T2609 Attachment 1 01-12-22.pdf

Attachment #1 Table of Contents

T2609-Medical Examinations, Testing and Services Bid Solicitation # 22DPP00676

Name Page #

A. Medical Deficiency Report…………………………………………2 B. Police & Firemen's Retirement System Form……………………3 - 4 C. Occupational & Corporate Health Medical Hold NJDOC ………5 D. DEP’s Initial Standard Threshold Shift Referral Form………….. 6 E. Immunization Sheet…………………………………………………7 F. Health Status/Recommendations Form (ADM-204)……………..8 G. Confidential Health History (ADM-196)…………………………...9 - 12 H. Medical Services Sign-off Sheet…………………………………..13 I. Authorization to Disclose Medical Records...…………………….14 J. Antimicrobial Post-Exposure Program Medical Review Form….15 K. Police Training Commission Medical Screening…..…………….16 - 18 L. Police Training Commission Health History Statement…………19 - 24 M. Police Training Commission (PTC) Medical Certification……….25 - 34 N. Custody Recruitment Tattoo Identification Form ………………. 35 - 36 O. Hearing Conservation Program Questionnaire…………………...37 P. 40 hour Respiratory Clearance Letter……………………………..38 Q. Quantitative Fit Test Form…………………………………………..39 - 40 R. Confidential Respirator Questionnaire……………………………..41 - 44 S. OHSA Respirator Medical Evaluation Questionnaire…………….45 – 50 T. Respirator Medical Clearance Form………………………………..51 U. DEP’s Initial Medical Hearing Test Referral Form………………...52 - 53 V. NJDOT Medical Surveillance/Testing Clearance Report…………54 - 55

�Occupational & Corporate Health

MEDICAL HOU)

l\lew Jersey Department of Corrections

------�------------- Nas examined at our office and needs the following condition(s) to be corrected to qualify for employment.

D Flev.aied Blood Pressure

_J:a"\t1s1on Correction Required

D Abnormal El<G o Abnormal Blood work results

0 Abnormal Chest 'l<.-Ra.')I

0 Undocumented Condition or Surgery

D Other: _____________________________

After correcting the above, the applicant may return to our._office for a re-check. He/she must bring:

D Note from personal Physician stating, Diagnosis, Treatment, and abiBi1ty 1to work and abllitv

11:o u:»JJrJi-.,...c11!:e in D-UIEAVV enercise program.

�ou� from ophthalmologist stating:

A) Best corrected vision B) Color Vision C) Depth perception

0 Information regarding past condition or surgery

D Other: _-L___:-L-------------------------

Oat lf-Drnvoa:llers Sogr. -------------- D

1', O l

□ D Other

I o

ADM-202

11/06

�tttie of � efn m�rs�11

DEPARTMENT OF ENVIRONMENTAL PROTECTION

Office of Occupational Health and Safety 428 E. State Street PO Box 416

Trenton, NJ 08625 Phone (609) 292-1408 Fax (609) 984-2488

AUTHORIZATION TO DISCLOSE MEDICAL RECORDS

Patient Name: Date of Birth:

Patient Maiden Name: Phone#:

Home Address:

1. Authorization

I authorize the Office of Occupational Health and Safety to usc or disclose the above named individual's health information as described below.

To release any and all* medical information of treatments or examinations rendered to me through the department's contracted medical vendor.

* Note: Medical Surveillance Program Participants -A copy of your most current exam on file will be sent unless otherwise specifically instructed.

2. Release information to: please mark which box applies

D Myself (the patient or representative) D Organization/Individual below

Name of Organization/Individual: ______________________ _

Address of Organization/Individual:

□ Please mail to above address □ Please prepare records for pick-up on this date: __

3. I understand that I may be charged a fee for copies ofmy medical records and any applicable mailing/postage fees.

Signature of Patient or Legal Representative Date

If Signed by Legal Representative, Relationship to Patient Signature of Witness (OOHS rep)

Authorization Use.Disclosure of PHI HIPPA P-2. I Copy To Patient New Jersey is an Equal Opportunity Employer, Printed on Recycled Paper and Recyclable

Pl-llLIP D, MURPHY

Governor

SHEILA Y. OLIVER

LI. Governor

DEPARTMENT OF ENVIRONMENTAL PROTECTION

Office of Occupational Health and Safety

PO Box 420, Mail Code 428-02 Trenton, NJ 08625

Phone: (609) 292-1408 Fax: (609) 984-2488

NJDEP ANTIMICROBIAL POST-EXPOSURE PROGRAM

MEDICAL REVIEW FORM

CATHERINE R. MCCABE

Commissioner

Name: ___________________ Date of Birth: __________ _

(Circle)

