attmt__16_Psychiatric_Consultation_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: Psychiatric Medical Qualification

I have reviewed [##] pages of information in response to your request for a consultation.

Summary of Medical Findings: [Documentation of important/relevant facts from the applicants history as noted in the submitted records (e.g. exam, evaluation, records, VA, etc.) in paragraph form. Include the date and author of the record referenced.]

1. DSM IV (or most current version) diagnosis/diagnoses: [Please provide actual diagnoses, avoiding “likely” or “possible” diagnoses.]

2. Medications with the potential for affecting cognition: [Will the current use of this medication affect performance of weapon carrying law enforcement duties? If applicable.]

3. Psychiatric Specialist conclusions and rationale: [e.g., active symptoms, not demonstrated to be a stable condition, conflicting evidence provided.]

4. Nexus: [What specific CBPO/BPA duties are affected by symptoms? These duties will be found in the position description and PEPR. Provide a nexus when the recommendation is “does NOT meet minimum medical qualifications.”]

5. Recommendation: [Meets or Does NOT meet minimum medical qualifications.]

[Psychiatric Specialist Signature] [Name and Credentials]