Section J Att J.12 Physical Quals Certification.pdf

DTFAWA-17-R-00015

PART III – SECTION J, ATTACHMENT J.12

CERTIFICATION OF PHYSICAL QUALIFICATIONS

FEDERAL AVIATION ADMINISTRATION SECURITY OFFICERS

EMPLOYEE NAME: ----------------------------------- DATE OF BIRTH:----------------.

ADDRESS: _______________________________________________________________.

CONTRACTOR: _________________________________________________________.

CONTRACT NUMBER: ___________________________________________________.

// YES // NO The individual named above has submitted to drug testing and screening. The results will be sent to the Contractor via separate correspondence.

// YES // NO The individual named above is physically fit to perform guard duties and is in good general health without any physical defects or abnormalities.

// YES // NO The individual named above possesses binocular vision correctable to 20/30 (Snellen) and is not color blind.

// YES // NO The individual named above has the ability to hear normal conversation at 20 feet and whispered conversation at 10 feet without the benefit of a hearing aid.

// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) at 500, 1000, 2000, and 3000 Hertz (Hz) at a level that is less than or equal to 25 decibels.

// YES // NO The individual named above possesses hearing (corrected by a hearing aid or uncorrected) at 4000 and 5000 Hz at a level that is less than or equal to 45 decibels.

// YES // NO The individual named above possesses a hearing (corrected with a hearing aid or uncorrected) difference between the individual’s ears in the 500-3000 Hz range that is less than or equal to 15 decibels.

// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) that is not affected by an ear disorder that affects equilibrium

DTFAWA-17-R-00015

PART III – SECTION J, ATTACHMENT J.12

Physician’s Typed or Printed Name

Physician’s Signature Date

License Number

Address

Phone Number

CERTIFIED BY:

Contractor’ Representative’ Signature Date

Printed or Typed Name

Phone Number