Contact Phone Numbers (Cell): __________ Work/Home: __________ _

Allergies: ______________ Medication(s): _____________ _

Medical Problems: _____________________________ _

Height: ______________ _

I. Do you have a known allergy to Ciprofloxacin (Cipro)?

2. Do you have a known allergy to Doxycllcline?

3. Do you have any kidney dysfunction?

4. Are you or could you be pregnant?

5. Are you currently breastfeeding?

Weight: ___________ _

6. Do you have any questions or concerns that may become an issue while taking the antibiotics?

(If you wish to describe your concerns or questions, please explain below.)

I understand that my signature, below, indicates that J have read and understand the infonnation provided with this form regarding Ciprofloxacin (i.e., "Cipro"), including: What Cipro is used for; other important information about Cipro: side effects and incompatibilities with other drugs; how Cipro should be taken; and what to do about missed doses or inadvertent overdoses. [Source: http://www.drugs.com]

Signature: ________________ _ Date: ______ _

Form version·3:

Please return this form to OOHS when completed at the above address.

New Jersey is an Equal Opportunity Employer Recycled Paper

Appendix A: Medical Screening

Contents:

Description of Medical Screening Process

Letter to Prospective Trainee

Health History Statement (PTC-7) fillable .pdf

Letter to Physician

Medical Certification Form (PTC-8) fillable .pdf

DESCRIPTION OF MEDICAL SCREENING PROCESS

Any person attending the following basic courses must undergo a medical examination by a licensed physician to determine if the individual is fit to undergo training:

❍ Basic Course for Police Officers ❍ Basic Course for Class Two Special Law Enforcement Officers ❍ Basic Course for Investigators ❍ Basic Course for State Correctional Police Officers ❍ Basic Course for County Corrections Officers ❍ Basic Course for Juvenile Detention Officers ❍ Basic Course for County Park Rangers ❍ Basic Course for Juvenile Residential and Day Program Youth Workers ❍ Basic Course for Parole Officers ❍ Basic Course for Juvenile Correctional Police Officers ❍ Basic Course for Juvenile Parole Officers

The medical examination shall be administered within 90 days of an officer’s admittance to a basic course. The physician shall state, on a form prescribed by the commission, whether or not the individual is fit to undergo training.

The following materials pertain to the medical screening process:

❍ LETTER TO THE PROSPECTIVE TRAINEE - This letter informs the prospective trainee that he or she must obtain a medical clearance prior to acceptance into a commission basic course.

The employing agency shall provide the prospective trainee with a copy of this letter.

❍ HEALTH HISTORY STATEMENT (PTC-7) - The prospective trainee shall complete this form and shall give it to the examining physician. The physician shall return the completed form to the employing agency where it shall be treated confidentially. It must be pointed out that the information on the form was obtained specifically for training purposes and access to the form shall be strictly limited. It is the responsibility of the employing agency to make known to the trainee whether or not the agency wishes to retain copies of the PTC-7 and to provide a copy of this completed form to the school that the trainee will attend.

❍ LETTER TO THE PHYSICIAN - This is to be given to the examining physician by the prospective trainee. The letter contains information with respect to the commission’s Physicial Conditioning Training Program, Defensive Tactics training (unarmed defense), Physicial Restraint training, Firearms training, Baton training, exposure to chemical agents, and the medical screening process.

❍ MEDICAL CERTIFICATION FORM (PTC-8) - This form is to be completed by the examining physician and returned to the employing agency. It is the responsibility of the employing agency to indicate to the trainee whether or not the agency wishes to retain copies of the Medical Certification Form and to provide a completed copy of this form to the school the trainee will attend.

Police Training Commission

PTC

New Jersey

Revised 07/31/081 of 1

NOTICE TO TRAINEE

As part of the basic course you are planning to attend, you will be required to participate in certain training requiring physical activity. Depending on the basic course you are entering, these activities may include physical conditioning training, defensive tactics (unarmed defense), physical restraint training, baton training, exposure to chemical agents, and firearms training.* The purpose of this letter is to advise you that under N.J.A.C. 13:1-8.1(a)5, you are required to obtain medical clearance from a licensed physician prior to participation in the basic course.

