Physical Fitness Assessment Page 2
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4INSTRUCTIONS FOR COMPLETING FORM CJSTC-75B
An applicant approved to enter a basic recruit training program (BRTP) shall review and complete form CJSTC-75B to indicate the presence of any medical conditions that may
prevent participation in the Physical Fitness Program and Chemical Agent Contamination. A copy of the Physical Fitness Program for law enforcement, correctional, or correctional
probation discipline shall be attached to this form for the applicant to review.
1.
Applicant’s Name. Enter the applicant’s last name, first name, and middle initial.
2.
Applicant’s Address. Enter the applicant’s current address, city, state, and zip code.
3.
Applicant’s Social Security Number. Enter the last four digits of the applicant’s social security number as in this example: 000-00-1234.
4.
Training School Name. Enter the name of the Commission-certified criminal justice training school where the applicant is enrolled.
5.
Basic Recruit Training Program Discipline. Place a check mark in one of the box(es) for the law enforcement, correctional, or correctional probation basic recruit training
program discipline for which the applicant is requesting admission.
6.
Student Participation in Basic Recruit Training Program Activities. Defensive Tactics (includes chemical agent contamination), Firearms, and Physical Fitness
Conditioning and Physical Fitness Testing: High-liability training in defensive tactics, firearms, and chemical agent contamination is a component of the curriculum
mandated by the Criminal Justice Standards and Training Commission and participation in the activities is a requirement for successfully completing a BRTP. There is no
pass or fail at this time. The test results for each of the five required tests will be recorded on the Academy Physical Fitness Standards Report, form CJSTC-67A as “I” if
the student did not perform the test component or “D” if the student was dismissed from the basic recruit training program.
A.
Defensive Tactics and Firearms Training. Firearms training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires
sustained physical exertion and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).
B.
Physical Fitness Conditioning and Physical Fitness Testing. The Physical Fitness Test includes the following measures and are defined as follows:
•
Vertical Jump. This measures leg power by measuring how high a person jumps.
•
One Minute Sit Ups. This measures abdominal, or trunk, muscular endurance. While lying on his/her back, the student will be given one minute to do as many
bent-leg sit ups as possible.
•
300 Meter Run. This measures anaerobic power, or the ability to make an intense burst of effort for a short time period or distance. This component consists of
sprinting 300 meters as fast as possible.
•
Maximum Push Ups. This measures the muscular endurance of the upper body. This component consists of doing as many push ups as possible until
muscular failure. Males are required to perform the standard push-up and females have the option to perform the standard or modified push-up.
•
1.5 Mile Run/Walk. This measures aerobic power or cardiovascular endurance (stamina over time). To complete this component, the student runs or walks a
distance of 1.5 miles as fast as possible.
C.
A physical fitness conditioning program developed by the training school shall be attached to form CJSTC-75B prior to the student’s examination by a
physician, certified advanced registered nurse practitioner, or the physician’s assistant.
7.
Medical Conditions Regarding Chemical Agent Contamination. The student shall review the listed medical conditions and list other conditions that may restrict him or
her from participating in Chemical Agent Contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).
8.
Basic Recruit Training Program Activities Certification. The student shall check the appropriate box to indicate if he or she does or does not have a medical condition
that would restrict participation in the basic recruit training program activities indicated in item numbers 6, 6A, and 6B of this form.
9.
Student’s Printed Name. The student shall print his or her first name, last name, and middle initial.
10.
Student’s Signature and Date. The student shall provide a signature and date to verify the information provided by the student is true and correct.
11.
Prior Exposure to Chemical Agent Contamination. The student shall Indicate in the appropriate box if he or she has been previously exposed to chemical agent
contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS), and shall attach supporting documentation of such contamination.
12.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Attestment. The physician shall check the appropriate box to indicate if the
student is capable or not capable of participating in the basic recruit training program activities indicated in item numbers 6, 6A, and 6B of this form.
13.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Signature, Printed Name, and Examination Date. The physician shall
complete this item to verify his or her attestment to item number 12 of this form.
14.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number and Licensing State. The physician shall complete this item
to verify his or her valid license number and licensing state.
15.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address. The physician shall print his or her complete
professional address.
16.
Training Center Director/Designee’s Printed Name, Signature and Date. The training center director/designee who signs this form shall print his or her legal first and last
name. The training center director/designee shall sign and date this form.
FORM CJSTC-75B
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