Form ATF F 2300.10 ATF F 2300.10 Special Agent Medical Preplacement

OMB No. 1140-0056 (07/31/2007)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

1.

Special Agent Medical (Preplacement/Incumbent)

Part I - Demographic Data (To be completed by special agent/applicant)
2. Date of Birth
3. Date of Testing
4. Social Security Number

Name (Please print or type)

5.

Sex
Male

6.

Home Address

9.

Field Office

7.

12. Current Employer

Home Telephone Number

8.

Female

Work Telephone Number

10. Field Office Mailing Address

11. Personal Telephone Number

13. Current Occupation

14. How Long in Current Position?
(Years/months)

Part II - Medical History (To be completed by special agent/applicant. Please check each item yes or no. If yes, please explain)
15. Have you been refused employment or been unable to hold a job or stay in school due to any medical condition?

16. Have you ever been treated for any mental condition?

Yes

Yes

No

No

17. Have you ever been denied life or health insurance? (If yes, state reason and provide details.)

18. Have you had, or been advised to have, any operation?

Yes

Yes

No

No

19. Have you ever been a patient in any type of hospital? (If yes, specify when, where and give details.)

Yes

No

20. Have you ever had any illness or injury other than those already noted? (including learning disabilities and Attention Deficit Disorder (ADD), etc. If
yes, specify when, where and give details.)
Yes
No
21. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illness? (If yes,
give complete address of doctor, hospital, clinic, and give details.)
Yes
No
22. Females Only: Are you currently pregnant? (If yes, provide trimester. This question relates only to issue of the safe participation in training.)
Yes
No
23. Have you ever been rejected or discharged from military service because of physical, mental condition, or for other reasons? (If yes, give date, reason
and type of discharge: whether honorable, other than honorable, for unfitness or unsuitability.)
Yes
No
24. Have you ever received, is there pending, or have you applied for pension or compensation for existing disability? (If yes, specify what kind, granted
by whom, what amount, when, and why.)
Yes
No
25. Have you had or are you currently experiencing any of the following? (If yes, please explain)
Blurred vision?
Yes
No
Color blindness?

Yes

No

Glaucoma?

Yes

No

26. Do You? (If yes, please explain)
Wear glasses or contact lenses? Yes
Have cataracts?

Yes

No

No

Have you ever been diagnosed with any eye disease? (If yes, please explain)

Yes

No
ATF Form 2300.10
Revised July 2004

Have you had any type of eye surgery (i.e., RK, PRK, cataracts, etc.)? (If yes, please explain what specific surgery was performed and the date of
surgery.)
Yes
No

27. Have You Experienced Any of the Following? (If yes, please
Difficulty hearing
Yes
Dizziness
Yes
Loud, impact noise in past 14 hours
Yes
Are you in a hearing conservation program?
Yes
Chest pains
Yes
Leg pains
Yes
Heart murmur
Yes
Coronary bypass surgery/other heart surgery
Yes
Abnormal EKG (Resting)
Yes
Heart disease, stroke or heart attack in parents
or siblings prior to age 55
Yes
Numbness in feet/hands
Yes
Phlebitis or blood clots
Yes
Bronchitis, tuberculosis
Yes
Asthma
Yes
Heat/sun stroke
Yes
Thyroid disease
Yes
Blood disorder
Yes
Back pain
Yes
Joint pain or swelling
Yes
Lack of coordination
Yes
Tremors/shakiness
Yes
Persistent stomach/abdominal pain
Yes
Vomiting blood
Yes
Trouble walking
Yes
Loss of strength/muscle weakness
Yes
Arthritis
Yes
Skin problems, urticaria
Yes
Kidney disease
Yes
Are you left handed?
Yes
Persistent diarrhea/constipation
Yes
Liver disease
Yes
Gall bladder problems
Yes
Psychiatric/psychologic consult
Yes
Periods of nervousness
Yes
Ringing or buzzing in ears
Yes

explain
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

below)
Loud, constant noise or music within the last 14 hours
Do you wear a hearing aid?
Do you use hearing protective equipment?
Ankles or feet swelling
Palpitations (rapid or skipped heart beat)
Past history or diagnosis of heart disease
Heart attack or stroke
Abnormal treadmill
Cold hands or feet when others are comfortable in same
room
High blood pressure
Problems with breathing, wheezing, persistent cough,
/shortness of breath
Past history or diagnosis of lung disease or surgery
Diabetes
Pituitary gland problem
Anemia
Back surgery
Tingling in head/hands/legs
Epilepsy (seizure)
Loss of sensation
Stomach ulcers
Trouble using hip/knee/shoulder
Loss of joint/limb movement
Any limb or finger amputations
Gout
Urinary pain/infection/bleeding
Localized weakness/numbness
Are you right handed?
Blood in stool
Hepatitis
Hernia
Feelings of depression
Fainting
Syncope

