Attachment 2(L) - CSO Form 012.pdf

1 OF 4 CSO FORM 012 (REV. 04/06)

Section J – Attachment 2(O)

COURT SECURITY OFFICER CONTRACTOR’S

REQUEST TO REEVALUATE AN INDIVIDUAL’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 Judicial Protective Services for a qualification determination. A Court Security Officer may not resume security services until the Judicial Protective Services has provided written approval for the individual to resume performing under the applicable contract. Please fax and submit the completed form to the Judicial Protective Services at (202) 307-5217, Attention: Personnel Support Branch, Washington, DC 20530-1000.

COURT SECURITY OFFICER INFORMATION DISTRICT: DISTRICT NO:

NAME:

LAST FIRST MIDDLE

SSN: DATE OF INJURY, ILLNESS, AND/OR SURGERY: / /

GIVE A DESCRIPTION OF THE INDIVIDUAL’S INJURY, ILLNESS, AND/OR SURGERY. (PLEASE IDENTIFY THE AREA(S)

OF THE BODY AFFECTED):

ATTENTION ATTENDING PHYSICIAN: The individual listed above 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 four, consider your medical assessment of the individual’s medical condition, and provide a written response to each of the questions listed below.

1. Diagnosis (include all associated conditions/symptoms detected):

2. Does the individual have any physical or mental restrictions or limitations? Yes No

a. If restrictions or limitations exist, please explain the circumstances in detail, including how long such challenges may exist.

b. Are the restrictions or limitations temporary or permanent? Temporary Permanent

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3. Describe all treatments, including physical therapy or psychotherapy, and the duration of the treatment(s) provided to the individual. List all medications, including the name of the medication, the dosage prescribed as well as frequency, and any potential side effects the medication may cause. In addition, list any supportive devices, i.e., braces, crutches, hearing aids, etc., that the individual received.

4. Will the treatment affect the individual’s ability to perform any of the Court Security Officer duties identified on page four? If yes, please explain in detail below. Yes No

5. Prognosis (Please address whether or not the individual’s symptoms are likely to reoccur, progress, or be aggravated if the Court Security Officer performs any of the duties listed on page four.

6. Can the individual return to full, unrestricted security duties? * Yes No (If no, please explain below.)

For instance, does the individual have the ability to:

a. Safely use and retain a handgun? Yes No

b. Physically subdue an attacker(s)? Yes No

c. Physically control violent or unruly crowds? Yes No

d. Climb two flights of stairs in pursuit or in an emergency? Yes No

e. Sit or stand in one position for at least two hours? Yes No

* Please note that your response must indicate that the individual has the ability to meet all of the 29 CSO job functions listed on page four.

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’S NAME: (Print)

ATTENDING PHYSICIAN’S SIGNATURE:

DATE:

MEDICAL FACILITY INFORMATION:

ADDRESS:

TELEPHONE NUMBER:

PLEASE ATTACH YOUR BUSINESS CARD, LETTERHEAD, OR OFFICE STAMP ON THIS FORM AND RETURN THE FORM TO THE

COURT SECURITY OFFICER’S EMPLOYER IN A SEALED ENVELOPE.

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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.

NAME OF OFFICIAL REPRESENTATIVE:

OFFICIAL REPRESENTATIVE’S SIGNATURE:

DATE:

CONTRACTOR’S INFORMATION:

ADDRESS:

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.

PHYSICIAN’S NAME: (Please print.)

PHYSICIAN’S SIGNATURE:

DATE:

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COURT SECURITY OFFICERS 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