Fillable Form F-2 (DJJDP): CRIMINAL JUSTICE EDUCATION AND TRAINING (Mitchell Community College)

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Form F-2 (DJJDP): CRIMINAL JUSTICE EDUCATION AND TRAINING (Mitchell Community College)

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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
THIS INFORMATION IS FOR OFFICIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS.
Form F-2 (DJJDP)
(Rev.6/11)
INSTRUCTIONS:
To be completed by either a Physician/Physician’s Assistant/Nurse Practitioner or Surgeon licensed to practice
medicine in N.C. or by a Physician and/or Surgeon authorized to practice medicine in accordance with the rules and
regulations of the U.S. Armed Forces following an actual physical examination. The original or a copy of this report
must be retained in personnel file by the appointing agency.
Date: ___________________
Name: ___________________________________________________ Date of Birth: _________________________
Last First Middle
Well nourished
Height: ____________ Weight: ____________
Obese
Muscular
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 / ____________
Depth Perception:
Normal Abnormal: ___________________________________
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: ____________________________________
(Continued on reverse side)
CARDIOVASCULAR
Blood Pressure: _________________________ Resting Pulse: _________________
Cardiac Examination:
Normal Abnormal: __________________
Peripheral Circulation:
Normal Abnormal: __________________
ECG:
Indicated by hx or exam:
ABNORMAL DETAILS
NORMAL
HEENT: _______________________________________________________________________________
LUNGS ________________________________________________________________________________
ABDOMEN: ____________________________________________________________________________
MUSCULOSKELETAL: __________________________________________________________________
GENITOURINARY: ______________________________________________________________________
NEUROLOGICAL: ______________________________________________________________________
SKIN: _________________________________________________________________________________
URINALYSIS Normal Abnormal: __________________________________________________________
TB SKIN TEST
Negative Positive ____________________________________________________________
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
Juvenile Justice Officers and Chief/Juvenile Court Counselors in the State of North Carolina.
________________________________________________________________________________________________
Signature of Physician/Physician’s Assistant/Nurse Practitioner Date
Name and Address of Physician/Physician’s Assistant/Nurse Practitioner - Typed
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Form F-2 (DJJDP), Rev. 6/11
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Form F-2 (DJJDP): CRIMINAL JUSTICE EDUCATION AND TRAINING (Mitchell Community College)

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Completed 1 October 2020

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