Fill - Free fillable Potential BLET Student, By obtaining the Isothermal Community (Isothermal Community College) PDF form

Potential BLET Student,

By obtaining the Isothermal Community College Basic Law Enforcement Training Application, you have

taken the first step towards a rewarding career in the field of policing. This application contains all of the

documentation required by the Criminal Justice Education and Training Standards Commission, whom

govern BLET, as well as some additional requirements set by Isothermal Community College.

Integrity and attention to detail are at the cornerstone of our BLET Program and the law enforcement

profession. As you progress through this application, please keep these attributes in mind and be sure to

dot your I’s and cross your T’s as well as being truthful in divulging all the information that is being

requested.

The BLET staff at Isothermal Community College is willing and able to assist you through the application

process. I encourage you to stay in contact, bring in documents as you complete them, and ask any

questions as they arise. I applaud your decision to seek out this challenge in becoming the next generation

of law enforcement officers.

Sincerely,

Philip G. Bailey

Director, Basic Law Enforcement Training

Isothermal Community College

BLET Director: Philip G. Bailey pbailey@isothermal.edu 828-395-1644

Admin. Assistant: Brenda McFarland bmcfarland@isothermal.edu 828-395-1668

Qualified Assistant: Thomas Tarker ttarker@isothermal.edu 828-395-1448

1

CRIMINAL JUSTICE TRAINING CENTER

ISOTHERMAL COMMUNITY COLLEGE

It is the determination of Isothermal Community College that these questions are necessary in

order to fully and adequately evaluate applicants for the Basic Law Enforcement Training

Program. These question are designed to ascertain whether the applicants meets the minimum

requirements set forth by the Isothermal Community College Basic Law Enforcement Training

program and the North Carolina Criminal Justice Education and Training Standards Commission.

BASIC LAW ENFORCEMENT TRAINING APPLICATION

Rev. 4/28/16

2

CRIMINAL JUSTICE TRAINING CENTER

ISOTHERMAL COMMUNITY COLLEGE

286 ICC Loop Rd., P.O. Box 804 Spindale, NC 28160

Director Philip Bailey 828-395-1644

Email: pbailey@isothermal.edu

Isothermal Community College Personal History Application

NOTE: All Statements are subject to verification and any incorrect statements or omissions

may result in immediate dismissal from the Basic Law Enforcement Program.

Date of Application: Month ________________ Day________________ Year_____________

Personal Information

Name: ______________________________________________________________________

First Middle Last

Social Security Number_________________________________________________________

Maiden Name: ________________________________________________________________

Other Previous Names: _________________________________________________________

Nicknames or Aliases: __________________________________________________________

Present Mailing address: ________________________________________________________

Street

________________________________________________________________________

City County State

Telephone: ____________________ ______________________ ___________________

Home Work Cell

Email Address ______________________________________________________________

Date of Birth___________________ 5. Place of Birth: _________________________________

Citizenship: ____ U.S. Born ____ U.S. Naturalized Other

-Specify _____________________

3

Military Service

Were you

ever in the U.S. Military Service or other military organization? Yes______ No______

Were you ever denied entrance into the Military? Yes______ No________ If yes, Why?

____________________________________________________________________________

(If you answered NO to Military Service skip to Educational)

List each tour

of active duty where a DD-214 was issued:

Branch

Unit (Company

or Ship)

Location

From

Mo./ yr.

To

Mo./Yr.

List all duty stations:

Branch

Unit (Company

or Ship)

Location

From

Mo./Yr.

To

Mo. /Yr.

Have you

ever received any of the following types of discharge?

Uncharacterized Yes____________ No____________

Honorable Yes_____________ No____________

General (Under Honorable Conditions) Yes _____________ No____________

Under other than Honorable Conditions Yes______________ No____________

Bad Conduct Discharge Yes _____________ No____________

Dishonorable Discharge Yes _____________ No____________

Dismissal Yes______________ No____________

Were you ever court-martialed, tried on charges, or the subject of a summary court, desk court,

non-judicial punishment, captain’s mast, company punishment, article 15, and/or disciplinary

action while a member of the military, national guard or reserve unit?

