fd-300 10212009.pdf

FD-300 (Rev. 10-21-2009) Attachment to Standard Form (SF) 88, Report of Medical Examination

For Information and Guidance of Medical Examiner

Name of Examinee__________________________________________________________________________________________ (Type or print) Last First Middle

The following portions of the attached SF-88 need not be completed: 3, 9, 45a, 45b

For All Examinees, the Medical Examiner should answer the following question:

Examinee □ is □ is not qualified for strenuous physical exertion.

1. For all Special Agents, Police Officers, Special Agent Applicants and Police Officer Applicants, does examinee have any defects restricting or prohibiting his/her participation in defensive tactics and dangerous assignments which might entail the practical use of firearms?

□ Yes □ No If “yes” please specify defects._______________________________________________________________________________

2. Does examinee have any defects prohibiting safe operation of motor vehicles?

□ Yes □ No If “yes” please specify defects._______________________________________________________________________________

3. Examinees should possess uncorrected visual acuity no worse than 20/200 (Snellen) in each eye, with correction to 20/20 in one eye and at least 20/40 in the other eye. For safe driving of motor vehicles, Office of Personnel Management requires distant vision must test at least 20/40 in one eye and 20/100 in the other, corrected or uncorrected.

Should examinee wear corrective lenses while operating a motor vehicle? □ Yes □ No

If recommendation is based on a factor other than above standard, indicate basis______________________________________________________

Desirable Weight Ranges

MALES FEMALES

Height Weight Height Weight 5’4 117-163 5’0 96-138 5’5 120-167 5’1 99-141 5’6 124-173 5’2 102-144 5’7 128-178 5’3 105-149 5’8 132-183 5’4 108-152 5’9 136-187 5’5 111-156

5’10 140-193 5’6 114-161 5’11 144-198 5’7 118-165 6’0 148-204 5’8 122-169 6’1 152-209 5’9 126-174 6’2 156-215 5’10 130-179 6’3 160-220 5’11 134-185 6’4 169-231 6’0 138-190 6’5 174-238

4. Considering above weight table, I consider his/her present weight

□ Satisfactory □ Excessive □ Deficient

5. Under proper medical supervision, employee should □ lose __________ pounds

□ gain __________ pounds

Signature of Medical Examiner

Date