The medical clearance is required to provide reasonable assurance that there is no medical reason why you should not participate in the training program. To obtain medical clearance, it is necessary for you to complete the Health History Statement (PTC-7) and to provide the completed statement to the examining physician. Please complete the Health History Statement prior to your physical examination.

Along with the Health History Statement and this letter to you, your agency chief (or designee) will provide you with the Medical Certification Form (PTC-8) and a letter to the examining physician. Please provide the following to the examining physician:

• Notice to Physician

• Health History Statement (PTC-7 completed)

• Medical Certification Form (PTC-8)

• An envelope which is marked Confidential and is addressed to the chief executive of the employing agency

* These activities are fully described in the Notice to Physician which your agency chief (or designee) will provide to you for submission to your examining physician. For your information, please review the description of physical activities that are applicable to the basic course you plan to attend.

The physician will be asked to return the completed Medical Certification Form to your agency. Medical clearance will depend upon the information contained in your Health History Statement and the results of your medical examination.

Thank you for your cooperation in complying with Commission requirements regarding medical clearance and best wishes for success in your career.

STATE OF NEW JERSEY

DEPARTMENT OF LAW AND PUBLIC SAFETY

DIVISION OF CRIMINAL JUSTICE

POLICE TRAINING COMMISSION

HEALTH HISTORY STATEMENT

Candidate’s Name_________________________________________________________

Social Security No.___________________________Date of Birth____________________

Candidate’s Address:_______________________________________________________

Candidate’s Employing Agency_______________________________________________

Police Training Commission - Approved School Candidate Will Attend:

Name of Course:__________________________________________________________

Course Dates:____________________________________________________________

To the Candidate: Please complete in ink the following questionaire concerning your past and present health. If you have an electronic copy of this form, it is a fillable .pdf, which can be typed and printed but cannot be saved.

Provide details for any positive answers on this statement.

(You need not explain positive answers for question 16.)

If additional pages are necessary, reproduce the last page.

The information on this form will be used strictly to determine training eligibility and the information will be treated confidentially.

1. Name and address of family doctor _________________________________________

2. Date last seen and reason________________________________________________

3. Do you use Tobacco products? Yes No What type?__________________

How often? ____________________ Quantity? ______________________________

PTC-7 (Rev. 7/1/02)

4. Do you use alcoholic beverages? Yes No If Yes, what is your approximate intake of these beverages?

None Occasional Often Drinks per week?

Beer

Wine

Hard liquor

5. a. Have you taken any drugs or medications prescribed by a physician in the last year? Yes No

b. Have you taken any over-the-counter or non-prescription medications in the last year? Yes No

c. Are you now on any medication? Yes No

6. a. Have you ever undergone a drug test for any employment or admission into a law enforcement training program? Yes No

b. Have you ever produced a positive result on any drug test reported in 6.a.?

Yes No

7. Do you have any hearing problem or deafness? Yes No Explain:_______

8. Do you wear glasses, contact lenses or have any other eye disorder? Yes No

Explain:_________________________________________________________________

9. Do you have any dental problems? Yes No Explain:___________________

10. Have you ever been hospitalized? Yes No If so, when?_________________

11. Have you ever had any surgery or operations? Yes No Explain:_________

12. Do you have any physical or mental condition that would prevent you from participating in any form of strenuous, prolonged exercise? Yes No Explain:____________

13. Do you participate in any regular exercise program or sport? Yes No

Explain:__________________________________________________________________

14. Has your weight changed in the last year? Yes No

How much? ___________ (+ or - lbs.)

15. Have you ever experienced any heat stress related emergencies, including heat fatigue, heat cramps, heat exhaustion or heat stroke? Yes No Explain:_______

16. Are you pregnant? Yes No Have you ever been pregnant? Yes No

Have you given birth during the six-week period of time preceding the start of the basic course? Yes No

17. Have you ever been discharged from the armed services for medical reasons?

Yes No

Family History

Age Health or Cause of Death Age Health of Cause of Death

Mother Father

Brothers Sisters

Heart and Blood Vessels

18. Have you ever had high blood pressure? Yes No When?______________

19. Have you ever had any type of heart trouble (murmer, leaky valve, rheutatic fever, heart attack, coronary?) Yes No Explain_______________________________

20. Do you have any chest pain, skipped heart beats or palpitations? Yes No

Explain__________________________________________________________________

21. Do you have any kind of circulation problem (cold hands or feet, leg pain while walking, varicose veins, swollen legs or ankles, vein problem, phlebitis)? Yes No