Yes_____ No_________

4

If yes, explain what occurred and what type of punishment you received:

____________________________________________________________________________

List all medals and decorations awarded you during your military service:

____________________________________________________________________________

EDUCATIONAL

Indicate below the schools you have attended (include incomplete courses) indicate the type of

High School you attended: Traditional ______Distance Learning ______Home School________

Did not attend high school other: _________________________________________________

Name

Address

(City & State)

# Full

years’

Work

Completed

When

attended

Graduate

d

(Yes/No)

Degree

Awarded

Major

Field

High School

Universities or College

5

If you did not graduate from high school, have you passed the General Educational Development

(GED) Test? Yes ____________ No_____________ If yes, when and where did you complete

the GED? ____________________________________________________________________

RESIDENCIES

List every city/county in which you have lived since attaining the age of 16, with present address

at top”

From

Mo./Yr.

To

Mo./yr.

Address of Residence

City, Zip Code

State

County

EMPLOYMENT

List all jobs, positions or appointment you have held in the last ten years to include temporary,

part time, paid or non-paid employment, active or inactive reserve, and internships. Put your

present or most recent job first.

Title of present or last position____________________________________________________

Employer Address and Phone Number_____________________________________________

Name Phone Number

____________________________________________________________________________

Street City State Zip Code

Date employed _____________ Starting Salary_______________ Last Salary _____________

6

Date Separated_____________ Name/Title of Supervisor ______________________________

Full time _________Yrs. _________Mos. Part time ________ Yr. ________ Mos.

If part time, number of hours worked per week_____ No. Employees supervised by you: ______

Duties:

____________________________________________________________________________

Reason for leaving _____________________________________________________________

____________________________________________________________________________

Title of present or last position____________________________________________________

Employer Address and Phone Number_____________________________________________

Name Phone Number

____________________________________________________________________________

Street City State Zip Code

Date employed _____________ Starting Salary_______________ Last Salary _____________

Date Separated_____________ Name/Title of Supervisor ______________________________

Full time _________Yrs. _________Mos. Part time ________ Yr. ________ Mos.

If part time, number of hours worked per week_____ No. Employees supervised by you: ______

Duties:

____________________________________________________________________________

7

Reason for leaving _____________________________________________________________

____________________________________________________________________________

Title of present or last position____________________________________________________

Employer Address and Phone Number_____________________________________________

Name Phone Number

____________________________________________________________________________

Street City State Zip Code

Date employed _____________ Starting Salary_______________ Last Salary _____________

Date Separated_____________ Name/Title of Supervisor ______________________________

Full time _________Yrs. _________Mos. Part time ________ Yr. ________ Mos.

If part time, number of hours worked per week_____ No. Employees supervised by you: ______

Duties:

____________________________________________________________________________

Reason for leaving _____________________________________________________________

____________________________________________________________________________

Title of present or last position____________________________________________________

Employer Address and Phone Number_____________________________________________

Name Phone Number

____________________________________________________________________________

Street City State Zip Code

8

Date employed _____________ Starting Salary_______________ Last Salary _____________

Date Separated_____________ Name/Title of Supervisor ______________________________

Full time _________Yrs. _________Mos. Part time ________ Yr. ________ Mos.

If part time, number of hours worked per week_____ No. Employees supervised by you: ______

Duties:

____________________________________________________________________________

Reason for leaving _____________________________________________________________

____________________________________________________________________________

USE OF ALCHOL OR DRUGS

Do you drink alcoholic beverages? Yes_______ No_____

(If yes please explain to what extant)

____________________________________________________________________________

Note: The word “used” means one time or more, including experimentations.” If any answer is

yes, give full and complete details. (Attach extra sheets if necessary)

Have you ever used, to include tasting, any illegal drugs including but not limited to marijuana,

steroids, opiates, pills, heroin, cocaine, crack, LSD, designer or synthetic drugs, etc. to include

even one time use or experimentation?

Yes _______________ No_______________ I don’t know explain below__________________

If yes, what were the circumstances, drugs used, and when did the usage last occur?

____________________________________________________________________________

9

When was the last time?

____________________________________________________________________________

Have you ever used prescription drugs other than under the supervision of, or as prescribed by,

a physician?

Yes_________ No______________ I don’t know (explain below) ________________________

If yes, what were the circumstances, drugs used, and when did the last usage occur?

____________________________________________________________________________

Have you ever purchased, possessed, manufactured, grown, delivered or sold any amount of

illegal drugs or controlled substances for which you did not have a valid prescription?

Yes_____ No_____ I don’t know ____________ (explain below) If yes, identify the drugs and

provide details concerning the purchase, possession, manufacture, growth delivery, or sale.

