State of California Department of Justice medical examination report peace Officer




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State of California – Department of Justice

MEDICAL EXAMINATION REPORT – Peace Officer


POST 2-253 (Rev 12/2012)

Commission on

Peace Officer Standards and Training (POST)

860 Stillwater Road, Suite 100

West Sacramento, CA 95605-1630


SECTION 1. EXAMINATION FINDINGS


1. CANDIDATE’S NAME (LAST, FIRST, MI)

     


2. BIRTH DATE (MM/DD/YYYY)

     


3. SOCIAL SECURITY NUMBER

Last 4 digits:     



4. SEX

 M  F


5. HEIGHT

Without shoes:   FT    INCHES



6. WEIGHT

Without shoes and coat:     LBS



7. VISION

8. BLOOD PRESSURE

9. HEARING TEST

10. RETEST





UNCORRECTED

CORRECTED

Far

Near

Far

Near

Right

     

     

     

     

Left

     

     

     

     

Both

     

     

     

     




 GLASSES  CONTACTS

COLOR VISION:      

OTHER VISION TESTS:

     





PERIPHERAL
VISION:

Right

    °

Left

    °




Initial test

BP after 3–5 min in chair:



   /    Pulse:    

Repeat if BP>120/80:

   /    Pulse:    

Third test if 1st & 2nd reads
differ by >5 mm Hg:


   /    Pulse:    






Left

Right

500

    

    

1000

    

    

2000

    

    

3000

    

    

4000

    

    

6000

    

    

8000

    

    







Left

Right

500

    

    

1000

    

    

2000

    

    

3000

    

    

4000

    

    

6000

    

    

8000

    

    




11. For each of the following conditions, indicate Normal, Abnormal, or Not Examined and include additional findings as needed.

CHECKLIST

NORM

AB

NE

descriBE ANY abnormal findings and/or supplemental tests

A) SKIN

Color / Texture

Lesions, scars, etc.









     

Tattoos

Racist, gang-related, removal









     

Other







     

B) HEAD / EYES




Corneas (RK scars)







     

Pupils / Light reaction







     

Fundi







     

EOM







     

Other







     

C) EARS / NOSE / THROAT / MOUTH




Pinna / Canals / TM







     

Nasal septum / Mucosa







     

Teeth / Gums







     

Tongue / Palate







     

Other







     

D) NECK




Bruit







     

ROM







     

Thyroid







     

Cervical nodes







     

C5-C7 sensory







     

Palpation







     

Other







     



SECTION 1. EXAMINATION FINDINGS continued


CHECKLIST

NORM

AB

NE

descriBE ANY abnormal findings and/or supplemental tests

E) ABDOMEN




Hernia







     

Bowel sounds (Bruits)







     

Liver / Kidney / Spleen







     

Masses







     

Other







     

F) CARDIOVASCULAR




Pulses: Radial / Femoral







     

Pulses: D. Pedis / P. Tibial







     

Apex impulse







     

Heart sounds (murmurs)







     

Heart rate and rhythm







     

Other







     

G) CHEST / LUNGS




Auscultation







     

Breasts

Females age 50 and over









     

Axillary nodes







     

Chest wall expansion







     

Other







     

H) MUSCULOSKELETAL

Upper Extremity:

 Shoulder ROM







     

 Shoulder strength







     

 Wrists / Fingers







     

 Shoulder Apprehension Test







     

Grip strength







     

 Other







     

Back:

 Inspection Radial, Femoral







     

 Palpation Radial, Femoral







     

 Heel / Toe walk Radial, Femoral







     

 Flexion / Extension Radial, Femoral







     

 Passive SLR Radial, Femoral







     

 L3-S1 sensory Radial, Femoral







     

 Other







     



SECTION 1. EXAMINATION FINDINGS continued


CHECKLIST

NORM

AB

NE

descriBE ANY abnormal findings and/or supplemental tests

H) MUSCULOSKELETAL continued

Knees:

 Inspection Radial, Femoral







     

 Patellar apprehension Radial, Femoral







     

Squat Radial, Femoral







     

 Duck-walk Radial, Femoral







     

 Thigh circumference Radial, Femoral







     

Lachman Test Radial, Femoral







     

 Collateral stability Radial, Femoral







     

 One-leg hop for distance Radial, Femoral







     

 Anterior / Posterior drawer Radial, Femoral







     

 Other







     

I) NERVOUS SYSTEM

Tremor







     

Reflexes







     

Gait







     

Other







     

J) GENITALIA / RECTAL – NOTE: Recent exam and test results from candidate’s private physician are permissible.

Rectal

Age 50 and over









     

Inguinal Hernia







     

Male: Genitalia







     

Female: Pap smear Pap smear







     

Other







     

K) LABORATORY FINDINGS

CBC







     

Chem. Panel







     

Urinalysis







     

ECG







     

Spirometry







     

Mammogram

Age 50 and over









     

Sigmoidoscopy

Age 50 and over









     

PPD Mantoux

If assigned to prisons









     

CXR

Smokers age 40 and over









     

Other







     



SECTION 1. EXAMINATION FINDINGS continued


NOTES:

     



SIGNATURE OF LICENSED EXAMINING PHYSICIAN



PRINT PHYSICIAN’S NAME

     


DATE

     


ADDRESS OF PRACTICE (Street, City, State, Zip)

     


PHONE:

(     )     -     




SECTION 2. EVALUATION REPORT





Instructions to the Physician:

  • This section is to be completed and submitted to the hiring department.

  • The hiring department will maintain the Medical Evaluation Report page in the individual’s background investigation file. Do not include medical information on this page.

M
[date of evaluation]
edical Evaluation Report
Candidate’s Name

Birth Date Last 4 digits of Social Security Number

On , I completed a pre-employment medical screening evaluation
on the above-named peace officer candidate, in accordance with California Government Code Section 1031(f) and POST Commission Regulation 1954. Based on the results and findings of that evaluation:


  • I certify that the candidate is medically suitable to perform the peace officer duties and responsibilities
    as defined and provided by the hiring department either without any accommodations, or provided
    that the specified work restrictions, limitations, or reasonable accommodations can be implemented. (Describe any work restrictions, limitations, or reasonable accommodation requirements on
    the following page.)


I cannot certify that the candidate is medically suitable to perform the peace officer duties and responsibilities as defined and provided by the hiring department.

Physician’s Signature ►

Printed Name, Medical License Number,
and Contact Information:







SECTION 3. SUPPLEMENTAL INFORMATION


Instructions to the Physician:

Provide any additional information to the hiring department regarding the candidate’s job relevant functional limitations, reasonable accommodation requirements, work restrictions, and/or a description of the nature and degree of potential risks posed by the detected medical conditions. Include that information which is necessary and appropriate for the hiring department in making a hiring decision.


To the Hiring Department:

This page should be maintained separate from the candidate’s background investigation file. Access to the information on this page should be limited to those who have a need to know (e.g., hiring authorities, supervisors).





















































































































































































































Candidate’s Name

Birth Date

Last 4 Digits of SSN

Examining Physician’s Name (please print)

Report Date




Page 1 of 6


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