Explain__________________________________________________________________

22. Have you ever had any type of stroke? Yes No Explain_________________

Lung Problems:

23. Have you ever had any lung problem (shortness of breath, chronic cough, wheezing, asthma, emphysema, bronchitis, pneumonia)? Yes No Explain_____________

24. Are you now or have you ever used inhalers? Yes No When/how often?

Muscle - Bone - Joint Problems

Have you ever had:

25. Any type of back problem (slipped disk, low back strain, back pain, neck pain)?

Explain__________________________________________________________________

26. Recurrent dislocations of any joint, recurrent strains or sprains or any type of arthritis?

4PTC-7 (Rev. 7/1/02)

PTC-7 (Rev. 7/1/02)5

27. Any athletic or other injury, broken bones, requiring medical attention?_____________

Nervous, Mental or Emotional Disorders

28. Have you ever had any nervous or emotional disorders (seizures, fits, epilepsy, blackouts, fainting spells, mental illness, depression, head injury or concussion)?

Yes No Explain_________________________________________________

Allergies

29. List and explain any allergy problems (food, rash, hay fever, sinus trouble, wheezing, reaction to medicines)______________________________________________________

Blood Sugar, Blood Tests, Cancer

30 List and explain any high or low blood sugar, abnormal cholesterol, thyroid, anemia or other abnormal blood test, leukemia or cancer ___________________________________

Please list anything else which you feel may be important in your medical history, including any conditions not specifically referred to in the preceding questions.__________________

Details of “Yes” Answers. Include details as to when the condition was treated, and whether treatment was successful. Place appropriate question numbers for responses.

Attach additional pages as necessary.

Question # Details

6PTC-7 (Rev. 7/1/02)

Police Training Commission

PTC

New Jersey

1 of 3 Revised 07/31/08

Notice to Physician

Under N.J.A.C. 13:1-8.1(a)5, the individual you are examining is required to obtain medical clearance prior to acceptance into a Police Training Commission basic course involving physical activity. This training may include physical conditioning, defensive tactics (unarmed defense) training, baton training, physical restraint training, exposure to chemical agents and firearms training.

Physical conditioning consists of a series of physical fitness assessments and a program of physical exercise conducted at a school approved by the Police Training Commission. The exercise program will be conducted a minimum of three and a maximum of five times per week, each session lasting sixty minutes. For individuals who are more highly fit, an additional ten minutes of aerobic activity is permitted. The program of physical exercise will focus on flexibility, cardiorespiratory endurance (aerobics), strength, power, speed, and neuromuscular coordination (agility, balance). The intensity of training is individualized to the extent possible in a group setting and is gradually increased throughout the course of the exercise program.

Please note that some of the commission-approved schools have requested and received commission approval to include variations to the mandated physical conditioning training program. These variations include the use of Universal equipment, super-circuit weight training, boxing, obstacle courses and the horizontal ladder. The director of the school where the trainee will be enrolled has been informed to supply directly to you information concerning a school’s variation from the commission-mandated physical conditioning program.

Defensive tactics (unarmed defense) training teaches the trainee to use body parts as defensive weapons. The trainee will use the open hand, elbow, forearm, knee, foot, and hand during the defensive moves. Take-down tactics, holds, punching, straight kicks and headblocks are some of the defensive tactics employed during the training. Balance and leverage (extensive use of trunk and abdominal muscles) are part of the defensive stance used by the trainee.

Chemical agent training is held at either an indoor or an outdoor training area. A trainee may be exposed to either a direct facial spray of Oleoresin Capsicum (OC) or a room in which the chemical agent has been released. The trainee experiences the physiological impairments and reactions associated with the agent as well as understanding the aftercare required.

Firearms training is held either in an indoor or an outdoor range and the trainees use handguns and shotguns. A trainee walks briskly or slowly jogs from the 25-yard to the 1-yard line, with intermittent stops at designated yard lines, and fires the handgun. Standing, prone, kneeling and barricaded positions are assumed. Trainees use both the strong and support hands for handgun firing. Shotguns, weighing approximately 11 pounds, are fired from a standing position using the strong shoulder position. In the Basic Course for State Corrections Officers, rifle training is required. Rifles, weighing approximately 12 -13 pounds are fired from behind barricades from a standing and kneeling position. The strong shoulder and strong knee positions are used.

For firearms training, manual dexterity is required and there may be problems if any fingers or limbs are missing or if there are problems with vision.