____________________________________________________________________________

CRIMINAL OFFENSE RECORDS & DICIPLINARY ACTIONS

NOTE: Answer all of the following questions completely and accurately. Any falsifications or

misstatements of facts may be sufficient to disqualify you. If any doubt exists in your mind as to

whether or not you were arrested or charged with a criminal offense at some point in your life or

whether an offense remains on your record, you should answer “Yes.” You must list any and

criminal charges regardless of the date of offense and the deposition (to include dismissals, not

guilty, no pros, PJC, or any other disposition where you entered a plea of guilty). Juvenile charges

or arrest should also be listed.

Include all offenses other than minor traffic offenses. Specifically include DWI, DUI, driving while

under the influence of drugs, driving while license permanently revoked, speeding to elude arrest,

or duty to stop in event of accident. Attached to this form is an additional list of North Carolina

traffic offenses which must be listed.

You must include any and all convictions regardless of whether or not the convictions were

expunged pursuant to NCGS 15A-145.4 and 15A-145.5. If you list a charge(s), please attach

certified and true copies of warrants(s) and judgment (s) for each offense, even if documentation

and charges have previously been reported to this agency.

10

Have you ever been arrested by a Law Enforcement Officer or otherwise charged with a criminal

offense? (The term “charged” as used in this question includes being issued a criminal citation or

summons). Yes ___________ No__________ If yes, give details below:

Offense Charged________________________ Law Enforcement _______________________

Date_________________ Disposition of case _______________________________________

Offense Charged________________________ Law Enforcement _______________________

Date_________________ Disposition of case _______________________________________

Offense Charged________________________ Law Enforcement _______________________

Date_________________ Disposition of case _______________________________________

Offense Charged________________________ Law Enforcement _______________________

Date_________________ Disposition of case _______________________________________

(Attach extra sheets if necessary)

Have you ever had a Domestic Violence Protection Order issued against you? (Include both ex-

Parte Domestic Violence Protective Orders and those entered Subsequent to a hearing.)

Yes _______________ No_______________

Date of Issuance: ______________________________________________________________

County of Issuance: ____________________________________________________________

Name of Plaintiff: ______________________________________________________________

Date of expiration: _____________________________________________________________

Have you ever been convicted of a misdemeanor under federal or state law which has, as an

element, the use or attempted use of physical force or threatened use of deadly weapon?

_______Yes _______________No ______________ I don’t know _______________________

Have you ever been charged with a felony (Including any charges expunged)?

_______Yes ______________ No _______________ I don’t know ______________________

If yes, explain: ________________________________________________________________

____________________________________________________________________________

11

Have you ever been placed on probation? Yes _____ No _____

If yes, explain _________________________________________________________________

____________________________________________________________________________

Do you possess a valid driver’s license from the State of North Carolina? Yes _____ No ______

Driver’s licenses Number __________________________ Year Issued___________________

Do you now possess, or have ever possessed a driver’s license by any state other than North

Carolina? Yes _____ No _____ If yes give state and number __________________________

AMERICANS WITH DISABILITIES ACT

Having been signed into law July 26, 1990; the Americans with

Disabilities Act attempts to remove workplace discrimination against

those who have disabilities.

The Criminal Justice Training Center and Isothermal Community

College shall have as a goal, to be in full compliance with the spirit and

intent of this Act and provisions therein.

We shall not knowingly discriminate against any qualified individual

with a disability nor shall a qualified individual with a disability, by

reason of said disability, be excluded from participation in or denied

benefits of any program.

However; the following two (2) special considerations shall govern

admission to this Criminal Justice Training Center B.L.E.T. program……..

(1) Personal Characteristics:

Since law enforcement officers are required to enforce the law and

they are exposed to certain temptations such as favoritism, corruption

or unlawful monetary gain; it is a business necessity that candidates

exhibit a history and characteristics of honesty, reliability,

interpersonal skills, integrity and the ability to manage personal

finances.

Additionally, law enforcement officers are frequently placed in a

position of physical and mental stress. Therefore; a history of mental or

physical disability may be grounds for denying employment or these

factors may be a consideration during the hiring process. Applicants

posing a substantial risk of injury to themselves, other officers and the

public may be at a substantial disadvantage during the hiring process.

