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TEXAS COMMISSION ON LAW ENFORCEMENT

OFFICER STANDARDS AND EDUCATION

6330 U.S. Highway 290 East, Suite 200

Austin, Texas 78723
Phone: (512) 936-7700
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L-2

DECLARATION OF MEDICAL CONDITION

Commission Rule §217.1(a)(11)

APPLICANT INFORMATION

1. First Name

/ 2. M. I. /

3. Last Name

/

4. Suffix (Jr., etc.)

/

5. TCLEOSE PID or SSN

6. Home Mailing Address / 7. City / 8. State / 9. Zip Code

APPOINTMENT AND DEPARTMENT INFORMATION

10. Peace Officer Reserve Officer Temp/County Jailer Public Security Officer
11. TCLEOSE Agency Number / 12. Appointing Agency / 13. Agency Mailing Address
14. City / 15. County / 16. Zip Code / 17 Phone Number

Attention Examining Professional: The above information must be completed by the requesting agency prior to the examining professional completing and signing this form.

I certify that I have completed my examination of the examinee and I have concluded that on this date, the examinee is found:

NEW APPLICANTS MUST COMPLETE BOTH EXAMS
180 DAY BREAK IN SERVICE NEEDS DRUG SCREEN ONLY

Check the appropriate box(s)

□PHYSICAL EXAM -To be physically sound and free from any defect which may adversely affect the performance of duty appropriate to the type of license sought.

□DRUG SCREEN - To show no trace of drug dependency or illegal drug use after a physical examination, blood test or other medical test.

Physician:______

Printed Name State License Number

Mailing Address:______

StreetCityStateZip

Phone Number:______

______

Date of Examination(s) SignatureDate

THIS DECLARATION IS NOT PUBLIC INFORMATION AND IS VALID UNLESS WITHDRAWN OR INVALIDATED, AND IS VALID ONLY IF SIGNED BY A LICENSED PHYSICIAN.

DECLARATION OF MEDICAL CONDITION (PART TWO)

NAME:______

INSTRUCTIONS TO HEALTH CARE PROVIDER:

The physical requirements below are among those required of the employee in performance of his/her duties. A comprehensive listing is included on pages 3 and 4. Please mark the indicated column with a response of "Yes" or "No” to indicate if the employee is capable of accomplishing the specific task.

REQUIREMENTYES NOREQUIREMENT YES NO____

Heavy lifting and/or carrying, 45 lbs. & up ______Reaching above shoulders ______

Moderate lifting and/or carrying, 15-45 lb______Repeated Bending______

Light lifting and/ or carrying, up to 15 lbs______Operating a motor vehicle______

Pulling straight______Pulling hand over hand______

Simple grasping______Dual simultaneous grasping______

Walking______Standing______

Sitting______Crawling______

Twisting______Kneeling ______

Pushing______Stooping______

Climbing stairs______Climbing ladders______

Capable of strenuous physical exertion______

Eyes:Vision--Right Eye 20/______Color Blind______Pupil Reaction______

Vision--Left Eye20/______Color Blind______Pupil Reaction______

(Required: Not exceed 20/200 uncorrected or 20/30 corrected; no color blindness)

Ears:Hearing --Right Ear ______Circulation:Blood Pressure______

Hearing -- Left Ear ______

Heart:Action (before exertion) ______Pulse ______

Action (after exertion) ______Pulse ______

Physicaldisabilities or deformities ______If so, describe______

______

______

REMARKS AND/OR RECOMMENDATIONS:

______Physician's Signature Date

HR-34

PHYSICAL REQUIREMENTS – TABC AGENT

(FIREARMS)

Able to fire handgun and shotgun with accuracy using both hands (use of strong hand to support weak hand and weak hand supported by strong hand)

Able to load handgun with ammo

Able to take handgun apart for cleaning

Able to hear instructions for training

Able to walk/run/crawl as qualifying course dictates

Able to carry handgun on belt and wear when on duty

Good vision necessary

(DEFENSIVE TACTICS)

Able to use physical strength and voice commands to control suspect(s)

Able to use all techniques, which assist or enhance defensive tactics

Able to practice defensive tactics to minimize injury to offenders or self

(TRANSPORT OFFENDERS)

Able to use proper handcuffing techniques

Able to use both hands to pat down and handcuff offender

Able to drive and maintain degree of safety for offender and self

(INSPECTIONS)

Seize contraband and lift heavy boxes

Able to get down on hands and knees to count evidence

Able to use handcart

Able to lift heavy kegs and other contraband

Walk distances

Climb ladders, kneeling, crawling and handling various equipment

Work in smoke filled rooms

Work around construction sites

(COURT DISPOSITIONS)

Able to use stepladder to reach files

Able to lift court docket books weighing 20 lbs.

(APPREHENSION)

Chase suspects on foot

Physically execute arrest

Face and arrest offenders with dangerous weapons

Crawl into and under vehicles to detect violators

Ability to handle several prisoners at one time

PHYSICAL REQUIREMENTS – TABC AGENT (Continued)

(MOTOR VEHICLE)

Operate motor vehicle under stressful and adverse conditions

Operate motor vehicles at high speeds

Operate vehicle while monitoring and transmitting on radio

Be able to make split second decision while operating vehicle

Be able to fix flat tire

Be able to perform simple maintenance

Drive extended distances

Enter and exit vehicle quickly and frequently

(EXECUTE SEARCH WARRANTS)

Crawl into attics and under houses to execute warrants

(MISC)

Tasks involve bending, lifting, walking, carrying or using a force equal to lifting 40-50 pounds.

Must be in good physical condition, capable of strenuous physical exertion and have no physical exertion and have no physical disabilities or deformities, which would interfere with police duties.

A sound physical condition is required. The body must be free of deformity and must be well proportioned and well developed.

Corrected vision of not less than 20/200 in both eyes, corrected 20/20 in one eye and 20/40 in the other.

No defects, which would interfere in firearms use, raids or defensive tactics.

Manual dexterity, comparatively free motion of fingers, wrists, elbows, shoulders, hips and knee joints is required. Vision must be good in each eye with or without glasses/contacts. The ability to hear the conversational voice and whispered speech without the use of a hearing aid is required. Any physical condition, which would cause the applicant to be a hazard to themselves or others, is not acceptable.

Declaration of Medical Condition 1/1/2006Page 1 of 1