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.
[date of evaluation] edical Evaluation Report
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:
Provide any additional information to the hiring department regarding the candidate’s job relevant functional limitations, reasonable accommodationrequirements,work restrictions, and/or a description of the nature and degree ofpotential 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).