Medical Consent Form - Chicago Police Department printable pdf download

MEDICAL CONSENT FORM

Police Officer (Assigned as Explosives Detection Canine Handler)

Chicago Police Department

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Name (Last, First, M.I.)

Star No.

Employee No.

__________________________________________________________________________________________

Home Address

Home Telephone

__________________________________________________________________________________________

NOTE TO APPLICANT’S PHYSICIAN / NURSE PRACTITIONER

You are receiving this form because the above individual is applying for a position with the Chicago Police

Department as Police Officer (Assigned as Explosives Detection Canine Handler). An applicant must present their

Medical Statement to their reviewing medical professional for thorough review and confirmation. Your examination

of the applicant is required to ensure they are medically fit to proceed further in the selection process, especially if

the applicant has indicated a prior and/or existing medical condition on their Medical Statement. For your

convenience, guidelines for the duties of a Police Officer (Assigned as Explosives Detection Canine Handler) are

noted in Employee Resource E05-22.

PHYSICIAN’S / NURSE PRACTITIONER'S INFORMATION

Name _______________________________________________

Date_________________________

Clinic/Hospital ______________________________________________________________________________

Address __________________________________________ Telephone Number (____)___________________

I have reviewed the duties of a Police Officer Assigned as Explosives Detection Canine Handler.

Physician’s / Nurse Practitioner's Signature ___________________________________________

NOTE:

Physician / Nurse Practitioner must also sign below to indicate consent.

PHYSICIAN’S CONSENT

APPROVE

______________________________ (print applicant’s name) has no medical condition that I consider

incompatible with the duties of a Police Officer (Assigned as Explosives Detection Canine Handler).

Physician’s / Nurse Practitioner's Signature ____________________________________

DISAPPROVE

I do not recommend ______________________________ (print applicant’s name) for Police Officer

(Assigned as Explosives Detection Canine Handler) duties because of the following medical conditions:

If more space is needed, attach a separate sheet of letterhead paper.

Physician’s / Nurse Practitioner's Signature _____________________________________

MEDICAL CONSENT FORM

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Medical Consent Form - Chicago Police Department