fd-948 06122003.pdf

FD-948 (Rev. 6 12-03)

U.S. Department of Justice

Federal Bureau of Investigation

Washington, D. C. 20535-0001

Regarding: ____________________

Based upon your examination of your patient, please provide us with the following information, ensuring that all restrictions regarding his/her medical conditions are included.

Diagnosis: _________________________________ ICD Code: _________________________________ Medications: __________________________________________________________ Is this patient receiving physical therapy treatment? G Yes G No

Please give us a brief synopsis of his/her prognosis: __________________________________________________

1. G No lifting/carrying 0 - 20 pounds. 2. G No lifting/carrying 20 - 50 pounds.

3. G No lifting/carrying 50 - 100 pounds. 4. G No sitting for long periods of time

5. G No standing for long periods of time. 6. G No pushing/pulling, including push-ups and pull-ups.

7. G No climbing ladders, poles, etc. 8. G No jumping.

9. G No defensive tactics. 10. G No kneeling, bending, or twisting.

11. G No stretching or working above shoulders. 12. G No running.

13. G No operating a motor vehicle. 14. G No simple grasping.

15. G No firearms. 16. G No assignments in altitudes over 7,000 feet.

17. G No participation in raids/arrest or any undercover surveillance activities, or reactive squad duty.

18. G No direct assignments or duties that are expected to require the use of firearms.

19. G No restrictions needed

Expected length of limitations: _____________________________________________________________________

Date of next visit with you: __________________________

Other comments: ________________________________________________________________________________

Date: _____________________ Physician's Signature: _________________________________________

Type Name of Physician: ______________________________________

Board Certification: G Yes G No Speciality: __________________________________________________