Exhibit_H_Police_Officer_Physical_-CJSTC-075-effective_6-9-08.pdf

Florida Department of Law Enforcement

PHYSICIAN’S ASSESSMENT

Incorporated by Reference in Rules 11B-27.002(1)(d), F.A.C.

Created 1/1/1996 Original - Agency 1 of 2 Commission-Approved Revisions: 11/8/2007 Form Effective Date: 6/9/2008

CJSTC

1. Applicant’s Name:

Last First MI

2. Applicant’s Home Address:

3. Last Four Digits of the Applicant’s Social Security Number:

4. Hiring Agency:

5. The Applicant Is Requesting Employment in one of the Following Disciplines:

Law Enforcement Correctional Correctional Probation

Note: A position description was provided that describes the job duties the applicant will perform.

6a. To the Examining Physician:

The examination of this applicant is for employment as an officer, and shall include a complete physical examination at a level of specificity sufficient to determine whether there is any medical or physiological reason that would prevent the applicant from performing the essential functions for employment as an officer for the discipline indicated in number 5 above. Disabilities, impairment, or limitations identified by the examination, which would prevent the applicant from performing the essential functions for the officer position, should be reported to the employing agency.

6b. Physician’s Attestment:

I hereby attest that I have examined the above named applicant and find him/her CAPABLE of performing the essential functions of the law enforcement, correctional, or correctional probation officer job for which the applicant is seeking employment reflected in number 5 above.

I hereby attest that I have examined the above named applicant and find him/her NOT CAPABLE of performing the essential functions of the law enforcement, correctional, or correctional probation officer job for which the applicant is seeking employment reflected in number 5 above.

7. Pre-existing Conditions: Sections 112.18 and 943.13, F.S., require agency knowledge of the following three pre-existing conditions.

However, these outcomes do not statutorily disqualify the applicant from employment.

Please respond to the following “in my professional opinion, this examination”:

7a. Did or did not reveal evidence of tuberculosis.

7b. Did or did not reveal evidence of heart disease.

7c. Did or did not reveal evidence of hypertension.

8. ________ Physician, Certified Advanced Registered Nurse Printed Name Examination Date Practitioner, or Physician Assistant’s Signature

9.

Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number Licensing State

10.

Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address

FORM CJSTC-75

INSTRUCTIONS FOR COMPLETING FORM CJSTC-75

Use this form to document and verify the applicant’s compliance with the employment requirements of Section 943.13, F.S.

GENERAL INSTRUCTIONS

• This form or an equivalent form, indicating that the officer is capable of performing the essential functions of the law enforcement, correctional, or correctional probation officer duties for which the applicant is seeking employment, is required and shall be used in conjunction with the Patient Information form CJSTC-75A or an equivalent form, to assist the physician, certified advanced registered nurse practitioner, or physician assistant, by providing testing guidelines to examine the applicant.

• An employing agency shall provide a position description to the physician, certified advanced registered nurse practitioner, or physician assistant that describes the job duties the applicant will perform. The position description will assist in determining whether the applicant is capable of performing the essential functions of a law enforcement, correctional, or correctional probation officer duties for which the applicant is seeking employment.

• This form or an equivalent form shall be used to satisfy the requirements of Section 943.13(6), F.S., and Rule 11B-27.002(1)(d), F.A.C. The completed form CJSTC-75 or an equivalent form shall be completed for each new employment or appointment of an officer, and shall not be completed more than one year prior to an officer’s employment or appointment. A CJSTC-75 form completed for a specific employing agency shall not be used by any other employing agency.

INSTRUCTIONS ON HOW TO

COMPLETE THIS FORM

1. Applicant’s Name: Enter the applicant’s full legal name.

2. Applicant’s Address: Enter the applicant’s home address.

3. Last Four Digits of the Social Security Number: Enter the last four digits of the applicant’s social security number as in this example: 000-00-1234.

4. Hiring Agency: Enter the hiring agency’s name.

5. Request for Employment as an officer: Place a check mark in the box for one of the following disciplines: Law Enforcement, Correctional, or Correctional Probation.

6a. Examining Physician: The examining physician shall examine the applicant for any medical or physiological reasons that would prevent the applicant for employment as an officer pursuant to the attached job duties.

6b. Physician’s Attestment: The physician, certified advanced registered nurse practitioner, or physician assistant shall mark the appropriate box attesting that the applicant is capable or not capable of performing the essential functions of the law enforcement, correctional, or correctional probation officer discipline for which the officer/applicant is seeking employment.

7. Sections 112.18 and 943.13, Florida Statutes, require agency knowledge of the following three pre-existing conditions for potential future disability claims. These outcomes are not disqualifying for employment.

a. Place a check mark in the appropriate box to indicate whether the examination did or did not reveal evidence of tuberculosis.

b. Place a check mark in the appropriate box to indicate whether the examination did or did not reveal evidence of heart disease.

c. Place a check mark in the appropriate box to indicate whether the examination did or did not reveal evidence of hypertension.

8. Signature: The physician, certified advanced registered nurse, or Physician Assistant shall sign and print his or her name and enter the examination date.

9. License Number: Enter the physician, certified advanced registered nurse practitioner, or physician assistant’s license number.

Licensing State: Enter the state in which the physician, certified advanced registered nurse practitioner, or physician assistant is licensed.

10. Professional Address: Enter the physician, certified advanced registered nurse, or physician assistant’s professional address.