ESBD_510338_1777061211700_SOL_EXH_F.7_L-2 Form Sample.pdf

L-2 Form 9.1.2024 Page 1 of 2

TEXAS COMMISSION ON LAW ENFORCEMENT

6330 E. Highway 290, STE. 200

Austin, Texas 78723-1035 Phone: (512) 936-7700 https://www.tcole.texas.gov

LICENSEE MEDICAL CONDITION DECLARATION (L-2)

Occupations Code § 1701.306; Commission Rules §§ 217.1, 217.7

INDIVIDUAL INFORMATION (TO BE COMPLETED BY ACADEMY OR AGENCY)

1. TCOLE PID 2. INDIVIDUAL LAST NAME 3. INDIVIDUAL FIRST NAME 4. M.I. 5. SUFFIX (Jr., etc.)

6. HOME MAILING ADDRESS 7. CITY 8. STATE 9. ZIP CODE 10. EMAIL

11. LICENSE TYPE SOUGHT (FOR STUDENT SEEKING ENROLLMENT IN ACADEMY – DO NOT CHECK IF SEEKING APPOINTMENT)

☐ PEACE OFFICER ☐ COUNTY JAILER ☐ TELECOMMUNICATOR (DRUG SCREEN ONLY)

12. APPOINTMENT TYPE(S) SOUGHT (FOR LICENSEE SEEKING APPOINTMENT WITH AGENCY – DO NOT CHECK IF SEEKING ENROLLMENT)

☐ PEACE OFFICER ☐ RESERVE OFFICER ☐ COUNTY JAILER ☐ PUBLIC SECURITY OFFICER

☐ TELECOMMUNICATOR (DRUG SCREEN ONLY)

13. EXAMINATION REQUESTED

☐ MEDICAL EXAMINATION AND DRUG SCREEN

(For academy enrollment, initial appointment after 180 days from academy graduation, withdrawn or invalidated L-2, or appointment upon agency request)

☐ DRUG SCREEN ONLY

(For subsequent appointments after a 180-day break in service or Telecommunicators)

ACADEMY OR AGENCY INFORMATION (TO BE COMPLETED BY ACADEMY OR AGENCY)

14. TCOLE NUMBER 15. ACADEMY OR AGENCY NAME 16. EMAIL

17. MAILING ADDRESS 18. CITY 19. STATE 20. ZIP CODE 21. PHONE NUMBER

INDIVIDUAL ACKNOWLEDGEMENT AND RELEASE (TO BE COMPLETED BY INDIVIDUAL)

22. I hereby authorize the release of the results of this medical examination, drug screen, or both, and any other relevant information to the above requesting academy or law enforcement agency and the Texas Commission on Law Enforcement.

INDIVIDUAL NAME (TYPE OR PRINT) INDIVIDUAL SIGNATURE DATE

Attention Requesting Academy or Agency and Examining Practitioner: State Law and Commission Rules require that a medical examination and drug screen be performed by a physician licensed in Texas. TCOLE policy allows a physician's assistant or a nurse practitioner licensed in Texas and working under the supervision of a physician licensed in Texas to perform the medical examination and drug screen. TCOLE policy allows a Department of Transportation (DoT) Provider to perform the drug screen.

Requesting Academy or Agency: After the above sections are completed, submit this form by mail or email to the practitioner selected by the academy or agency to perform the medical examination, drug screen, or both. For a medical examination, also submit a description of job duties for the license or appointment sought to the practitioner.

Examining Practitioner: The medical examination process must consist of a review of the description of job duties for the license or appointment sought. Given the nature of law enforcement and the potential consequences to the agency, the individual, and the public, the purpose of the medical examination and drug screen is to determine whether the individual is physically sound and free from any defect which may adversely affect the performance of duties appropriate to the type of license or appointment sought and whether the individual shows traces of drug dependency or illegal drug use.

MEDICAL EXAMINATION (TO BE COMPLETED BY PRACTITIONER)

23. Practitioner License Type

☐ PHYSICIAN ☐ PHYSICIAN'S ASSISTANT ☐ NURSE PRACTITIONER

24. PRACTITIONER LAST NAME 25. PRACTITIONER FIRST NAME 26. LICENSE NUMBER 27. EMAIL

28. MAILING ADDRESS 29. CITY 30. STATE 31. ZIP CODE 32. PHONE NUMBER

https://www.tcole.texas.gov/

TCOLE PID INDIVIDUAL LAST NAME INDIVIDUAL FIRST NAME M.I. SUFFIX (Jr., etc.)

