Medical Clearance Form
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4MARSHFIELD POLICE DEPARTMENT
MEDICAL CLEARANCE FORM
NAME _______________________________________________
Individuals working in the field of public safety (police, fire fighters, etc.) are required to
perform a variety of essential demanding tasks including the following:
Walking for extended periods
•
Short sprints
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Long-pursuit running lasting over two minutes
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Running up and down stairs
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Pushing heavy objects
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Jumping over and around obstacles
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Lifting and carrying objects sometimes up and down stairs
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Using hands and feet in use-of-force situations
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Using force in short- and long-term (greater than two minutes) efforts
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Bending and reaching
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Dragging people and objects
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To measure an individual’s capability to perform these critical tasks, applicants and
incumbents must undergo a physical fitness test consisting of the following five items:
1.
1.5 mile run to measure aerobic power
2.
300 meter run to measure anaerobic power
3.
Maximum push up to measure upper body muscular endurance
4.
90 Second sit up to measure abdominal muscular endurance
5.
Vertical jump to measure leg power
Your professional opinion is requested as to whether the individual can safely participate
in physical fitness testing and exercise training.
PLEASE CHECK ONE:
____ There are no contraindications to the individual: 1) being capable of performing
the essential physical tasks and 2) being capable of undergoing the physical
fitness test items.
____ There are contraindications and it is not recommended that the individual
participate in the physical fitness testing or exercise training at this time.
PHYSICIAN’S SIGNATURE ________________________________________
DATE ___________________________
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