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An agency hiring a person for whom a (Angelina College)

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FS 02.001 Licensee Medical Condition Declaration 5.31.2017 Page 1 of 1
LICENSEE MEDICAL CONDITION DECLARATION (L-2) Commission Rule §217.1, 217.7
INDIVIDUAL INFORMATION
1. TCOLE PID
2. Last Name
3. First Name
4. M.I.
5. Suffix (Jr., etc.)
6. Home Mailing Address
7. City
8. State
9. Zip Code
APPOINTMENT (Do not check if student is in an academy)
DEPARTMENT / ACADEMY INFORMATION
An agency hiring a person for whom a license is sought shall select the examining physician. The hiring agency shall
maintain a copy of the report on file in a format readily accessible to the commission.
12. TCOLE Number
13. Appointing Agency or Academy
Attention Examining Professional: The above information must be completed by the requesting agency prior
to the examining professional completing and signing the L-2 form.
INITIAL APPOINTMENTS: Peace Officer (both exams), County Jailer (both exams), Telecommunicator (drug screen
only).
MORE THAN 180 day break in service: Peace Officer, County Jailer, and Telecommunicator: Drug Screen ONLY.
I certify that I have completed my examination of the examinee, on this date and determine the examinee is found:
MEDICAL 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.
Physician Physician’s Assistant Nurse Practitioner (State License # not required)
14. Name (type or print)
15. License No
16. Street Address
17. City
18. State
19. Zip Code
20. Phone Number
21. Date of Examination
22. Signature
23. Date
I certify that I have completed my examination of the examinee, on this date and determine the examinee is found:
DRUG SCREEN - To show no trace of drug dependency or illegal drug use after a physical examination, blood test or other
medical test.
Physician Physician’s Assistant Nurse Practitioner (State License # not required) DoT Provider
24. Name (type or print)
25. License No
26. Street Address
27. City
28. State
29. Zip Code
30. Phone Number
31. Date of Examination
32. Signature
33. Date
THIS DECLARATION IS NOT PUBLIC INFORMATION PER TEXAS OCCUPATIONS CODE 1701.306. VALID FOR
180 DAYS FROM GRADUATION DATE OF ACADEMY, IF ACCEPTED BY APPOINTING AGENCY OR VALID FOR
180 DAYS FROM DATE SIGNED UNLESS WITHDRAWN OR INVALIDATED. MUST BE SIGNED BY A LICENSED
PHYSICIAN, NURSE PRACTITIONER, or PHYSICIANS ASSISTANT WITH A VALID PHYSICIANS ID, or in the case
of a DoT drug screen only, authorized DoT personnel.
TEXAS COMMISSION ON LAW ENFORCEMENT
6330 E. Highway 290, STE. 200, Austin, Texas 78723-1035
Phone: (512) 936-7700
http://www.tcole.texas.gov
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An agency hiring a person for whom a (Angelina College)

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Completed 27 July 2020

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