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PHYSICAL EXAMINATION http://www.psp.pa.gov/MPOETC MUNICIPAL POLICE OFFICERS EDUCATION AND (City of Reading)

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MPO-210 (7/2019) 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. THE APPLICANT IS APPLYING FOR TRAINING OR CERTIFICATION AS A POLICE OFFICER IN
PENNSYLVANIA AND WILL BE EXPECTED TO BE PHYSICALLY CAPABLE OF PERFORMING THE VARIOUS TASKS ASSOCIATED WITH THIS
PROFESSION. MORE INFORMATION ABOUT THE SPECIFIC JOB TASKS IS CONTAINED ON THE BACK OF THIS FORM.
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 they can reasonably be expected to withstand significant cardiovascular stress required to perform the
essential functions of a police officer or safely participate in required training? YES
NO
B. Is the applicant free from debilitating conditions such as tremor, incoordination, convulsion, fainting episodes, or other neurological conditions which
would limit their ability to perform the essential functions of a police officer or safely participate in required training? YES NO
C. Is the applicant free from any other significant physical limitations or disability which would, in the physician’s opinion, impair their ability to perform
the essential functions of a police officer or safely participate in required training? YES NO
D. Is the applicant free from the use of medications which would impair their ability to perform the essential functions of a police officer or safely
participate in required training? YES NO
E. Does the applicant have all extremities, including digits, required to perform the essential functions of a police officer or safely participate in required
training? 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 free from the excessive, addictive, or illegal use of controlled substances as determined using a five-panel
drug screen. The results of the drug screen must be attached to this form and reviewed by the examining practitioner who may provide comments
related to any positive results. The detection of illegal or unprescribed controlled substances renders the applicant “UNFIT” to participate in training or
be employed as a police officer.
DATE TESTED _________________________________ TEST RESULTS ATTACHED YES NO
THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF SUPPORTED BY THE RESULTS OF THE DRUG SCREEN
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. If the applicant fails the whisper test, they must take
and pass a decibel audio test using an audiometer with an average loss not to exceed 25 or more decibels at the 500Hz, 1000Hz, 2000Hz, and 3000Hz
levels in either ear, with no single frequency loss in excess of 40 decibels. The applicant is prohibited from using a hearing aid during the testing.
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, normal 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
REMARKS
PROFESSIONAL OPINION
PHYSICALLY CAPABLE - I have examined the applicant, and it is my professional opinion that this person is PHYSICALLY CAPABLE of
performing the duties a certified police officer in Pennsylvania, including but not limited to:
• Standing, walking, and sitting for extended periods of time and while carrying assigned and/or required equipment.
• Participating in firearms training, responding to active shooter situations, and firing a weapon in defense of self and others.
• Operating an emergency law enforcement vehicle during daylight and at night, including at high speeds in congested areas.
• Physically struggling with and subduing individuals who are resisting or actively attacking, including after being hit or kicked.
• Maintaining concentration and making decisions regarding the appropriate use of force in noisy and high-stress situations.
PHYSICALLY UNFIT - I have examined the applicant, and it is my professional opinion that this person is currently PHYSICALLY UNFIT to
perform the duties of a certified police officer in Pennsylvania. If this option is selected, a copy of the completed form must be forwarded to the
Municipal Police Officers’ Education and Training Commission by email (
mpocertification@pa.gov) or fax (717-346-7782).
I hereby certify that the information and statements contained in the tables above and in the attached examination report are
true and correct, and that I am signing this document with the full understanding that any false information or statement will
subject me to criminal penalties of Title 18, Crimes code, Section 4904, relating to unsworn falsification to authorities.
SIGNATURE – PENNSYLVANIA LICENSED EXAMINING PHYSICIAN/PA/CNP DATE
PHYSICIAN PRINTED NAME LICENSE NO. TELEPHONE NO.
STREET ADDRESS CITY/BORO STATE ZIP CODE
RELEASE OF PHYSICAL INFORMATION
Having applied for certification/training as a police officer in Pennsylvania and having subjected myself to a physical examination by a
licensed physician, as required by the Act, I reserve the right to have the data and conclusions of the physician remain confidential
except to those whom I designate. Accordingly, I hereby authorize the physician named above to release all information related to my
physical examination to the Municipal Police Officer’s Education and Training Commission (MPOETC) AND to any additional police
departments and/or academies listed below, for purposes consistent with the application process pursuant to this Act. No other release
of this information, explicit or implied, is granted at this time.
____________________________________________________________________________
NAME OF MUNICIPAL POLICE DEPARTMENT AND/OR CERTIFIED ACT 120 ACADEMY (Print)
_______________________________________________________________________________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE FAX EMAIL
SIGNATURE – APPLICANT DATE
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PHYSICAL EXAMINATION http:www.psp.pa.govMPOETC MUNICIPAL POLICE OFFICERS EDUCATION AND (City of Reading)

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Completed 24 January 2021

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