Medical Approval Form For Physical Agility Exam printable pdf download

Medical Approval Form For Physical Agility Exam

Medical Approval Form for Physical Agility Exam

TO:

City of New Haven Department of Police Service

FROM:

_________________________________________

Physician Name (M.D. or D.O) Please Print

To be filled in by physician:

This is to certify that I have reviewed the four elements of the Connecticut Police Officer Standards and

Training Council’s Physical Ability Assessment printed on the back side of this form. After reviewing

said document, it is my professional opinion that the candidate named below:

Candidate’s Name:

Applying to:

New Haven Department of Police Service for position of Police Officer

CAN SAFELY PERFORM THE PHYSICAL ABILITY ASSESSMENT.

Physician’s Signature:

Date:

Physician’s Name and

Address (Type or Imprint

With Office Stamp)

(Medical approval forms back dated more that 6 months cannot be accepted)

City of New Haven Department of Human Resources

200 Orange Street – Room #102

New Haven, CT 06510

Candidate Emergency Contact:

Name: ___________________________________________ Tel#: ______________ Relationship: _____________

DO NOT SUBMIT THIS FORM WITH YOUR APPLICATION! YOU MUST PRESENT THIS

FORM AT CHECK-IN FOR THE PHYSICAL AGILITY EXAM.

Medical Approval Form For Physical Agility Exam