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No

Yes
Yes

No
No

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

Explanation:

28. Your Current Physical Activity or Exercise
Program Intensity
Low
Moderate
High

29. Frequency of

30. Duration of

Days Per Week

31. Activities

Minutes Per Session

32. Medications (List all medications (prescription and non-prescription) you are currently taking with dosage, frequency and reason.)

33. Allergies (Please check where applicable)
None

Dust or molds (Specify)

Drugs (Specify)

Animals (Specify)

Pollens (Specify)

Food (Specify)

Other (Specify)
34. Have You Ever Smoked?
Yes

No

Part III - Social History (To be completed by special agent/applicant)
35. If Yes, When?
36. Type
CUrrently

37. How Many Do or Did You Smoke Per Day?

Past (Number of years since you quit)

Cigarette

Pipe

Cigar

38. For How Many Years?

ATF Form 2300.10
RevisedJuly 2004

39. What is Your Average Alcohol Consumption in a Week? (1 drink = 12 oz. beer, 1 glass of wine, 1.5 oz. liquor)
Drinks
40. How Often Do You Drink Alcohol?
Weekdays
Weekends
Both
41. Father
Alive

Deceased

42. Mother
Alive

Part IV - Family Medical History (To be completed by special agent/applicant)
Current Age
Current General Health
Age and Cause of Death or Reason for Poor
Excellent
Fair
Unknown Health
Good
Poor
Current Age

Current General Health
Excellent
Fair
Good
Poor

Deceased

Unknown

Age and Cause of Death or Reason For Poor
Health

43. Number of Brothers

Age Range

Health Problems, If Any

Age and Cause of Death or Reason For Poor
Health

44. Number of Sisters

Age Range

Health Problems, If Any

Age and Cause of Death or Reason For Poor
Health

45. Familial Diseases (Have any of your blood relatives, i.e. grandparents, parents, siblings) Had Any of the Following:
Stroke
Heart Attacks or Strokes
Migraine Headaches
Goiter
Cancer
Heart Operations
Back Trouble
Hepatitis
Emphysema
Elevated Cholesterol
Herpes
Gall Bladder Disease
Bleeding Tendencies
Asthma
Anemia
Hernia
Diabetes
Hay Fever
Glaucoma
Obesity
Epilepsy
Nervous Breakdown
Arthritis
Syncope/Sudden Death
Thyroid Disorder
Gout
Colitis
Other (Specify)
Fainting Spells
Leukemia
Tuberculosis
High Blood Pressure
Kidney Disease
Alcohol/Drug Abuse
Heart Disease
Mental Disorder
Stomach Ulcers
I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize
any of the doctors, hospitals, or clinics mentioned on these forms to furnish the Government a complete transcript of my medical record for
purposes of processing my application for this employment or service. I authorize the release of all medical information to the Federal Occupational Health/Law Enforcement Medical Program and the Bureau of Alcohol, Tobacco, Firearms and Explosives point of contact.
Client’s Signature

Date

Witness’s Signature

Date

Name of Clinic

Part V - To Be Completed By Clinic (Please print)
Address/Location of Clinic

RN

Telephone Number (Include area
code)

MD/DO

Part VI - To Be Completed By Health Care Provider
Disclaimer: This examination does not substitute for a periodic health examination conducted by your private provider. It is being conducted for occupational purposes.
1.