To assist you in understanding the training program this individual will participate in, we have enclosed the following:

Chart 1 - Physical Conditioning Exercise Program Overview and Sequence of Exercises for Five-Day Week

Chart 2 - Physical Conditioning Exercise Program Overview and Sequence of Exercises for Three-Day Week

Chart 3 - Static and Dynamic Flexibility Exercises

Chart 4 - Calisthenics/Strength Exercises

Chart 5 - Defensive Tactics

Other - Medical Certification Form

The Commission-approved Physical Conditioning Training Program manual specifies that the following shall be included in the physical examination:

o A hearing examination.

o Physical examination of the spine and limbs for bone and joint abnormalities and of the neck, chest, abdomen, eyes, ears, nose, and throat o Auscultation of heart and lung sounds for identification of possible cardiac murmurs, dysrhythmias, or chronic lung disease o Measurement of resting heart rate, blood pressure and respiration o Height and weight

The following laboratory work is required:

o Chemical analysis of blood for levels of serum cholesterol, triglycerides, glucose, and uric acid and illegal drugs.

o Urinalysis 2 of 3 Revised 07/31/08 o Electrocardiogram.

If indicated because of medical history or a finding on the examination, a chest x-ray may be required.

A maximal exercise stress test may be required. In keeping with the guidelines of the

American College of Sports Medicine, it is desirable for an individual 45 years of age or older to have a maximal exercise stress test before beginning the training program. An exercise stress test prior to acceptance into the school is strongly recommended for prospective trainees whose medical screening and fitness evaluation indicate a higher risk status or the presence of disease. The physician, however, will determine whether or not the stress test is to be administered.

A Health History Statement (PTC-7) including cardiac-related information has been completed by the trainee to assist you in determining whether or not the individual is fit to undergo the commission-approved programs as specified in this letter. The trainee has been directed to provide you with the completed Health History Statement so that it may be reviewed during the medical examination. The responses contained in the Health History Statement are to be used as a starting point in the medical examination. Please feel free to inquire into any other areas which, in your medical opinion, are necessary so that you may accurately determine whether the prospective trainee is medically fit to undergo the programs described.

Please retain a copy of the completed Health History Statement (PTC-7) in your files in accordance with N.J.A.C. 13:35-6.5.

Following the examination it is requested that you complete the enclosed Medical

Certification Form (PTC-8). Please indicate whether the individual is:

Medically fit to participate in Defensive Tactics (unarmed defense), Chemical

Agent exposure, Baton training, Physical Restraint training, Firearms Training and in the Police

Training Commission’s Physical Conditioning Training Program without limitations.

If the individual has a temporary illness or injury which will clear prior to the training program, please note that on the PTC-8 form.

Not medically fit to undergo training.

The nature and severity of any risks or disease should be viewed in light of the content of the training programs and the trainee’s physical condition.

To ensure confidentiality of the completed Medical Certification Form and the Health

History Statement, please return both in the envelope which is marked Confidential and is addressed to the chief executive of the employing agency.

Please retain a copy of the completed Medical Certification Form for your records.

Your cooperation is greatly appreciated.

3 of 3 Revised 07/31/08

CHART 1

PHYSICAL CONDITIONING EXERCISE PROGRAM

OVERVIEW AND SEQUENCE OF EXERCISES FOR FIVE-DAY WEEK

Warm-Up.....................................................5 minute walk accelerating to a slow jog.

Flexibility Exercises....................................7 minutes of stretching exercises to enhance range of motion of the principal joints associated with musculature. Flexibility exercises are to be selected from the exercises listed in Chart 3 and described in the Flexibility Exercises section.

Exercises are to include stretching of the primary muscle groups that are going to be used during the conditioning phase.

Aerobic Activities.........................................15-20 minutes of exercises from the following list of options: jogging/running, rope jumping, swimming, and bicycling. Trainees at the intermediate level of fitness (Level II) and at the advanced level (Level III) may add no more than an additional 10 minutes of aerobic activities to this component of the exercise session as specified in the Aerobic Activities Prescription Guidelines.

Transition Cool-down..................................3 minutes of rhythmic movement including stretching.

Calisthenics/Strength Exercises................20 minutes of strength exercises three times a week and 10 minutes, two times a week. Exercises are to be selected from the exercises listed in Chart 5 and described in the Calisthenics/Strength Exercises section.

