USM-600.pdf

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Form USM-600 Rev. 03/20 Page of U.S. Department of Justice United States Marshals Service District/Aviation Security Officers (DSO/ASO) Physical Requirements OMB Number 1105-0099 (Exp. 01/31/2023) NOTE TO PHYSICIAN/NURSE PRACTITIONER: DSO/ASOs are required to assist in the transportation, handling, processing and security of federal prisoners. They are subject to irregular hours and may be exposed to extreme climatic conditions for long periods of time. They are required to have good vision and hearing and be capable of sitting, walking, running, or riding in vehicles or aircraft for extended periods. Their general physical condition must in no way involve any defect that might become a hazard to themselves or others. In order to be Fit-for-Duty, DSOs/ASOs must be medically able to perform efficiently and safely the full range of duties of the position described above.

Please check the appropriate box beside each requirement/factor indicating restrictions for this individual, complete the back of this form and sign at the bottom of both pages. Within two weeks, please mail or fax this information to:

United States Marshals Service

FUNCTIONAL REQUIREMENTS

Not Restricted Restricted Heavy lifting, 45 lbs. and over Heavy carrying, 45 lb. and over Reaching above the shoulder Use of fingers Use of both hands Use of both legs Climbing, use of legs and arms Operation of a motor vehicle Ability for rapid mental and muscular coordination simultaneously Ability to use firearms Ability to stand for unusually prolonged periods Ability to sit for unusually prolonged periods Ability to function normally with irregularly scheduled intake of food Traveling in aircraft for extended periods

ENVIRONMENTAL REQUIREMENTS

Not Restricted Restricted Outdoor environment Indoor environment Excessive heat Excessive cold Excessive humidity Excessive dampness or chilling Dry atmospheric conditions Working around moving objects or vehicles Slippery or uneven walking surfaces Unusual fatigue factors Working closely with others Working alone Prolonged or irregular hours of work Aggressive law enforcement activities Airplane rear cabin crew member Restrictions must be explained using the back of this form.

SUMMARY - FINDINGS - RELATED MEDICAL INFORMATION

Summarize below any findings that need further medical attention and any findings that would limit the applicant's performance or present a hazard to the applicant or others.

PHYSICIAN/NURSE PRACTITIONER CERTIFICATION

Name of Applicant Date and he/she appears to be:

INSTRUCTIONS FOR COMPLETION OF THIS FORM

1. Complete all fields. Incomplete forms will not be accepted.

2. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

3. Do not use "white out" or correction tape. Initial and date any changes made to the form.

4. All dates provided on this form must be in Month/Day/Year (mm/dd/yyyy) or Month/Year (mm/yyyy) format. Use numbers (1-12) to indicate months. For example, May 27, 2017 should be shown as 5/27/2017.

5. If you need additional space to complete this form, use a blank sheet of paper and note the patient's name and date of birth on each page.

6. Submit completed form, along with any lab/screening forms or results (if any), to the address noted at the top of page 1.

PURPOSE OF THE FORM

Completion of Form USM-600 is required to ensure that all applicant (after conditional offer) and incumbent District Security Officers/Aviation Security Officers (DSO/ASO) meet the medical standards as outlined in the Statement of Work and are medically qualified to perform all duties. This form must be completed by the applicant or incumbent and the designated examining physician/nurse practitioner and submitted to the appropriate district office.

AUTHORITY TO REQUEST THIS INFORMATION

The authority for collection of this information is 5 U.S.C. 3301 and 28 U.S.C. 561. The USMS needs the information requested in this form to evaluate your qualifications to perform the duties of a DSO/ASO with respect to the transportation, handling, processing and security of federal prisoners.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

Providing the information on this form is voluntary, however, failure to furnish the requested information may delay or prevent action on your employment. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays in processing the form for employment, termination of employment, or criminal sanction.

PRIVACY ACT ROUTINE USES

This form or information contained therein may be disclosed in accordance with the routine disclosures set forth in the Office of Personnel Management government-wide system of records, OPM/Govt-1, General Personnel Records, 76 Fed.Reg. 32997 (June 7, 2011), including but not limited to:

1. The disclosure of pertinent information to the appropriate Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order, when the disclosing agency becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.

2. The disclosure of information to any source from which additional information is requested (to the extent necessary to identify the individual, inform the source of the purpose(s) of the request, and to identify the type of information requested), when necessary to obtain information relevant to an agency decision to hire or retain an employee, issue a security clearance, conduct a security or suitability investigation of an individual, classify jobs, let a contract, or issue a license, grant, or other benefits.

3. The disclosure to a Federal agency in the executive, legislative, or judicial branch of Government, in response to its request, or at the initiation of the agency maintaining the records, information in connection with the hiring of an employee, the issuance of a security clearance or determination concerning eligibility to hold a sensitive position, the conducting of an investigation for purposes of a credentialing, national security, fitness, or suitability adjudication concerning an individual, the classifying or designation of jobs, the letting of a contract, the issuance of a license, grant, or other benefit by the requesting agency, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is relevant and necessary to the requesting agency's decision.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to Prisoner Operations Division, CG-3, Rm #3008A, U.S. Marshals Service, Washington, DC 20530-0001. Do not return this document to this address.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

9.0.0.2.20120627.2.874785