01-EXHIBIT_11__Medical_Questionnaire_-_FINAL_MC.pdf

EXHIBIT 11

Medical Questionnaire

And

Physical Abilities Test Manual

Armed Security Officer (ASO) Security Guard II Medical and

Certification Standards

General Background

ASO’s (aka Guards/Security Guards/Guard II) provide support and security services to the

Internal Revenue Service (IRS), other building tenants and visitors at federally owned/leased facilities nationwide. ASO’s present a visible deterrent while safeguarding and securing IRS assets. Additionally, ASO’s provide a safe environment for facility occupants.

Medical Exam Questionnaire and Certification Standards

The Purpose of the Medical Exam Questionnaire is to guide physicians in determining an ASO candidate’s medical fitness to perform job tasks. This questionnaire contains both specific medical standards and direction as to additional diagnostic required. A licensed physician must review and complete this questionnaire. A licensed physician’s determination of a limiting condition will result in a failure to meet medical standards. The questionnaire has three(3) sections and two attachments:

Section 1: Critical Tasks performed by ASO’s. Identifies medical and physical limiting tasks.

Section 2: Medical Exam Questionnaire which includes licensed physicians review of specific standards for vision, hearing, cardiovascular fitness, musculoskeletal condition, and general health.

Section 3: Conclusions- provides licensed physician an opportunity to communicate their observations and determine a conclusion on the candidate’s ability to perform job functions.

Section 1: Critical Tasks

ASO’s must have the physical capacity and training to accomplish common and occasional tasks.

The Checklist below is based on and abbreviated and consolidated list of critical tasks

(Attachment 1 to this document) that are indicative of demands placed upon ASO’s. Critical tasks are divided into two types:

Common Critical Tasks: Normal everyday duties

Occasional Critical Tasks: Occur less frequently, but are critical to successful job performance and public safety.

ASO’s may be exposed to a wide variety of environmental conditions including, but not limited to:

Working Outdoors Shifts lasting more than 8 hours

Excessive Heat Working alone

Excessive Cold Frequent close contact with persons

Constant Noise Physical /security threats and risks

Slippery or uneven walking surfaces Construction environment hazzards

Work around moving vehicles/objects

Common Critical Tasks

1. Stand Post at the entry/exit gates to verify persons’ identification. . Conduct inquiries and surveillance of items, packages and people. Check packages, briefcases, containers, or any other items in the possession of people entering or leaving a federally controlled facility.

2. Operate metal detectors to search persons for prohibited items. Operate x-ray machine to inspect deliveries, equipment, and/or hand carried items possessed by persons.

3. Monitor security and fire systems, Video Monitoring / Surveillance Systems (CCTV) to detect security threats or risks.

4. Conduct inspection /searches of vehicles which may include under seats, trunk, engine compartment and under carriage of the vehicle

5. Conduct patrols in accordance with routes and schedules contained in post orders.

Inspect facilities and perimeters for hazards, mechanical problems and unsafe conditions. Report problems to appropriate authorities as outlined in post orders. Close and secure windows, doors or other access points.

6. Investigate the source of suspicious odors or sounds.

7. Patrol locations in areas which are potentially hazardous to the public. Respond to calls for assistance.

8. Observe unique characteristics of an individual or vehicle for identification purposes.

Observe a person’s body language to assess attitude and intention.

9. Close off areas to traffic, establish perimeters, set up barricades and secure incident scenes or facilities.

10. Locate and review documents and information. Read memos and other written material to obtain and maintain knowledge. Review maps, floor plans, diagrams, or other information to become familiar with a facility, boundaries and requirements.

Occasional Critical Tasks

1. Use defensive tactics to prevent or control movements of individuals

2. Subdue violent persons with or without assistance. Break up fights.

3. Apply handcuffs to individuals who require restraint.

4. Use baton or Oleoresin Capsicum /pepper or chemical sprays to temporarily incapacitate individual when appropriate. Participate in the training in the use of chemical agents, restraining devices and batons to be used as appropriate.

5. Discharge firearm during daylight, in dark or low light environments with or without the aid of a flashlight.

6. Evacuate individuals from dangerous and/or life threatening situations.

7. Administer cardio-pulmonary resuscitation (CPR) or first aid.

8. Run- Pursue fleeing individuals on foot for up to 1.5 miles.

9. Lift heavy objects more than 75 pounds. Move unconscious individuals to safety in emergencies with or without assistance.