(2) INEXPERIENCED LAW ENFORCEMENT OFFICER ESSENTIAL JOB

FUNCTIONS:

The following are the “essential job functions” that are common to

all inexperienced law enforcement officers in North Carolina, as

determined by The N.C. Criminal Justice Education and Training

Standards Commission and the Sheriff’s Education and Training

Standards Commission. The successful applicant must be able to

perform ALL of the essential job functions of an inexperienced law

enforcement officer, generally unassisted and at a pace and level of

performance consistent with the actual job performance requirements.

This requires a high level of physical ability to include vision, hearing,

speaking, flexibility and strength.

1. Effect an arrest, forcibly if necessary, using handcuffs and other

restraints; Subdue resisting suspects using maneuvers and weapons

and resort to the use of hands and feet and other approved weapons in

self-defense.

2. Prepare investigative and other reports, including sketches, using

appropriate Grammar, symbols and mathematical computations.

3. Exercise independent judgment in determining when there is

reasonable Suspicion to detain, when probable cause exists to search

and arrest and when Force may be used and to what degree.

4. Operate a law enforcement vehicle during both the day and night; in

emergency Situations involving speeds in excess of posted limits, in

congested traffic and in Unsafe road conditions caused by factors such

as fog, smoke, rain, ice and snow.

5. Communicate effectively and coherently over law enforcement radio

channels while initiating and responding to radio communications.

6. Gather information in criminal investigations by interviewing and

obtaining the Statements of victims, witnesses, suspects and

confidential informers.

7. Pursue fleeing suspects and perform rescue operations which may

involve Quickly entering and exiting law enforcement patrol vehicles;

lifting, carrying and Dragging heavy objects; climbing over and pulling

up oneself over obstacles; Jumping down from elevated surfaces;

climbing through openings; jumping over Obstacles, ditches and

streams; crawling in confined areas; balancing on uneven Or narrow

surfaces and using body force to gain entrance through barriers.

8. Load, unload, aim and fire from a variety of body positions handguns,

shotguns and other agency firearms under conditions of stress that

justify the use of deadly force and at levels of proficiency prescribed in

certification standard

9. Perform searches of people, vehicles, buildings and large outdoor

areas which may involve feeling and detecting objects, walking for long

periods of time, detaining people and stopping suspicious vehicles and

persons. 10/31/2012

10. Conduct visual and audio surveillance for extended periods of time.

11. Engage in law enforcement patrol functions that include such things

as working rotating shifts, walking on foot patrol and physically

checking the doors and windows of buildings to ensure they are secure.

12. Effectively communicate with people, including juveniles, by giving

information and directions, mediating disputes and advising of rights

and processes.

13. Demonstrate communication skills in court and other formal

settings.

14. Detect and collect evidence and substances that provide the basis

of criminal offenses and infractions and that indicate the presence of

dangerous conditions.

15. Endure verbal and mental abuse when confronted with the hostile

views and opinions of suspects and other people encountered in an

antagonistic environment.

16. Perform rescue functions at accidents, emergencies and disasters

to include directing traffic for long periods of time, administering

emergency medical aid, lifting, dragging and carrying people away from

dangerous situations and securing and evacuating people from

particular areas.

17. Process and transport prisoners and committed mental patients

using handcuffs and other appropriate restraints.

18. Put on and operate a gas mask in situations where chemical

munitions are being deployed.

19. Extinguish small fires by using a fire extinguisher and other

appropriate means.

20. Read and comprehend legal and non-legal documents, including the

preparation and processing of such documents as citations, affidavits

and warrants.

21. Process arrested suspects to include taking their photographs and

obtaining a legible set of inked fingerprint impressions.

Note:

The successful candidate must be able to perform ALL of the

above listed essential job functions of an inexperienced law

enforcement officer, unassisted, and at a pace and level of performance

consistent with the actual job performance requirements. This requires

a high level of physical ability to include vision, hearing, speaking,

flexibility and strength.

