ESBD_510338_1777061298767_SOL_EXH_F.10_RC-14-Notice to Physician Form Sample.pdf

RC-14 (Revised 4/15) 1

TEXAS DEPARTMENT OF PUBLIC SAFETY

(CONDITIONAL JOB OFFER)

NOTICE TO PHYSICIAN

Name of Applicant: __________________________________ Last Four SSN:____________________

The person you are about to examine has applied for the position of Trooper-Trainee with the Texas Department of Public Safety. If selected, the cadet will undergo an 8 week intensive training (for current peace officers only) or the 21 to 26 weeks of training to become a DPS Licensed Peace Officer. Each training class is held at the Law Enforcement Academy and will include at least two (2) hours of strenuous physical training each day. The following is an example of the kind of activity that would be expected during the Academy, the following are performed during time sequenced events with a rest period between each event. The timed sequences are 12 minutes and 15 minutes or for best time. All circuits must be performed within safety protocols and performed with all out intensity and effort for the duration of the timed event:

1. Power-lifting: Dead-lifts, Cleans, Snatches, Clean and Jerks, Bench Press, and Military

Presses.

2. Crossfit/Cross-Training: Cross Fit is the principal strength and conditioning program for many police academies and tactical operations teams, military special operations units, champion martial artists, and hundreds of other elite and professional athletes worldwide. The Cross Fit program is designed for universal scalability. Cross Fit is a strength and conditioning fitness methodology that promotes broad and general overall physical fitness. Cross Fit combines weightlifting and sprinting.

Proficiency is required in each of the ten fitness domains: cardiovascular/respiratory endurance, stamina, strength, flexibility, power, speed, agility, balance, coordination, and accuracy. A total body core fitness regimen. The purpose behind this training is to reduce the amount of injuries associated with long distant running and to optimally develop and enhance the entire body.

Examples would include: Wall Ball (20lbs Men and 12-14lbs for Women); KettleBell (Swings, Presses, Dead-lifts, Snatches, and Jerks); Pull-ups; Jump-Pulls; Knee to Elbows and Toes to Bar (Pull-up Bar); Jump Rope; TRX Suspension Cables (Inverted Push-ups (raised Legs); Rope Drills (alternating Hand; Hands together; outward circles, inward circles, double hand right;

and double hand left); Tire Flips; Vertical Jumps; Standing Broad Jumps; Fire-man carries;

Core-Ball Sit-ups, V-ups, and 90 degrees (18lbs for men and 12lbs for women); and 24”Box Jumps; Dips; Push-ups (narrow, neutral, and wide; sometimes legs will be elevated); and regular sit-ups without additional weight.

3. Cardio Tabata: (Based on sprint work and timing) Tabata is an interval training method designed to improve maximum aerobic capacity and anaerobic capacity. By comparison, a study of traditional aerobic training, running at 70% of aerobic capacity for 60 minutes, for the same number of weeks

RC-14 (Revised 4/15) 2 showed an improvement in aerobic capacity of only 9.5% and no effect on anaerobic capacity. When

Tabata intervals are practiced, research shows that the percentage of fuel from carbs is increased, while the amount of fat utilized is greater than that burned during low intensity exercise. Tabata’s research found that short-term intense interval training is highly effective in lowering the ratio of lean body mass to fat without wasting muscle. Additionally, Tabata increases your metabolism and keeps it elevated for some time after your workout ends. The bottom line is Tabata burns a greater number of total calories than low intensity training, and more calories burned equals more fat loss.

An example of the Tabata Protocol is as follows: Completing 8 sets of 20:10 (20 seconds of sprinting followed immediately by 10 seconds of jogging) on Monday. On Wednesday 10 sets of 20:10 and

Friday 12 sets of 20:10. The next week: Tuesday 10 sets of 30:20 and Thursday 12 sets of 30:20.

The next week Monday 8 sets of 40:30, Wednesday 10 sets of 40:30 and Friday 12 sets of 40:30.

This is a progressive and aggressive protocol.

The Texas Department of Public Safety training is designed to test the trainee’s ability to perform satisfactorily under the kinds of extreme physical and mental stress likely to be experienced in the position of Trooper. In addition to calisthenics and running listed above, the trainee will be expected to perform additional exercises such as those listed below.