L-2 Form 9.1.2024 Page 2 of 2

33. DESCRIPTION OF TESTS PERFORMED AND CONCLUSIONS, INCLUDING ANY EXISTING CONDITIONS OR RESTRICTIONS (ATTACH ADDITIONAL PAGES

AS NEEDED)

34. DATE MEDICAL EXAMINATION PERFORMED:

35. I certify that I have completed a medical examination of the above-named individual. I have concluded that the individual:

IS

physically sound and free from any defect which may adversely affect the performance of duties appropriate to the type of license or appointment sought.

IS NOT

physically sound and free from any defect which may adversely affect the performance of duties appropriate to the type of license or appointment sought.

PRACTITIONER NAME (TYPE OR PRINT) PRACTITIONER SIGNATURE DATE

STATE LAW AND COMMISSION RULES REQUIRE THAT A MEDICAL EXAMINATION BE PERFORMED BY A PHYSICIAN LICENSED IN TEXAS. TCOLE POLICY ALLOWS A PHYSICIAN'S ASSISTANT OR A NURSE PRACTITIONER LICENSED IN TEXAS AND WORKING UNDER THE SUPERVISION OF A PHYSICIAN LICENSED IN TEXAS TO PERFORM THE MEDICAL

EXAMINATION. THIS FORM IS ONLY VALID IF SIGNED BY THE APPROPRIATE PRACTITIONER.

DRUG SCREEN (TO BE COMPLETED BY PRACTITIONER)

36. Practitioner Type

☐ PHYSICIAN ☐ PHYSICIAN'S ASSISTANT ☐ NURSE PRACTITIONER ☐ DOT PROVIDER

37. PRACTITIONER LAST NAME 38. PRACTITIONER FIRST NAME 39. LICENSE NUMBER 40. EMAIL

41. MAILING ADDRESS 42. CITY 43. STATE 44. ZIP CODE 45. PHONE NUMBER

46. DATE DRUG SCREEN PERFORMED:

47. I certify that I have completed a drug screen of the above-named individual. I have concluded after a blood test or other medical test that the individual:

shows no trace of drug dependency or illegal drug use.

shows traces of drug dependency or illegal drug use.

PRACTITIONER NAME (TYPE OR PRINT) PRACTITIONER SIGNATURE DATE

STATE LAW AND COMMISSION RULES REQUIRE THAT A DRUG SCREEN BE PERFORMED BY A PHYSICIAN LICENSED IN TEXAS. TCOLE POLICY ALLOWS A PHYSICIAN'S ASSISTANT OR A NURSE PRACTITIONER LICENSED IN TEXAS AND WORKING UNDER THE SUPERVISION OF A PHYSICIAN LICENSED IN TEXAS TO PERFORM THE DRUG SCREEN, AS WELL AS A DOT PROVIDER. THIS FORM IS ONLY VALID IF SIGNED BY THE APPROPRIATE PRACTITIONER.

Examining Practitioner: After completing the above requested examination sections, return this form and any additional documents by mail or email to the requesting academy or law enforcement agency. If the individual is determined to not be physically sound or free from any defect which may adversely affect the performance of duties or shows traces of drug dependency or illegal drug use, please submit this form to TCOLE at fitforduty@tcole.texas.gov.

Requesting Academy or Agency: If the individual is determined to not be physically sound or free from any defect which may adversely affect the performance of duties or shows traces of drug dependency or illegal drug use, submit this form to TCOLE at fitforduty@tcole.texas.gov within 30 days of the examination.

This L-2 Form remains valid for 180 days from the individual's graduation date from the academy, if accepted by the appointing agency, or is valid for 180 days from the date signed by the practitioner, unless withdrawn or invalidated.

THIS DOCUMENT IS CONFIDENTIAL AND NOT SUBJECT TO DISCLOSURE

UNDER THE PUBLIC INFORMATION ACT, GOVERNMENT CODE CHAPTER 552.

mailto:fitforduty@tcole.texas.gov mailto:fitforduty@tcole.texas.gov