reason)

II. Have you ever been denied life insurance?

(Give reason for denial and details.)

III. Have you been advised to have any operations not listed under ''Surgical History'' above? (Give type of procedure and when recommended.)

IV. Have you ever been rejected for, or discharged from, military service because of physical, mental, or other reasons? (Give date, reason, type of discharge, if any.)

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

Check each of the following items YES or NO. Every item checked YES MUST be carefully explained in the blank space on the right. (Use the supplemental information page located at the end of the exam if additional space is needed)

PART III. REPORT OF MEDICAL HISTORY, CONTINUED

Date of Surgery Diagnosis Type of Procedure Outcome

-5-

NAME (Last, First, Middle): Social Security #:

PART III. REPORT OF MEDICAL HISTORY, CONTINUED

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 in the Comments section below)

8. Growth (Specify type/location in the Comments section below)

9. Cyst (Specify type/location in the Comments section below)

10. Cancer (Specify type/location in the Comments section 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

GENERAL CONDITION

Contractor's employee/applicant MUST PROVIDE an explanation in the Comments section below for each YES (current or past) item checked below.

All italicized areas MUST be completed by the Contractor's employee/applicant.

Have you now or have you ever had (check one box for each item below):

Contract Employee/Applicant Comments: (Use the Supplemental information page located on page 8 if additional space is needed). Contract Employee/Applicant MUST provide an explanation of all above YES answers. (See example below.)

No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

PART IV. PHYSICAL EXAM

Doctor's Comments: Doctor Comments: (Check one and explain as necessary for each organ system)

Item # Diagnosis (if known)

Date of onset

Date of recovery

(if resolved)

Doctor's Comments: Please review comments in the italicized area at left for completeness and add any additional clarifications in the unshaded area below.

3 Eczema (EXAMPLE) 1994 1994

-6-

NAME (Last, First, Middle): Social Security #:

17. Eye trouble or surgery (RK, PR, Lasik, or 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 right ear left ear

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

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

PART III. REPORT OF MEDICAL HISTORY, CONTINUED PART IV. PHYSICAL EXAM

GASTROINTESTINAL

38. Frequent Indigestion/Reflux

39. Gallbladder trouble/Stones

40. Jaundice or hepatitis

41. Hemorrhoids

42. Stomach, Liver, intestinal trouble

YES

NOW

YES

PAST NO

Contract Employee/Applicant Comments: (Use the Supplemental information page located on page 8 if additional space is needed). Contract Employee/Applicant MUST provide an explanation of all above YES answers. (See example below.)

No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

CARDIORESPIRATORY

No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

Doctor's Comments: (Check one)

Doctor's Comments: (Check one)

Doctor's Comments: (Check one)

Item # Diagnosis (if known)

Date of onset

Date of recovery

(if resolved)

Doctor's Comments: Please review comments in the italicized area at left for completeness and add any additional clarifications in the unshaded area below.

41 Hemmoroids (EXAMPLE) 2001 2001

-7-

NAME (Last, First, Middle): Social Security #:

NERVOUS SYSTEM

GENITOURINARY/HERNIAS

MUSCULOSKELETAL

PART III. REPORT OF MEDICAL HISTORY, CONTINUED PART IV. PHYSICAL EXAM

43. Rupture/hernias

44. Frequent or painful urination

45. Kidney Stone or blood in urine

46. Protein in urine

47. Prostate trouble / surgery

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

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

YES

NOW

YES

PAST NO

Item # Diagnosis (if known)

Date of onset

Date of recovery

(if resolved)

66 Broken left arm (EXAMPLE) 1994 1994

Doctor's Comments: Please review comments in the italicized area at left for completeness and add any additional clarifications in the unshaded area below.

Contract Employee/Applicant Comments: (Use the Supplemental information page located on page 8 if additional space is needed). Contract Employee/Applicant MUST provide an explanation of all above YES answers. (See example below.)

Doctor's Comments: (Check one) No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

Doctor's Comments: (Check one) No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

Doctor's Comments: (Check one) No positive or pertinent negative findings were noted upon exam.

The following positive and/or pertinent negative findings were noted:

-8-

NAME (Last, First, Middle): Social Security #:

SUPPLEMENTAL INFORMATION PAGE

CSO/APPLICANT COMMENTS: EXAMINING PHYSICIAN'S COMMENTS:

-9-

NAME (Last, First, Middle): Social Security #:

Is there any other medical disorder or physical impairment that has not been documented above which could interfere with the full performance of the duties listed on page 11?

YES (Explain below) NO

DATEPRINT (INCUMBENT) APPLICANT NAME SIGNATURE

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 III. REPORT OF MEDICAL HISTORY, CONTINUED

All un-italicized areas are to be completed by the Examining Physician or clinic staff.

Vital signs

Weight ________ Height ___Ft. ___In. Blood Pressure ____/____ Pulse ________________

Vision-Acuity: Both Right Left Both Right Left

Uncorrected Near 20/_____ 20/_____ 20/_____ Uncorrected Far 20/_____ 20/_____ 20/_____

Corrected Near 20/_____ 20/_____ 20/_____ Corrected Far 20/_____ 20/_____ 20/_____

Vision-Color:

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

Type of test: Ishihara Other _______________ # of plates correct: _____ # of plates tested _____

Vision-Peripheral:

Is the peripheral vision normal? (Check one) YES NO

Vision-Depth Perception:

Results must be recorded in seconds of arc.

Type of test: ___________________________ Score: _____________ Seconds of arc: __________

PART V. PHYSICAL MEASUREMENTS

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 page.

Results: 500 1000 2000 3000 4000

Right ear

Left ear

-10-

NAME (Last, First, Middle): Social Security #:

Fasting Chemistry Panel to include liver and renal function tests, fasting glucose by venipuncture, and electrolytes.

Fasting Lipid Panel CBC with WBC differential and platelet count.

Urinalysis for specific gravity, Blood, Glucose and Protein.

12 Lead ECG (original) lead placement must be verified by the examiner.

Audiometer Printout or results recorded on page if printout is not available.

Vision test results (Test records may be attached to this form).

Are there any contraindications to the performance of aggressive security activities? YES NO Check if supplemental information page is used

(Use the supplemental information page if additional space is needed)

Doctor, please affirm the three following statements with a check in the associated box and sign below. Thank you for your assistance in this important clearance process:

SIGNATUREEXAMINING PHYSICIAN'S NAME (Type or print)

ADDRESS (including ZIP code)

The following must be attached to this exam form:

I have reviewed and understand the available materials describing the requirements of the CSO position.

I have reviewed the attached ECG for adequacy and proper lead placement.

I have reviewed the currently available laboratory reports and other testing for adequacy and completeness.

OFFICE TELEPHONE NUMBER FACSIMILE NUMBER

PART VI. EXAMINATION SUMMARY

DOCTOR PLEASE NOTE:

Please be advised that the COURT SECURITY OFFICER 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 11.

Problem List (past & present medical/surgical conditions): Recommended Limitations (Essential job functions are listed on page 11.)

COURT SECURITY OFFICER'S 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

-11-