Speed and Agility Exercises.......................5 minutes of sprinting and 5 minutes of agility running two times a week. (Trainees, however, may require additional time for the speed and agility components because of the rest periods specified in the Speed and Agility Prescription Guidelines.)

Cool-down....................................................5 minutes

CHART 2

PHYSICAL CONDITIONING EXERCISE PROGRAM

OVERVIEW AND SEQUENCE OF EXERCISES FOR THREE-DAY WEEK

Warm-up .........................................5 minute walk accelerating to a slow jog.

Flexibility Exercises....................... 7 minutes of stretching exercises to enhance range of motion of the principal joints associated with musculature.

Flexibility exercises are to be selected from the exercises listed in Chart 3 and described in the Flexibility Exercise section. Exercises are to include stretching of the primary muscle groups that are going to be used during the conditioning phase.

Aerobic Activities............................15-20 minutes of exercise from the following list of options:

jogging/running, rope jumping, swimming and bicycling. Trainees at the intermediate level of fitness (Level II) and at the advanced level (Level III) may add no more than an additional 10 minutes of aerobic activities to this component of the exercise session as specified in the Aerobic Activities Prescription Guidelines.

Transition Cool-Down.....................3 minutes of rhythmic movement including stretching.

Calisthenics/Strength Exercises.....20 minutes of strength exercises every other day;

10 minutes when time is allotted for Speed/Agility exercises. See below. Exercises are to be selected from the exercises listed in Chart 5 and described in the Calisthenics Strength Exercises section.

Speed and Agility Exercises ..........5 minutes of sprinting and 5 minutes of agility running every other day. See below. Trainees, however, may require additional time for the speed and agility components because of the rest periods specified in the Speed and Agility Prescription Guidelines.

Cool-Down.......................................5 minutes

CHART 3

STATIC AND DYNAMIC FLEXIBILITY EXERCISES

1. Neck Stretch (Dynamic)

2. Shoulder Stretches (Static)

3. Chest Stretch (Static)

4. Sitting Trunk Twist

5. Modified Indian Curl (Static)

6. Sitting Toe Touch (Static)

7. Straight Leg Abs

8. Lying Supine - Leg Over (Dynamic)

9. Prone Support Back Stretch (Static)

10. Standing Lateral Side Stretcher (Dynamic)

11. Supported Forward Stride Stretcher (Dynamic)

12. Standing Quad Stretches (Static)

13. Hamstring Stretch (Static)

14. Hamstring/Back of Knee Stretch (Static)

15. Hamstring and Calf Stretch (Static)

16. Standing Achilles and Calf Stretcher (Static)

17. Cross Body Arm Stretch

18. Standing Toe Touch

19. Lower Limb Neural Tension (Sitting)

20. Pelvic Tilt: Posterior - Legs Bent (Supine)

21. Knee-to-Chest with Neck Flexion Stretch (Supine)

22. Knee-to-Chest Stretch: Bilateral

23. Lumbar Rotation (Non-Weight Bearing)

24. Wall Slide

25. Hip Abduction (Side-Lying)

26. Hip Adduction (Side-Lying)

27. Terminal Knee Extension (Supine)

28. Hip Extension (Prone)

29. Knee Flexion (Standing)

30. Lower Limb Neural Tension (Long-Sitting)

31. Straight Leg Raise

CHART 3 , continued

32. Thoracolumbar Side-Bend: Double Arm (Standing)

33. Knee Flexion (Sitting)

34. Opposite Arm-Leg Lift (Prone)

35. Side Lunge

36. Quadras Stretch (3 Variations) 37 Thoracolumbar Side-Bend: Single Arm

38. Quadriceps Stretch

39. Lumbar Rotation Stretch

40. Gastrocnemius Stretch

41. Soleus Stretch

CHART 4

CALISTHENICS/STRENGTH EXERCISES

Back

1. Lateral Trunk Bends

2. Back Lifts

3. Sit-ups with Stabilizer Ball

Abdomen

1. Alternating Elbow to Knee Crunch

2. Bent Knee Sit-Ups (with partner)

3. Modified Curl-ups (with partner)

Chest

1. Recline Fly with Stabilizer Ball

Arms

1. Shoulder Rotations

2. Push-ups

Incline/Decline Push-up

3. Horizontal Dips

4. Pull-ups

5. Jumping Jacks

6. Tricep Extension with Heavy Ball

7. Reverse Hammer Curl

Shoulders

1. Dumbbell Exercises (6 variations)

2. Recline Press with Stabilizer Ball

Legs

1. Platform Balancing Exercise - Side Dip

2. Heel Raises

3. Knee Bends

4. Modified Knee Bends

5. Mountain Climbing

6. Squat Thrusts

7. Windshield Wiper (Advanced Exercise)

CHART 5

DEFENSIVE TACTICS

Goal: Trainees use body parts as defensive weapons.

