Appendix_F_ICE_Deportation_Officer_Fitness_Test_Scoresheet_updated.pdf

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

DEPORTATION OFFICER

PRE-EMPLOYMENT FITNESS TEST (PFT) SCORESHEET

APPLICANT INFORMATION

Name (Last, First, MI): Social Security Number

Date of Birth: (MM/DD/YYYY) Age Gender (M/F)

Dominant Hand (R/L) Height (Inches) Weight (Pounds)

TESTING INFORMATION

1. KNEEL/STAND TEST

Kneeling/Standing tests completed without assistance/postural deviation?

Kneeling/Standing tests completed in 25 seconds?

STOP further testing if applicant has not passed Kneel/Stand tests without assistance/ postural deviation and within 25 seconds – Check FAILED in test summary box.

Maintained Upright Bilateral kneeling position for 2 minutes and stood without assistance/postural deviation?

STOP further testing if applicant has not passed Upright Bilateral kneeling position for 2 minutes and stood without assistance/postural deviation. – Check FAILED in test summary box.

Yes No Yes No

Yes No

2. FIFTEEN (15) PROPER FORM PUSH-UPS WITHIN TWO (2) MINUTES

15 Push-ups completed within 2 minutes If NO list number completed __________________

STOP further testing if applicant failed to complete 15 Proper Form Push-ups within 2 minutes.

Yes No

Time of Day ______AM

PM

3. STEP TEST

5 Minute Step Test successfully completed?

If test not successfully completed, enter time test stopped.

Failure Reason: Failed to keep cadence for 3 CONSECUTIVE SEQUENCES.

Failed a total of 6 CADENCE SEQUENCES after attaining initial step cadence .

Yes No _______ minutes _______ seconds

Yes No

Yes No

Check FAILED in test summary box if applicant did not successfully complete the Step Test.

TEST SUMMARY BOX

Applicant successfully completed all 3 (three) fitness tests.

Applicant failed to complete the: Kneel/Stand Test Push-Up Test Step Test

PERSON ADMINISTERING TEST

Name: Signature:

Phone Number: Date of Test (MM/DD/YYYY): Test Site (Location):

City: State:

O F F I C I A L ICE U S E O N L Y - Do Not Write Below This Line Based on the results of pre-employment fitness test results listed above, the applicant has:

PASSED and has been found physically fit for further consideration for the Deportation Officer position.

FAILED and is now removed from any further consideration for the Deportation Officer position.

Fitness Program Manager

Name:__________________________________________Signature:_____________________________Date:________

FOH Rev 04/2016

Name of Applicant (Last, First) SSN

Test Administrator Name (Last, First)

Date of Statement (Same as Date Tested)

Statement Regarding Immigration Enforcement Agent Pre-Employment Fitness Test Failure

Sworn Statement

I do so declare under penalty of law that this is an accurate and truthful documentation of the circumstances of the ICE Pre-Employment Fitness Test battery administered to the applicant named above.

Test Administrator Signature X

Date Telephone Number

Clinic Code City State Zip

FOH Rev 04/2016

STATEMENT

Acceptance of Responsibility for Physical Conditioning

It is my understanding that the law enforcement positions within the Office of Detention and Removal Operations (DRO) are vigorous, physically demanding, and requires a high level of physical fitness and stamina.

These physical requirements are stated within the position descriptions of DRO Law Enforcement occupations and have been repeated time and again in the materials I have received form the Minneapolis Hiring Center, as well as in telephone calls to confirm my interest in this position and to schedule my Preemployment Physical Fitness Test (PFT).

I understand that upon passing the PFT, I have the responsibility to maintain a high level of physical fitness to prepare myself for attendance at the DRO Academy and potentially for a career as a DRO Law Enforcement officer.

My signature hereto verifies that I fully understand and accept my personal responsibility with regards to physical conditioning. I pledge that I will diligently pursue a personal physical fitness program to assure that I meet all employment qualifications and Immigration and Customs Enforcement (ICE) expectations.

Printed name of Applicant :________________________________________

Signature of Applicant :________________________________________

Date :________________________________________

(Attention Test Administrators - include this signed Statement with all other materials that are to be sent to the Dallas Hiring Center)