attmt__10_Non-Psych_Level_I_Consult_Med_Qual_Template.pdf

[Date]

Department of Homeland Security US Customs and Border Protection [Addressee Office] [Addressee Street Address, Room/Suite #] [Addressee City, State, Zip Code]

Attn.: [Addressee Unit], [COR]

Name: ________________________

Medical ID: [#######]

Position: _____________________

Consult request date: _____________

Consult type: Level I Medical Qualification

Dear [COR]:

I have reviewed the supplementary information provided. The supplementary information reviewed consisted of [# pages]. It appears unlikely that the following condition(s) will adversely affect this candidate’s ability to perform the essential duties of the position:

_______[reviewed issue]________

_______[reviewed issue]________

Based on the additional information provided, I recommend that this candidate is medically qualified to perform the duties of [position].

The following issue(s) were not addressed in this recommendation:

__[“None” or list remaining issues]___

__[“None” or list remaining issues]___

[Signature of Reviewing Physician] [Signature Block of Reviewing Physician]