Medical Consent And Release Forms -City Of Louisville Page 2
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3Medical Consent and Release Forms
Physician’s Medical Release Form
Applicant Name: ___________________________ SS#:_______________________ Date of Birth: ____________
Corrections Officers are required to perform a variety of essential physically demanding tasks including the following:
Walking for extended periods of time
Short sprints
Long pursuits of running lasting over two minutes
Jumping over and around obstacles
Lifting and carrying objects, sometimes up and down stairs
Running up and down stairs
Using hands and feet in use-of-force situations
Using force in short and long-term (greater than two minutes) efforts
Bending and reaching
Moving people and objects
To measure an individual’s capability to perform these critical tasks, all applicants must undergo a physical fitness test
consisting of the below listed items with a 10-minute break between each:
1)
Running one mile in 12 minutes
2)
Complete a three-minute and thirty-second timed obstacle course consisting of:
o Running and bending under objects
o Running, ascending and descending the equivalent of four flights of stairs
o Running through a series of obstacles
o Flipping a four foot object weighing 100 lbs. five times
o Running and dragging an object weighing approximately 150 lbs. 50 feet
3)
Push off approximately 50% of the applicant’s body weight at an angle from a lying position
Your professional opinion is requested as to whether this individual can safely participate in physical agility testing.
Please Check One:
_____ There are no contraindications to this individual either 1) being capable of performing the essential physical tasks
or 2) being capable of undergoing the physical agility test items.
_____ There are contraindications and it is not recommended that this individual participate in the physical agility test
items.
I am a physician licensed to practice in either Indiana or the Commonwealth of Kentucky. I hereby verify that the above
information is true and accurate.
Signed this _____ day of __________________, 20_____
____________________________________
_________________________________________
Signature of Physician
Printed Name of Physician
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