Page 1 Form F-2(LE) rev. 3/16
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Fax (919) 779-8210
(Rev. 3/16)
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: ____________________________________________________
Page 2 Form F-2(LE) rev. 3/16
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: Normal Abnormal ______________________________________________________________
Lungs: Normal Abnormal ______________________________________________________________
Abdomen: Normal Abnormal ______________________________________________________________
Musculoskeletal: Normal Abnormal ______________________________________________________________
Genitourinary: Normal Abnormal ______________________________________________________________
Neurological: Normal Abnormal ______________________________________________________________
Skin: Normal Abnormal ______________________________________________________________
Urinalysis Normal Abnormal ______________________________________________________________
TB Risk Questionnaires Administered: Yes No Additional Screening Required: Yes No
Specify Additional Screening: ________________________________________________________________________
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 Medical License # Date
Name and Address of Qualified Medical Professional (Please Type)
Page 3 Form F-2(LE) rev. 3/16
Tuberculosis Risk Questionnaire
1) Were you born outside the USA in one of the following parts of the world: Yes No
Africa, Asia, Central America, South America or Eastern Europe?
2) Have you traveled outside the USA and lived for more than one month in one
of the following parts of the world: Africa, Asia Central America, South America Yes No
or Eastern Europe?
3) Do you have a compromised immune system such as from any of the following
conditions: HIV/AIDS, organ or bone marrow transplantation, diabetes, Yes No
immunosuppressive medicines (e.g. prednisone, Remicade), leukemia, lymphoma,
cancer of the head or neck, gastrectomy or jejeunal bypass, end-stage renal disease
(on dialysis), or silicosis?
4) Have you ever done one of the following: used crack cocaine, injected illegal drugs,
worked or resided in jail or prison, worked or resided at a homeless shelter, or worked Yes No
as a healthcare worker in direct contact with patients?
5) Have you ever been exposed to anyone with infectious tuberculosis? Yes No
Tuberculosis Symptom Questionnaire
Do you currently have any of the following symptoms?
1) Unexplained cough lasting more than 3 weeks Yes No
2) Unexplained fever lasting more than 3 weeks Yes No
3) Night sweats (sweating that leaves bedclothes and sheets wet) Yes No
4) Shortness of breath Yes No
5) Chest Pain Yes No
6) Unintentional weight loss Yes No
7) Unexplained fatigue (very tired for no reason) Yes No