______________________________________ ______________________

(candidate’s signature) (date)

BLET TOPIC LIST

1. Course Orientation - 2 hours

2. Physical Fitness Training - 54 hours

3. Ethics for Professional Law Enforcement - 4 hours

4. Arrest, Search & Seizure/Constitutional Law - 28 hours

5. Elements of Criminal Law - 24 hours

6. Communication Skills for Law Enforcement Officers - 8 hours

7. Law Enforcement Radio Procedures and Information Systems - 8 hours

8. Field Note taking & Report Writing - 12 hours

9. Interviews: Field & In-Custody - 16 hours

10. Subject Control/Arrest Techniques - 40 hours

11. Juvenile Law & Procedures - 8 hours

12. Fingerprinting & Photographing Arrestees - 6 hours

13. Responding to Victims & the Public - 10 hours

14. Firearms - 48 hours

15. Criminal Investigation - 34 hours

16. ABC Laws & Procedures - 4 hours

17. Motor Vehicle Law - 20 hours

18. Law Enforcement Driver Training - 40 hours

19. Crime Prevention Techniques - 6 hours

20. First Responder - 32 hours

21. Domestic Violence Response - 12 hours

22. Controlled Substances - 12 hours

23. Techniques of Traffic Law Enforcement - 24 hours

24. In-Custody Transportation - 8 hours

25. Traffic Crash Investigation - 20 hours

26. Explosives & Hazardous Materials Emergencies - 12 hours

27. Individuals With Mental Illness or Developmental Disabilities - 8 hours

28. Crowd Management - 12 hours

29. Preparing for Court & Testifying in Court - 12 hours

30. Patrol Techniques - 28 hours

31. Sheriff's Responsibilities: Detention Duties - 4 hours

32. Sheriff's Responsibilities: Court Duties - 6 hours

33. Civil Process - 24 hours

34. Anti-Terrorism - 4 hours

35. Rapid Deployment - 8 hours

36. Human Trafficking - 2 hours

Testing - 20 hours

TOTAL HOURS: 620

Taser, Pepper Spray and ASP (Baton) Training

Isothermal Community College

BLET Criminal Records

Request Form

Note to Candidate: This form is to be filled out with your name,

address, telephone number, and date of birth. Afterwards, present this

completed and signed form to the Clerk of Superior Court when

requesting a criminal records background check.

To be completed by student:

Full Name: __________________________________

Date of Birth: ________________________________

Address: ______________________________________

_______________________________________________

Telephone: _____________________________________

Clerk of Superior Court: This is to confirm that the above named

individual is applying for admission to Basic Law Enforcement Training

at Isothermal Community College P.O. Box 804, Spindale N.C. 28160.

Any accommodation that may be made for the candidate regarding

costs / fees is greatly appreciated by our staff. All fees incurred are

the candidate’s responsibility.

Philip G. Bailey

Director

Basic Law Enforcement Training

Isothermal Community College

(828) 395-1644

BLOODBORNE PATHOGENS

Rules and regulations have been set forth by the United States Occupational

Safety and Health Administration (OSHA) governing Bloodborne Pathogens and

the possible exposure thereto.

Bloodborne Pathogens means pathogenic microorganisms that are present in

human blood and can cause disease in humans. These pathogens include, but

are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus

(HIV).

Due to the scope and nature of Basic Law Enforcement Training, which

involves various blocks of instruction, the potential exists whereby a

candidate may be exposed to and / or come in contact with the blood of

another trainee. Such an exposure potential is considered as being minimal;

and any or all such contact is considered as being unintentional; none the less

this possibility does exist.

Therefore, each candidate is hereby notified as to the availability of a

vaccination for the Hepatitis B Virus (HBV). Should a candidate elect to

receive this vaccination, it shall be done so at the personal expense of the

candidate. Candidates who become enrolled in the Basic Law Enforcement

Training program shall be required to select from the following options:

1) Have already received the vaccination process.

2) Undergo the vaccination process (doing so at the candidate’s expense)

3) Execute a waiver of liability upon behalf of the Criminal Justice Training

Center and Isothermal Community College.

The candidate shall retain the option to elect to receive the vaccination after

execution of the waiver should he / she decide to do so. It shall be done at the

personal expense of the candidate.

__________________________________________ _________________________

(candidate’s signature) (date)

Page 1 F-1(LE) Rev. 6/11

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 HISTORY STATEMENT Form F-1(LE)

(Rev. 6/11)

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

Instructions:

To be completed by applicant for a certifiable position prior to the physical examination and presented to the examining 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,

at the time of examination [12 NCAC 9B .0104(a)]. All questions must be answered completely and accurately. The original or a

copy must be retained in personnel files by the appointing agency.

Date: _____________________

Name: _________________________________________________________ Date of Birth: _____________________

Last First Middle

Address: ____________________________________________________________________________________________

City: ___________________________________ State:

___________________ Zip Code: _____________________

Telephone: ___________________________________ Last 4 Digits of SSN: ______________________________

Current Medications

Prescription Medications: (Include pain relievers, birth control pills, etc.)

