attmt__12_Non-Psych_Specialist_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: Medical Qualification with Specialist(s) Review

Dear [COR]:

I have reviewed the supplementary information provided in support of [candidate name]’s application for the position of [position]. The supplementary information reviewed consisted of [# pages]. This review was performed in conjunction with [specialist name].

[Narrative of reviewed issues listing each issue reviewed and whether resolved or unresolved. If unresolved, provide what additional information is needed if applicable.]

Based on the additional information provided with respect to [medical issue(s)], [specialist name] and I recommend that [candidate name] (is / is not) medically qualified to perform the duties of [position]. Enclosed please find a written opinion from [specialist name].

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

[“None” or list remaining issues]

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