Preplacement Service:
Required Services
(Check when test is completed)
Labs (blood & urine)
Blood Lead & ZPP
Height, weight, vitals
EKG (12 lead with interpretation)
PPD Mantoux (TB skin test)
Audiometry (500 Hz - 8000 Hz)
Vision screening (Near & Far; Corrected & Uncorrected)
Color vision (14 plate Ishihara)
Peripheral vision (nasal & temporal)
Tonometry
Depth Perception (seconds of arc)
General Physical Exam
General Medical history
Attach copies of all test results

Lab Components Fasting Blood

Comprehensive
Metabolic Panel

CBC
(included Diff/Plat)

Cholesterol Total
Triglycerides
HDL - cholesterol
LDL - cholesterol
Chol/HDL
Bilirubin
Transferase
GGT
LDH, Total
Alanine Transminase

Glucose
Urea Nitrogen (BUN)
Creatinine
BUN/Creatinine
Sodium
Potassium
Chloride
Protein, Total
Globulin
Albumin/Globulin Ratio
Alkaline Phosphatase
AST (SGOT)

White blood cell count
Red blood cell count
Hemaglobin
Hematocrit
MCV
MCH
RDW
Platelet Count
Neutrophils
Lymphocytes
Absolutes Monocytes
Monocytes
Absolute Eosinophils
Eosinophils
Absolute Basophils
Basophils

Urinalysis
Color
Appearance
Specific Gravity
Glucose
Ketones
Occult Blood
Protein
Nitrite
Leukocyte Esterase
Microscopic if indicated

ATF Form 2300.10
RevisedJuly 2004

Part VII - Diagnosis and Physical Findings (To be completed by Health Care Provider)
2.

Head and Neck
Normal

3.

Abnormal

Color Vision (Require documentation of:)
# Correct

Head, Face Neck (thyroid) Scalp
Nose/Sinuses
Mouth/Throat
Pupils Equal/Reactive
Ocular Motility

Intraocular Pressure
Right

Titmus
Ishihara Plate
Other (Specify)
5.

mm/hg

Type of Test:

Left
Puff

Peripheral Vision (Require numerical values)

mm/hg

Shiotz

Right Temporal Eye

Left Temporal Eye

Nasal

Nasal

Total

Total

Depth Perception (Require documentation of:)
# Correct

of

Total Tested Arc

Type of Tester
6.

Seconds of Arc
Shepard - Fry %

Uncorrected Vision (Snellen Units)
Near:

Total Tested

Type Of Test

Ophthalmoscopic Findings
4.

of

Both 20/

7.

Corrected Vision (Snellen Units)

Right 20/

Left 20/

Near:

Both 20/

Right 20/

Left 20/

Left 20/

Far:

Both 20/

Right 20/

Left 20/

8.

Far:
Both 20/
Right 20/
Comment on Heent Abnormalities:

9.

Frequency

500 Hz

Part VIII - Audiology (To be completed by Health Care Provider)
1000 Hz
2000 Hz
3000 Hz
4000 Hz

Baseline

Annual

6000 Hz

8000 Hz

Right Ear
Left Ear
10. Audiogram:
Calibration Method:

Oscar

Review/Compare With Baseline:

Termination (Attach current and baseline audiogram)
Biological

Change

Date
No Change

Right Ear

Normal

Abnormal

Left Ear

Canal/External Ear:

Normal

Abnormal

Canal/External Ear:

Normal

Abnormal

Tympanic Membrane:

Normal

Abnormal

Tympanic Membrane:

Normal

Abnormal

Comments:

11. Vital Signs:
Height

Weight

Blood Pressure

Pulse

mm/hg (sitting)

Temperature (If indicated)
(sitting)

Comments:

12. Tuberculosis
Date Administered

Date Read

Degrees of Induration

Date of Last Chest X-ray

Comments (Chest X-rays, TB treatment/dates):

ATF Form 2300.10
Revised July 2004

13. Cardio/Pulmonary:
EKG (Attach with interpretation):
Normal
Abnormal

Lungs/Chest (includes breast):
Normal
Abnormal

Heart (murmur, palpitations, ectopic beats): Vascular (varicosities):
Normal
Abnormal
Normal
Abnormal

Comments:

14. Pulmonary Function Testing (Attach copy):
% Predicted FVC
% Predicted FEV1

% Predicted FEV1/FVC

% Predicted FEF 25 - 75

Comments:

Part IX - Diagnosis and Physical Findings (To be completed by Health Care Provider)
15. Musculoskeletal
Upper Extremities (strength):
Normal
Abnormal