A. Parts of the body to be used:

1. open hand and fist

2. elbow

3. forearm

4. knee

5. foot

6. head

B. Defensive stance:

1. balance

2. leverage - extensive use of trunk and abdominal muscles

3. concentration of power

4. use of opponent’s power

C. Defensive tactics employed:

1. breaking and countering choke and strangle holds

2. escaping

3. headblocks and headlocks

4. body and clothing grabs

5. blocking

6. counter actions and follow-ups

7. punching

8. straight kicks

9. come-along holds

a. arm locks

b. wrist locks c . fingerlocks

10. take-down tactics

a. wrist throw

b. stiff arm take-down

c. foot sweeps

11. break falls

D. Defensive tactics from the ground

E. Weapon retention

PTC-8 (Rev. 7/89)

DEPARTMENT OF LAW AND PUBLIC SAFETY

DIVISION OF CRIMINAL JUSTICE

POLICE TRAINING COMMISSION

MEDICAL CERTIFICATION FORM

(Please Print)

Candidate’s Name:________________________________________________________________________________

Social Security Number:____________________________________________________________________________

Candidates’s Employing Agency:_____________________________________________________________________

Agency Address:__________________________________________________________________________________

PTC-Approved School Candidate Will Attend:_____________________________________________________________________________

Name of Course:_____________________________________Course Dates:_________________________________

Physician’s Name:________________________________________________________________________________

Physician’s Address:______________________________________________________________________________

Based upon the medical examination and review of the Health History Statement, the above-named individual is determined to be:

(Check one)

Medically fit to participate in Defensive Tactics (unarmed defense), Chemical Agent exposure, Firearms Training, Baton Training, Physical Restraint Training, and in the Police Training Commission’s Physical Conditioning Training Program without limitations.

Not medically fit to participate in Defensive Tactics (unarmed defense), Chemical Agent exposure, Firearms Training, Baton Training, Physical Restraint Training, and in the Police Training Commission’s Physical Conditioning Training Program.

Physician’s Signature and License No. Date

PTC - 8 (Rev. 7/1/02)

Name: _________________________________ Social Security: _________________

Applicant Initials _____________ Date_____________

NJDOC USE ONLY

Physician’s Signature_______________________________ Date_____________

New Jersey Department of Corrections

Custody Recruitment Tattoo Identification

FRONT OF BODY

Draw line from figure showing location of tattoo & brandings

Number each tattoo or brand listed above and describe what it means._____________________________

Medical will confirm all tattoos; failure to cooperate will result in removal from the hiring process.

Name: _________________________________ Social Security: _________________

Applicant Initials _____________ Date_____________

NJDOC USE ONLY

Physician’s Signature_______________________________ Date_____________

New Jersey Department of Corrections

Custody Recruitment Tattoo Identification

BACK OF BODY

Draw line from figure showing location of tattoo & brandings

Number each tattoo or brand listed above and describe what it means._____________________________

Medical will confirm all tattoos; failure to cooperate will result in removal from the hiring process.

PHILIP D. MURPHY

SHEILA Y. OLIVER

Lt Governor

To:

Care of:

From:

Department of Environmental Protection

New Jersey Department of Environmental Protection Office of Occupational Health & Safety

428 E. State Street P.O. Box 416

Trenton, NJ 08625-0416 Phone# (609) 292-1408 Fax# (609) 984-2488

Environmental Response Training Program 1930 Radcliff Drive Cincinnati, OH 45204

Office of Occupational Health & Safety New Jersey Department of Environmental Protection

Medical Contract Provider for NJDEP

Subject: Medical Clearance for Training with Respiratory Protective Equipment

This letter is to attest __________________ has been medically (print name) evaluated and cleared to wear respiratory protective equipment in accordance with 29

CFR 1910.134.

Contractor's Signature

New Jersey is an Equal Opportunity Employer Recycled Paper

Date

CATHERINE R. McCABE Commissioner

PHILIP D. MURPHY

SHEILA Y. OLIVER

Lt. Governor

Institution:

Trainee Name:

Social Security No.:

Physician's Address:

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DEPARTMENT OF CORRECTIONS

CUSfODY RECRUITMENT UNIT POBox863

TRENTON NJ 08625-0863

(Print last name. first name. middle initial)

MARCUS 0. HICKS, ESQ.

