MPO-210 (3/2018) SUPERCEDES ALL PREVIOUS VERSIONS OF THE MUNICIPAL POLICE OFFICER PHYSICAL EXAMINATION FORM.
MUNICIPAL POLICE OFFICERS’ EDUCATION AND TRAINING COMMISSION
8002 Bretz Drive
Harrisburg, Pennsylvania 17112-9748
http://www.psp.pa.gov/MPOETC
PHYSICAL EXAMINATION
This form is to be used by both municipal police officer applicants and police academy cadet applicants.
NOTICE AND INSTRUCTIONS TO EXAMINING PHYSICIAN
THIS EXAMINATION MUST BE ADMINISTERED BY A LICENSED PHYSICIAN, PHYSICIAN’S ASSISTANT, OR CERTIFIED NURSE PRACTITIONER
WHO IS LICENSED IN PENNSYLVANIA. THIS EXAMINATION IS TO DETERMINE THE PHYSICAL FITNESS OF THE APPLICANT TO BE
CERTIFIED AS A POLICE OFFICER IN PENNSYLVANIA. THE APPLICANT WHO YOU ARE ABOUT TO EXAMINE IS APPLYING FOR
CERTIFICATION AND WILL BE VESTED WITH A POSITION OF PUBLIC TRUST. HE/SHE MAY, AT SOME FUTURE TIME, BE REQUIRED TO
EXERCISE SIGNIFICANT PHYSICAL STRENGTH AND UNDERGO HIGH EMOTIONAL STRESS.
LAST NAME FIRST NAME MIDDLE INITIAL
STREET ADDRESS
CITY/BORO STATE ZIP CODE
SOCIAL SECURITY NUMBER
DATE OF BIRTH GENDER DATE OF EXAM
OVERALL FITNESS
A. Is the applicant’s physical condition such that the applicant can reasonably be expected to withstand significant cardiovascular stress? This includes
normal function of the heart, lungs, blood pressure, etc. YES NO
B. Is the applicant free from any debilitating conditions such as tremor, incoordination, convulsion, fainting episodes, or other neurological conditions
which may affect the applicant’s ability to perform as a police officer? YES NO
C. Is the applicant free from any other significant physical limitations or disability which would, in the physician’s opinion, impair the applicant’s ability to
perform the duties of a police officer or complete the required minimum training requirements? YES NO
D. Does the applicant have all extremities, including digits, required to meet minimum training requirements and perform police officer duties?
YES NO
THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF ALL QUESTIONS ABOVE ARE MARKED “YES”
DRUG SCREEENING: The applicant must be tested for and free from the presence of illegal controlled substances using a minimum of a five-panel
drug screen. The results of the drug screen must be attached to this form for review. Include a list of all medications currently taken by the applicant.
DATE TESTED _________________________________ TEST RESULTS ATTACHED YES NO
APPLICANT IS CURRENTLY TAKING MEDICATION YES NO MEDICATION LIST ATTACHED YES N/A
THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF THE RESULTS OF THE DRUG SCREEN ARE ATTACHED
HEARING: The applicant must be able to distinguish a normal whisper at 15 feet. The test shall be independently conducted for each ear, with the
tested ear facing away from the speaker and the other ear firmly covered with the palm of the hand. The applicant is prohibited from using a hearing aid
during the testing. If the applicant fails the whisper test, a decibel audio test is required with the following results: 25db or better for pure tone stimulation
between 500Hz, 1000Hz, 2000Hz, and 3000Hz.
RIGHT EAR NORMAL LEFT EAR NORMAL
ABNORMAL ABNORMAL
THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF HEARING IS NORMAL IN BOTH EARS
VISION: The applicant must have vision of at least 20/70, uncorrected, in the stronger eye, correctable to 20/20; and at least 20/200, uncorrected, in the
weaker eye, correctable to at least 20/40; have normal depth perception and color vision, and must be free of any significant visual abnormality. If this
section is not completed during the physical, a separate vision exam must be completed using a Form MPO-211 (Vision Examination).
RIGHT EYE UNCORRECTED 20/_____ LEFT EYE UNCORRECTED 20/_____
CORRECTED 20/_____ CORRECTED 20/_____
Does the applicant have normal depth perception? (Stereopsis >48% or Arc Seconds <100) YES NO
Does the applicant have normal color perception? (Farnsworth or Ishihara) YES NO
Is the applicant free from any other significant visual abnormalities? YES NO
THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF VISION MEETS ALL STATED REQUIREMENTS