Upper Extremities (range of motion):
Normal
Abnormal

Lower Extremities (strength):
Normal
Abnormal

Lower Extremities (range of motion):
Normal
Abnormal
Flexibility
Normal
Abnormal

Feet

Spine

Normal
Abnormal
Deep Tendon Reflexes
Normal
Abnormal

Normal
Other Neurological
Normal

Abnormal
Abnormal

16. Can Applicant Participate in the Following:
Yes

Vigorous Aerobic Exercise Program 3 Hr/Wk (minimum)
Pull Ups

Yes

No

Sit Ups

Yes

No

No

Push Ups

Yes

One and One Half Mile (1.5) Time Run

No
Yes

No

Comments:

17. Is Applicant Capable of the Following:
Yes
Yes
Yes
Yes

No
No
No
No

Squat and rise without holding on to any object. Maintain squatting and kneeling for up to 45 seconds repeatedly.
Kneel on one knee with arms extended in front of body at eye level for seven (7) seconds.
Assume a one and two-knee kneeling position within two (2) seconds and be able to rise without assistance. Be able to repeat twice.
Maintain a kneeing position for 2 - 3 minutes repeatedly.

Please Comment on “Cannot Participate” Responses:

Normal

Abnormal

Mental/Emotional Affect (describe if abnormal)

Normal

Abnormal

G -U System

Normal

Abnormal

Abdomen, Viscera

Normal

Abnormal

Rectal/Prostate

Normal

Abnormal

Skin (scar/unique markings)

Normal

Abnormal

Lymphatic

Normal

Abnormal

Other

Comments:

ATF Form 2300.10
RevisedJuly 2004

Part X - Education and Referral (To be completed by the Health Care Provider)
18. Check the Topics Discussed During the Diagnosis Work-up or Physical Exam:
Lipids

Hypentension

Exercise

Obesity

Smoking Cessation

Alcohol Use

Hearing Protection

Vision Referral

Other Personal Protective Equipment

Job Stressors

Referral(s)

Immunizations

Part XI - Examining Physician’s Summary of Significant Findings With Recommendations
Note: Please do not provide any official statement (oral or written) concerning the applicant’s fitness or capability to perform the duties of any occupation.
The Agency’s Medical Review Officer will provide this statement.

Examining Physician’s Name (Print or type)

Examining Physician’s Signature

Date

When Exam is Complete, Fedex Within Two Days To:
Public Health Service
Division of Federal Occupational Health
Law Enforcement Medical Programs
Attn: P. Swan
Atlanta Federal Center, Suite 3R10
100 Alabama Street
Atlanta, GA 30303
ATF Use Only
Action Taken:
Hired or Retained
Non-selected For Appointment, or Eligibility Objected to
Action Taken to Separate
Agency Personnel Officer’s Name (Print or type) Agency Personnel Officer’s Signature

Date

Privacy Act Information
Executive Order, 9830 and 5 CFR 339.301 authorizes collection of this information. The primary use of this information is to determine medical suitability
to qualify for a position that has specific medical standards, physical requirements, or is covered by a medical evaluation program established under
these regulations. Furnishing this information is mandatory because such information is part of the basic qualifications for the position. If this information
were not provided, the applicant would fail to meet the qualifications for the position.
Additional disclosures of this information may be: To the Department of Labor when processing a claim for compensation regarding a job connected
injury or illness; to Federal Life Insurance or Health Benefits carriers regarding a claim; to another Federal agency; to a court, or a party in litigation
before a court or in an administrative proceeding when the government is a party or when the agency deems it to be relevant and necessary to the
litigation; to a Federal, State, or local law enforcement agency when such agency becomes aware of a violation or possible violation of civil or criminal
law; to a Federal agency when conducting an investigation for employment or security reasons; to the General Services Administration in connection with
responsibilities for records management.
Paperwork Reduction Act Notice
This information collection request is in accordance with The Paperwork Reduction Act of 1995. The purpose of this information is to determine whether
or not an applicant is actually qualified for the position. The information will be initially used to make a recommendation on either hiring or not hiring an
applicant or retaining an individual in a special agent position.
The estimated average burden associated with this collection of information is 45 minutes per respondent or recordkeeper, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports
Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.
ATF Form 2300.10
Revised July 2004