Page 1 Form F-2(LE) rev. 3/16
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
MEDICAL EXAMINATION REPORT Form F-2(LE)
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
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: ________________
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 / _______________
With contacts: R - 20 / ______________ L- 20 / ____________ Both - 20 / _______________
How long have contacts been worn? ________________
Color Perception: Normal Abnormal: _______________________________________________
Peripheral Vision: Normal Abnormal: _______________________________________________
Hearing Acuity: Audiogram or 15' whispered conversation (check one)
Right ear: Normal Abnormal: ___________________________________________________
Left Ear: Normal Abnormal: ____________________________________________________