Strenuous activities, such as judo, karate kicks, grappling with instructors for simulated knife and gun control and perform counter measure techniques will be expected of each trainee.

Once employees as a Trooper, they will face physical confrontation while alone on rural highways with offender(s) trying to escape, resist arrest and/or injure the officer or another.

They will also be called on to respond to emergency situations where they will be required to administer and/or coordinate life saving efforts at major accident scenes, explosions, hazardous chemical spills, etc. Applicants with medical limitations that would indicate likely inability to complete the training and perform as a Trooper should not be recommended for the position of Trooper-Trainee. It is of great importance that the candidates are in excellent physical condition to ensure that they have the physical capabilities to complete the training and are able to handle the physical challenges they face as Troopers.

Attached is a Certificate of Examination for your completion and a Medical History completed by the applicant. Please review the Medical History thoroughly and during your examination please address ALL possible problem areas listed by the applicant in the Medical History; Keeping in mind the aggressive and progressive nature of this Physical Fitness Training regiment.

RC-14 (Revised 4/15) 3

Date of Exam: _______________________________

Name:________________________ Last four SSN:__________________ DOB:_____________

CERTIFICATION OF EXAMINATION BY PHYSICIAN:

Weight: ___________ Height: __________ Age:________ Temp:____________ Pulse:_______

Blood Pressure: ___________________ High Low Normal

Legend:

1. WNL – within normal limits

2. NS/AB – no significant abnormalities

3. AB – Abnormal

ITEMS WNL NS/AB AB COMMENTS

General App

Skin

Lungs

Cardiac Sounds

Cardiac Size

Eyes

Ears

Nasal Passages

Throat/Mouth

Neck

Glands

Head

Abdomen

RC-14 (Revised 4/15) 4

Neurological

Reflexes

Coordination

Genitourinary

Hernias

Hemorrhoids

Back

Hands & Arms

Legs

Feet

Joints

Musculoskeletal

Varicose Veins

URINALYSIS:

Appearance

Color

Specific Gravity

PH

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CONT. URINALYSIS:

Leukocytes

Protein

Glucose

Ketones

Urobilinogen

Bilirubin

Blood

VISION: Uncorrected visual acuity of 20-200 that is correctable to 20/30 is required. (If uncorrected

20/100 or greater, contacts are required – otherwise glasses can be used.)

BOTH RIGHT LEFT

Peripheral

Color

Comments:

Distance

Near

RC-14 (Revised 4/15) 6

HEARING: (With or without hearing aid)

Audiogram:

Left Right

500 Must be 25 dB or less in each ear

Must be 30 dB or less in each ear

2000 Must be 35 dB or less in each ear

3000 Must be 40 dB or less in each ear

Any noted physical defects: ______________________________________________________________

Any noted communicable diseases or infections: _____________________________________________

RC-14 (Revised 4/15) 7

Did you find any information contained in the Medical History that could impact this applicant’s ability to take part in the Law Enforcement Academy physical fitness training regiment.

No Yes

If yes, please explain:

Other Comments: ______________________________________________________________________

Examining Physician Signature ____________________________________ Date: _________________

Physician Print Name: ____________________________________________

RC-14 (Revised 4/15) 8

After reviewing the information contained in this report and the applicant’s Medical History:

I DO NOT RECOMMEND: the applicant as physically fit to take part in this physical fitness training regiment because:

I AM UNABLE to recommend the applicant as physically fit to take part in this physical fitness training regiment at this time because further testing/examination needs to be conducted; specifically, the following testing/examination is required:

I DO RECOMMEND the applicant as physically fit to take part in this physical fitness training regiment.

Physician Signature

Physician Name (please print)

Date

RC-14 (Revised 4/15) 9

Name:________________________________ Last Four SSN:______________ DOB:_______________

ANNEX A

RESULTS OF REFERRAL FOR FURTHER TESTING/EXAMINATION

Body Parts Evaluated:

Medical findings and evaluation are as follows:

I certify that I have reviewed the information related to the additional testing/examination on this applicant and as a result:

After further medical examination, I DO RECOMMEND the applicant as physically fit to take part in this physical fitness training regiment because:

I DO NOT RECOMMEND the applicant as physically fit to take part in this physical fitness training regiment because:

Physician Signature Type of Practice

Physician Name (please print) Date