J.12 Certification of Physical Qualifications FAA Security Officers.pdf
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- Attached to
- Armed Guard Services, Federal Aviation Administration, Southern Regional Office, College Park, GA
- Solicitation number
- 697DCK-23-R-00123
About this file
This document contains a certification form for physical qualifications of Federal Aviation Administration security officers. The form requires certification that the named individual has passed drug screening, is physically fit to perform guard duties in good health without defects, has binocular vision correctable to 20/30 or better without color blindness, can hear normal conversation at 20 feet and whispered conversation at 10 feet without aids, and meets specified hearing level and difference requirements with or without hearing aids. The physician and contractor representative must sign with dates to certify the individual meets the qualifications.
The related federal contract opportunity is a solicitation for armed guard services at the Federal Aviation Administration Southern Regional Office in College Park, Georgia. The solicitation number is 697DCK-23-R-00123 and is issued by the Department of Transportation Federal Aviation Administration Southwestern Region.
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Text version
ATTACHMENT J.12
CERTIFICATION OF PHYSICAL QUALIFICATIONS
FEDERAL AVIATION ADMINISTRATION SECURITY OFFICERS
EMPLOYEE NAME: ----------------------------------- DATE OF BIRTH:----------------.
ADDRESS: _______________________________________________________________.
CONTRACTOR: _________________________________________________________.
CONTRACT NUMBER: ___________________________________________________.
// YES // NO The individual named above has submitted to drug testing and screening. The results will be sent to the Contractor via separate correspondence.
// YES // NO The individual named above is physically fit to perform guard duties and is in good general health without any physical defects or abnormalities.
// YES // NO The individual named above possesses binocular vision correctable to 20/30 (Snellen) and is not color blind.
// YES // NO The individual named above has the ability to hear normal conversation at 20 feet and whispered conversation at 10 feet without the benefit of a hearing aid.
// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) at 500, 1000, 2000, and 3000 Hertz (Hz) at a level that is less than or equal to 25 decibels.
// YES // NO The individual named above possesses hearing (corrected by a hearing aid or uncorrected) at 4000 and 5000 Hz at a level that is less than or equal to 45 decibels.
// YES // NO The individual named above possesses a hearing (corrected with a hearing aid or uncorrected) difference between the individual’s ears in the 500-3000 Hz range that is less than or equal to 15 decibels.
// YES // NO The individual named above possesses hearing (corrected with a hearing aid or uncorrected) that is not affected by an ear disorder that affects equilibrium
ATTACHMENT J.12
Physician’s Typed or Printed Name
Physician’s Signature Date
License Number
Address
Phone Number
CERTIFIED BY:
Contractor’ Representative’ Signature Date
Printed or Typed Name
Phone Number
File details come from the government source that posted it. Updated .