attmt__13_Non-Psych_Consult_Return_to_Academy_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: Return to Academy and Medical Qualification

Dear [COR]:

I have reviewed the supplementary information provided in support of [candidate name]’s ability to return to the training academy. The supplementary information reviewed consisted of [# pages].

[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)], I recommend that [candidate name] (is clear / is not clear) to return to the training academy and (is / is not) medically qualified to perform the duties of [position].

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