______________________________________________________________________________________________________________

Over the Counter Medications: ( Include all cold allergy, headache, vitamins, supplements, herbal remedies, etc.)

______________________________________________________________________________________________________________

Allergies

Drug Allergies: (Include your reaction to the mediation)

______________________________________________________________________________________________________________

All Other Allergies: food, insects, seasons, animals, materials, etc. (Include reaction)

______________________________________________________________________________________________________________

Page 2 F-1(LE) Rev. 6/11

Past Medical History

List ALL hospitalizations and operations since childhood:

(Include type of surgery, date of surgery, any complications or other significant information)

___________________________________________________________________________________________________________

Have you EVER, in your life, had any of the following types of medical problems? [check all that apply to you]

1. CANCER: any type of cancer including skin cancer, breast cancer, and leukemia?

2. MAJOR INFECTIOUS DISEASE: such as tuberculosis, hepatitis, HIV/AIDS, rheumatic fever and others?

3. NEUROLOGICAL PROBLEMS: such as seizure disorder, stroke, concussion, severe headache, skull fracture,

recurrent vertigo, balance problems, encephalitis, meningitis, tremors, multiple sclerosis, Huntington=s chorea,

peripheral neuropathy and others?

4. PSYCHOLOGICAL PROBLEMS: such as depression, manic episodes, psychotic episodes, post traumatic

stress disorder and others?

5. EYE PROBLEMS: such as eye injury, color blindness, poor night vision (night blindness), glaucoma,

blindness in one or both eyes, very poor vision when not corrected and others?

6. EAR PROBLEMS: such as ear injury, chronic ringing (tinnitus), chronic or long lasting ear infection,

Meniere=s disease, moderate to severe hearing loss in one or both ears and others?

7. NOSE PROBLEMS: such as nose injury, allergies, nasal bleeding, loss of sense of smell, chronic or long

lasting infections and others?

8. MOUTH OR THROAT PROBLEMS: such as injury, major dental work, any kind of speech defect, chronic

or long lasting infections, abnormality of nose, mouth or throat that would interfere with wearing a respirator

and others?

9. LUNG PROBLEMS: such as asthma, emphysema, chronic or recurrent bronchitis, pneumonia, tuberculosis or

lung abscess and others?

10. HEART AND CIRCULATION PROBLEMS: such as heart murmur, heart disease, heart attack, hypertension

(high blood pressure) irregular rhythm, valve abnormalities, varicose veins, phlebitis, peripheral vascular

disease, Raynaud=s disease and others?

11. DIGESTIVE SYSTEM PROBLEMS: such as any kind of ulcer disease, hepatitis or liver disorder, any kind of

colitis, Crohn=s disease, ulcerative colitis, irritable bowel syndrome, esophageal disorders, pancreatitis, gall

stones, stomach or intestinal bleeding and others?

12. HORMONE OR ENDOCRINE PROBLEMS: such as diabetes, thyroid disease, parathyroid or adrenal

problems and others?

13. URINARY TRACT PROBLEMS: such as kidney stones, pyelonephritis (kidney infection), nephrosis, single

functioning kidney, polycystic kidney disease, repeated bladder infections and others?

14. HERNIA: such as inguinal, umbilical, ventral, femoral, hiatal or incisional hernias?

15. MUSCLE, BONE AND JOINT PROBLEMS: such as chronic back or neck pain, numbness fibromyalgia, back

or neck disk disease, osteomyelitis (bone infection), muscular dystrophy, arthritis, spinal curvature, carpal tunnel

syndrome loss of a finger or toe, and others?

16. BLOOD SYSTEM PROBLEMS: such as anemia, hemophilia or bleeding disorder, white blood cell

abnormality and others?

(Continued on next page)

Page 3 F-1(LE) Rev. 6/11

Males Only:

17. Prostate problems such as enlargement or prostatitis?

18. Genital problems such as epididymitis or testicular injury?

Females Only:

19. Currently pregnant?

20. History of endometriosis, pelvic inflammatory disease, abnormal Pap smear, PMS or other problem with your

menstrual cycle?