Acting Commissioner

Based on my review of Appendix C to 1910.134: OSHA Respirator Medical Evaluation Questionnaire and any necessary follow-up medical evaluation, the above-named individual is medically cleared to wear or use self-contained breathing apparatus and/or an air-purifying respirator.

D Without Limitations

Signature and License No.

Other Licensed Health Care Professional's Signature and License No.

I have received a copy of this evaluation.

Trainee Signature

D With Limitations (Specify):

Date

Date

Date

NJDOT MEDICAL SURVEILLANCE/TESTING CLEARANCE REPORT

Bureau of Employee Safety

1035 Parkway Avenue Trenton, NJ 08625

(609) 963-2175 • Fax (609) 530-5719

EXAMINER SIGNATURE DATE EMPLOYEE SIGNATURE DATE

NAME: Employee ID#: DATE:

Crew #/Unit: Supervisor/Contact:

REQUESTED MEDICAL TASK

Asbestos Surveillance Examination (3.2.15) [27] Anthrax Vaccination/Booster (3.3.10) [39] Hazardous Waste Operation & Emergency Response Surveillance Examination (3.2.11) [12] x Hepatitis B Vaccination (3.3.2) [28]

Lead Surveillance Examination (3.2.13) [30] Rabies Prophalaxis (3.3.3) [17] Heavy Metals Surveillance Examination (3.2.13) [30]* Tuberculosis Vaccination/Booster (3.3.6) [32] Occupational Noise Surveillance Examination (3.2.3) [37] Silica Surveillance Examination (3.2.14) [20] x Additional Testing (3.3.14) [43]* Basic Medical Examination, Initial Physical (3.2.1) [1] Blood Lead Monitoring (3.2.13.1) [25] Basic Medical Examination, Surveillance (3.2.1.1) [2] Heavy Metals Monitoring (3.2.13.1) [25]* Basic Medical Examination, Variations (3.2.1.2) [3]* Chest X-Ray with B-Reading (3.2.1), (3.2.10), (3.3.14) [7] Consultation Services (3.4) [44]* EKG (3.3.14) [44] Fitness for Duty Physical Examination (3.2.5) [41] Hepatitis B Titer (3.3.2) [22] Hazardous Substance Post Exposure Evaluation Examination (3.2.12) [4]* Occupational Noise Surveillance Hearing Test (3.2.3.1) [10] Occupational Noise Surveillance Audiogram Review (3.2.3.2) [24] x Pulmonary Function Test (3.3.14) [18] Respiratory Clearance Examinations (3.2.10) [5] Tuberculosis Testing (Skin Test) (3.3.6) [45] Respiratory Fit Test (3.2.10.1) [31] Tuberculosis Testing (Blood Test) (3.3.14) [137] Testimony and Litigation Support (3.6) [42]

Visual Acuity Test (3.2.9) [34] NOTE: (Contract Spec Section) [Line Item #]

EXPOSURE DATA/WORK ACTIVITY: Unknown Chemicals (HAZWOPER)

*ADDITIONAL INFORMATION:

Environmental field personnel

MEDICAL DETERMINATION:

We have personally, examined/provided _______ with the above service and, have reviewed the results of the required ancillary studies and I have determined that this person

_____ Can wear a respirator and is medically qualified to do the essential functions for the job described _____ CAN NOT wear a respirator (See COMMENTS) _____ Is NOT medically qualified to do the essential functions or the job described (See COMMENTS)

COMMENTS:

EMPLOYEE NOTIFICATION:

_____ The employee has been informed of the examination results and any medical conditions requiring further examinations and/or treatment by their personal physician. The employee acknowledges that he/she has 30 days to obtain medical clearance from Robert Wood Johnson Medical Center.

An employee failing to obtain medical clearance will result in a review by Employee Relations to determine whether the employee should be removed for Inability to Perform Duties.

NJDOT MEDICAL SURVEILLANCE/TESTING CLEARANCE REPORT

Bureau of Employee Safety

1035 Parkway Avenue Trenton, NJ 08625

(609) 530-5472 • Fax (609) 530-5719

EXAMINER SIGNATURE DATE EMPLOYEE SIGNATURE DATE

Medical Certification Form