Page 1 F-2(LE) Rev 6/11
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8215
MEDICAL EXAMINATION REPORT Form F-2(LE)
(Rev. 6/11)
This information is for official use only and will not be released to unauthorized persons.
Payment for services rendered is the responsibility of the hiring agency or the individual.
The Criminal Justice Standards Division is NOT responsible for payment.
Mail form to hiring agency or individual
DO NOT mail form to Criminal Justice Standard Division
Instructions:
To be completed by a qualified medical professional (Physician, Physician’s Assistant, or Nurse Practitioner licensed to
practice medicine in North Carolina, or Physician and/or Surgeon authorized to practice medicine in accordance with the rules
and regulations of the U.S. Armed Forces, [12 NCAC 9B .0104(a)], following an actual physical examination. The original or
a copy of this report must be retained in personnel files by the appointing agency.
Date: __________________________ Last 4 Digits SSN: _______________
Name: ___________________________________________________ Date of Birth: _____________________
Last First Middle
Employing Agency: __________________________________________________________________________
Height: ___________________ Weight: ________________
Vision
Visual Acuity: If applicant wears glasses or contacts, test and record acuity with and without glasses
Without glasses: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________
With glasses: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________
Color Perception:
Normal Abnormal: _______________________________________________
Peripheral Vision:
Normal Abnormal: _______________________________________________
Hearing
Hearing Acuity:
Audiogram or 15' whispered conversation (check one)
Right ear:
Normal Abnormal: ___________________________________________________
Left Ear:
Normal Abnormal: ____________________________________________________
Page 2 F-2(LE) Rev 6/11
Cardiovascular
Blood Pressure: ____________________ Resting Pulse: ____________________
Cardiac Examination: Normal Abnormal: ________________________________________________
Peripheral Circulation:
Normal Abnormal: ________________________________________________
ECG:
Indicated by hx or exam: __________________ (If resting pulse is less than 50 or greater than 100)
Abnormal Findings
HEENT: __________________________________________________________________________________
Lungs: __________________________________________________________________________________
Abdomen: __________________________________________________________________________________
Musculoskeletal: __________________________________________________________________________________
Genitourinary: __________________________________________________________________________________
Neurological: __________________________________________________________________________________
Skin: __________________________________________________________________________________
Urinalysis
Normal Abnormal: _________________________________________________________
TB Skin Test Millimeters of Induration _________________________________________________________
Are there any conditions, physical, emotional or mental, which, in your opinion, suggest further examination?
No Yes:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have any reservations about this candidate=s ability to physically perform required duties?
No Yes:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
I have read and fully understand the Medical Screening Guidelines Implementation Manual for the certification
of Criminal Justice Officers in the State of North Carolina.
________________________________________________
Signature of Qualified Medical Professional
________________________________________________
Date
________________________________________________________________________________________________
Name and Address of Qualified Medical Professional (Please Type)
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