Immunizations

21. Have you ever had a positive TB test?

22. Have you received Hepatitis B vaccinations?

23. When did you receive your last tetanus (lockjaw) immunization? __________________________________

Occupational History

Have you ever been exposed to any of the following, whether at home, work, military or any other setting? [check all that

apply]

24. Repetitive Loud Noises (Including guns, jet engines, loud machinery)?

25. Chemical exposure to skin or lungs?

26. Dusty conditions (sandblasting, grinding, mining or drilling of rock, coal, silica, asbestos)?

Check all YES answers:

27. Have you ever sustained an injury while at work that necessitated extended care by a health care provider?

28. Have you ever had a motor vehicle accident or other injury event causing back or neck pain?

29. Are you limited or unable to perform any physical activity because of muscle or joint discomfort?

30. Do you have any missing limbs or non-functional joints?

31. Do you have numbness, weakness, or pain in your upper extremities (including your hands)?

32. Have you ever been advised by a physician to avoid sitting or standing over a certain time?

33. Have you ever worked in law enforcement?

33a.If yes, have you ever missed more than three consecutive days of work for any medical or psychological

problem?

34. Have you ever served in any of the armed forces?

34a.If yes, have you ever missed more than three consecutive days or service for any medical or psychological

problem?

35. Do you have any medical condition that would prevent you from working extended shift periods, rotating shifts,

or night shifts?

36. Do you have difficulty sitting for any extended period of time?

37. Have you ever been advised by a physician to avoid lifting above a certain weight limit?

38. Do you have any difficulty in properly holding, aiming or firing a handgun, rifle or shotgun?

39. Do you have any difficulty driving at high speeds in a motorized vehicle?

40. Have you ever had an automobile accident while driving over sixty (60) miles per hour?

41. Have you ever had any automobile accidents as a result of losing control of your vehicle?

42. Do you have any difficulty driving for three (3) consecutive hours without stopping?

43. Do you have any difficulty running for five (5) consecutive minutes without stopping?

44. Have you ever passed out, temporarily lost control of any part of your body, or had blackout spells (episodes you

do not remember)?

(Continued on reverse side)

Page 4 F-1(LE) Rev. 6/11

Explanation of any “Yes” answers: (Identify by number)

Additional pages may be attached and must include your name, the last four digits of your social security number, and must

be signed and dated.

________________________________________________________________________________________________

Penalty:

Any falsification, withholding or failure to answer all questions completely and accurately may disqualify you from receiving

or retaining employment or certification as a criminal justice officer. Falsification regarding pre-existing conditions may

disqualify you from receiving benefits from your employer.

Certification:

I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and

answers to questions, and that all statements and answers are true and correct to the best of my knowledge and belief.

______________________________________________ _______________________________________

Signature of Applicant (Use Ink) Date Signed

Qualified Medical Professional Review:

______________________________________________

_______________________________________

Signature of Qualified Medical Professional Date Reviewed

(Use Ink)

Name, Title and Address of qualified medical professional completing review – Please Type.

Page 1 Form F-2(LE) rev. 5.1.14

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)

(Rev. 5.1.14)

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

Instructions:

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: ________________

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 / _______________

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:

Page 2 Form F-2(LE) rev. 5.1.14

Cardiovascular

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: __________________________________________________________________________________

Lungs: __________________________________________________________________________________

Abdomen: __________________________________________________________________________________

Musculoskeletal: __________________________________________________________________________________

Genitourinary: __________________________________________________________________________________

Neurological: __________________________________________________________________________________

Skin: __________________________________________________________________________________

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. 5.1.14

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

Isothermal Community College

Basic Law Enforcement Training

EXPOSURE TO CHEMICAL AGENTS

RELEASE FORM

(CN, CS, OC)

To the examining physician:

During training this individual will be exposed to chemical agents during

mandated riot control training. Individuals with respiratory difficulties,

including asthma, are not suitable candidates for this type of training.

Please certify that this individual is physically able to engage in training

exercises using chemical agents.

IT IS ACCEPTABLE FOR:

Students Name: ___________________________________________________________

To participate in the above described activities including exposure to

chemical agents.

