Section J 4C Form CSO-012A Court Security Officers Medical Reevaluation Decision.pdf

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USMSCSO23
Solicitation number
15M10523RA4700028
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This document is a medical reevaluation form for court security officers under a federal contract. The form details requirements for reviewing and contractor representative certifications to verify an individual's medical qualification and ability to safely perform duties. The related solicitation is for court security officer services in several federal judicial circuits, requiring CSO services for the Department of Justice US Marshals Service. The requirement includes Circuits 2, 6, 7, 9, 10, 11 and 12.

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Form CSO-012A Rev. 01/18 Page of Note: Completed forms containing personally identifiable information (PII) must be encrypted and include the appropriate marking (U/FOUO) in the SUBJECT line of the message prior to dissemination via email.

UNCLASSIFIED // FOUO

UNCLASSIFIED // FOUO

Court Security Officer's Medical Qualification Reevaluation Decision U.S. Department of Justice United States Marshals Service

REVIEWING MEDICAL OFFICER (RMO) CERTIFICATION

Based on the company's personal observation and the information provided herein, it is the company's opinion that this individual meets all of the Court Security Officer medical standards.

I agree / disagree with the attending physician's recommendation regarding the individual's ability to safely perform Court Security Officer duties.

Additional documentation regarding my decision is attached/ not attached.

CONTRACTOR REPRESENTATIVE CERTIFICATION

Based on the company's personal observation and the information provided herein, it is the company's opinion that this individual meets all of the Court Security Officer medical standards.

I agree / disagree with the attending physician's recommendation regarding the individual's ability to safely perform Court Security Officer duties.

Additional documentation regarding my decision is attached/ not attached.

9.0.0.2.20101008.1.734229

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