Physical Fitness Assessment printable pdf download

CJSTC

PHYSICAL FITNESS ASSESSMENT

75B

Florida Department of

Law Enforcement

Incorporated by Reference in Rule 11B-35.001(11)(c)12., F.A.C.

Applicant’s Name:

Last

First

Applicant’s Address:

Enter Last Four Digits of Social Security Number:

Training School:

The Applicant Is Requesting Admission Into a Basic Recruit Training Program for One of the Following Disciplines:

Law Enforcement

Correctional

Correctional Probation

Student Participation in Basic Recruit Training Program Activities. A student enrolled in a basic recruit training program (BRTP) is required to participate in the

following activities:

Defensive tactics and firearms high-liability training, which is a component of the curriculum mandated by the Criminal Justice Standards and Training

Commission. Firearms training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires sustained physical exertion

and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).

Physical Fitness Conditioning and Physical Fitness Testing: A BRTP student shall participate in physical fitness conditioning and a fitness test and includes

the following measures:

• Vertical Jump

• One Minute Sit Ups

• 300 Meter Run

• Maximum Push Ups

• 1.5 Mile Run/Walk

The training center director has attached the training schools physical fitness conditioning program: Yes

**********TO BE COMPLETED BY THE APPLICANT*********

Medical Conditions Regarding OC/CS Contamination. A BRTP student should be aware of the following personal considerations that may restrict participation in

the chemical agent contamination of the BRTP and could possibly be aggravated to a severe degree during the contamination: Recent eye surgery, heart problems,

panic disorder or stress, respiratory disorder, emphysema (loss of elasticity/thinning of lung tissues), bronchial asthma, x-ray evidence of pneumoconiosis (black lung),

evidence of reduced pulmonary (lung) function, chronic obstructive pulmonary disease, coronary (heart) artery disease, cerebral (brain) blood vessel disease, severe or

progressive hypertension (high blood pressure), epilepsy, grand mal or petite mal (seizures), pernicious anemia (severe reduction in red blood cells), diabetes (any

form), pueumomediastinum gap (air in the sac surrounding lungs), history of skin allergies, or any condition for which the student is presently taking medication.

BRTP Student Certification. I certify that I have reviewed the above information and

I do or

do not have any medical restrictions that would prevent me from

participating in the basic recruit training program activities outlined in item numbers 6, 6A, and 6B above.

Student’s Printed Name: ___________________________________

10.

Student’s Signature:_____________________________________

Date:

11.

Prior Exposure to OC or CS. For a student who has had prior chemical agent exposure that includes chemical agent contamination and working through the effects

of chemical agent contamination in a training environment, please attach the supporting documentation of prior exposure and check one of the following boxes:

I certify that I have

OR I have not

been exposed to oleo-resin capsicum (OC) and/or orthochlorobenzal-malononitrile (CS) in the manner described in

item number 11.

**********TO BE COMPLETED BY THE EXAMINING PHYSICIAN*********

12.

Physician Attestment. The above applicant is seeking entry into a law enforcement, correctional, or correctional probation basic recruit training program. Rule 11B-

35.001(11)(c)12., F.A.C., requires a complete physical examination at a level of specificity sufficient to determine whether there are any medical or physiological

restrictions that would prevent the applicant from performing the required activities described in items 6, 6A, and 6B above. Disabilities, impairment, or limitations

identified by the examination that would prevent the applicant from performing the required activities should be reported to the training school indicated in item number

4 above.

I hereby attest that I have examined the above named applicant and find him or her CAPABLE of participating in the basic recruit training program activities

indicated in item numbers 6, 6A, and 6B above.

I hereby attest that I have examined the above named applicant and find him or her NOT CAPABLE of participating in the basic recruit training program activities

indicated in item numbers 6, 6A, and 6B above

13.

Physician, Certified Advanced Registered

Printed Name

Examination Date

Nurse Practitioner, or Physician Assistant’s Signature

14.

Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number

Licensing State

15.

Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address

**********TO BE COMPLETED BY THE TRAINING CENTER DIRECTOR OR DESIGNEE*********