___________________________________________

Physician’s Printed Name

___________________________________________ ________________________

Physician’s Signature Date

Required Documentation

Requirements for admission to Basic Law Enforcement Training (signature)

American’s with Disabilities Act statement (ADA) (signature)

Blood Borne Pathogens statement (signature)

Basic Law Enforcement Training Application (signature / notarized)

CJETSC Form F-1 (medical history statement) (signature)

CJETSC Form F-2 (medical examination report) (signature)

ICC Exposure to Chemical Agents Waiver (signature)

Certified Copy - Criminal History

(From every jurisdiction where candidate has resided since 16 years of age)

Certified Copy - Birth Certificate / Certificate of Naturalization

Copy of valid North Carolina driver’s license

Copy of valid Social Security card

Copy of High School Diploma or GED (transcripts are not accepted)

COMPASS reading placement test (10

th

grade reading level required)

(This test will be scheduled and administered through the admissions office)

DD-214 (Separation from active military service) (if applicable)

Early enrollment waiver if 19 years of age (CJETSC)

Sponsorship Letter

(Candidates must obtain sponsorship from a local (or area) law enforcement

agency. Sponsorship will waive tuition costs for the candidate. A letter of

sponsorship is included in the application packet)

Requirements for admission into a BLET course are:

• Must be a citizen of the United States;

• Must be 20 years of age;

• Priority admission is given to individuals holding full-time

employment with criminal justice agencies;

• Must provide to the School Director a medical examination

report, properly completed by a physician licensed to practice

medicine in North Carolina, a physician's assistant, or a nurse

practitioner, to determine the individual's fitness to perform

the essential job functions of a criminal justice officer.

• Must have a high school diploma or GED. High school

diplomas earned through correspondence enrollment are not

recognized toward the educational requirements.

• Must take a standardized reading comprehension test

and score at the tenth grade level or higher within one

year prior to entrance into Basic Law Enforcement Training.

• Must provide to the School Director a certified criminal record

check for local and state records for the time period since the

trainee has become an adult and from all locations where the

trainee has resided since becoming an adult. An

Administrative Office of the Courts criminal record check or a

comparable out-of-state criminal record check will satisfy this

requirement.

• Must have not been convicted of any of a felony or:

o a crime for which the punishment could have been

imprisonment for more than two years; or

o a crime or unlawful act defined as a "Class B

misdemeanor" within the five year period prior to the date of

application for employment unless the individual intends to

seek certification through the North Carolina Sheriffs'

Education and Training Standards Commission; or

o four or more crimes or unlawful acts defined as "Class B

Misdemeanors" regardless of the date of conviction; or

o four or more crimes or unlawful acts defined as "Class A

Misdemeanors" except the trainee may be enrolled if the last

conviction occurred more than two years prior to the date of

enrollment; or

o a combination of four or more "Class A Misdemeanors" or

"Class B Misdemeanors" regardless of the date of

conviction unless the individual intends to seek certification

through the North Carolina Criminal Justice Education and

Training Standards Commission.

Every individual who is admitted as a trainee in a presentation of the Basic Law

Enforcement Training Course shall notify the School Director of all criminal offenses

which the trainee is arrested for or charged with, pleads no contest to, pleads guilty to or

is found guilty of, and notify the School Director of all Domestic Violence Orders (G.S.

50B) which are issued by a judicial official and which provide an opportunity for both

parties to be present.

The notifications must be received by the School Director within 30 days of the date the

case was disposed of in court.

________________________________________ ______________________

(candidate’s signature) (date)

Isothermal Community College

Basic Law Enforcement Training

LETTER OF SPONSORSHIP

To: Philip G. Bailey

Director of BLET Training

Isothermal Community College

Please admit the candidate named below into Isothermal Community College’s

BLET training program under the sponsorship of this law enforcement agency.

By requesting the admission of this candidate, I attest that a thorough

background investigation was conducted and revealed nothing that would

prohibit this candidate from being employed by a law enforcement agency.

Furthermore, I attest that I am aware of nothing in this person’s character or

reputation that would bring discredit upon my agency, Isothermal Community

College or the law enforcement community.

The candidate understands that this sponsorship does not guarantee

employment with this or any other law enforcement agency, nor does this

sponsorship express or imply in any way a guarantee of employment with this

or any other agency in the future.

________________________________________________

(Agency Name)

_________________________________________________

(Printed Name of Agency Representative)

_________________________________________________ __________________

(Signature of Agency Representative) (Date)

_________________________________________________

(Printed Name of Candidate)

__________________________________________________ __________________

(Signature of Candidate) (Date)

Fill Online, Printable, Fillable, Blank Potential BLET Student, By obtaining the Isothermal Community (Isothermal Community College) Form

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Fillable Potential BLET Student, By obtaining the Isothermal Community (Isothermal Community College)

Fill Online, Printable, Fillable, Blank Potential BLET Student, By obtaining the Isothermal Community (Isothermal Community College) Form

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