10. Climb over walls, fences or other obstacles.

Section 2: Medical Exam Questionnaire

Patient’s Name:________________________________

(Printed: Last, First, MI )

Vision

1. Does Candidate wear corrective lenses? If yes, in the below chart indicate with a check mark the type of lenses used and are used most frequently and identify the prescription strength:

Visual Aid Yes Used most Frequently

Prescription Strength

Glasses

Soft Contact lenses

Hard Contact lenses

Gas Permeable lenses

YES NO

2. Does Candidate have 20/30 vision while using both eyes?

3. Visual Acuity: Identify candidate’s visual acuity with and without corrective lenses.

Normal Acuity ______________ Corrective Acuity ____________

4. Is Candidate capable, in at least one eye, of reading a minimum of Jaegar Number 2 or equivalent type and size letter at a distance of no

5. Does candidate exhibit normal color vision?

6. Does Candidate exhibit any visual conditions that may impact their ability to perform the critical tasks of an ASO?

Hearing

1. Does Candidate require use of a hearing aid?

2. Does Candidate have hearing less than or equal to 25db?

3. Identify candidate’s average hearing (corrected, if applicable) across the following 500, 1000, 2000, and 3000 Hz levels:__________ db.

4. Does Candidate have hearing less than or equal to 45db?

5. Identify candidates hearing (corrected, if applicable) at the 4000 and 5000 Hz levels:

________db.

6. Does Candidate have a hearing variance between left and right ears?

If yes, identify the ear with more hearing loss. Left ____ Right____ What is the difference between 500 to 3000 Hz range? ______ db What is the difference between 4000 to 5000 Hz range? ______db REQUIRED: Test Candidate further for sound localization deficiency if difference exceeds 30 db.

7. Does Candidate present evidence of inner/middle/outer ear disorders affecting equilibrium?

CARDIOVASCULAR SYSTEM

1. Identify the candidate’s aerobic capacity in METs ____________ and VO2 MAX

REQUIRED STANDARD: Minimum ten (10) METs and 35 ml/kg/min VO2 Max

2. Identify candidates resting blood pressure:

mmHg Systolic______________ mmHg Diastolic ______________

REQUIRED STANDARD: Maximum 159 mmHg systolic, 90 mmHg diastolic

3. A timed 1.5 mile run, sit-ups and pushup continuously for 1 minute and 300 meter sprinting are part of the fitness requirement; can the candidate perform these tests without limitations? YES_________ NO____________

4. Use this section to explain any limiting factors or why candidate does not meet the above requirements for the cardiovascular system.

MUSCULOSKELETAL SYSTEM

1. Does candidate exhibit full range of motion?

2. Is candidate able to easily get up from a kneeling position?

3. Is candidate able to lift 75 pounds minimum from the floor to waist?

4. Is Candidate able to bench press at least 50% of their body weight?

5. Is Candidate able to perform sit- ups and pushups continuously for at least one minute?

Is the candidate able to run or jog without limitation for at least

1.5 miles without stopping to rest?

Use this Section to Explain any limiting factors or why the candidate does not meet the above requirement for the musculoskeletal system.

GENERAL HEALTH

YES NO

1. Does Candidate exhibit a loss of sense of smell, aphonia, or other abnormalities of nose, throat, or ears that may prevent successful task performance?

2. Does candidate exhibit evidence of chronic bronchitis, emphysema, infectious pulmonary tuberculosis, or other respiratory abnormalities that may prevent successful task performance?

3. Does candidate exhibit evidence of eczema, psoriasis, dermatitis or other dermatological condition that may prevent successful task performance?

4. Does candidate exhibit evidence of a gastrointestinal or other condition that may prevent successful task performance? ( Candidates are required to stand or walk continuously for up to 8 hours without regular access to a restroom)

5. Does the candidate have any limitations that would prevent them from participating / performing recurring physical ability testing including strength, stamina and physical endurance testing?

6. Ability to meet cardiovascular, anaerobic power, and strength requirements and perform fitness testing ?

Use this Section to explain any limiting factors or why candidate does not meet the above requirements for general health:

Section 3: CONCLUSIONS

Summarize below any medical finding which, in your opinion, would limit this candidate from successfully performing ASO tasks or performing the required physical fitness exam based upon the NEW COOPER STANDARDS for Law Enforcement. The Physical fitness exam includes a 1.5 mile run, push-ups, sit-ups and 300 meter sprint. Do you find any medical limitations that would otherwise make this candidate a hazard to himself/herself or others?

_______NO limiting conditions noted

_______ Limiting Condition described below

Signature of Physician Date

Physician Name Printed Address