Form 10-2201E Form 10-2201E Physician Consent Form

USPP Form 10-2201E (Rev: 07/2017) OMB Control No. 1024-0245

National Park Service Expiration Date XX/XX/XXXX

PHYSICIAN CONSENT FORM

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

Dr.      

      is a candidate for employment with the United States Park Police. Prior to an offer of employment, all applicants must successfully complete a physical fitness assessment.

Physical fitness is assessed by using the Physical Efficiency Battery (PEB). The PEB consists of five measures of physical fitness, of which, applicants will be evaluated on four.

HOW WILL PHYSICAL FITNESS BE MEASURED?

There are four (4) physical fitness tests that will be given in one day as a battery of tests.

1. Sit and reach test. This measures flexibility and consists of sitting on the ground with leg outstretched and stretching out over a yardstick or testing box as far as possible. This test is measured in inches.

2. 1 Repetition Maximum (RM) Bench Press. This measures the absolute strength of the upper body. The test consists of a horizontal or vertical chest press, pushing as much weight as you can one time. This test is measured in pounds (lbs.)

3. Agility run (The Illinois Agility Test) This measures agility. The test consists of sprinting and dodging around obstacles over a 60 yard course as fast as possible. This test is measured in tenths of seconds,

4. 1.5 mile run. This measures aerobic power or cardiovascular endurance (the ability consume oxygen over time). The test consists of running/walking as fast as possible the distance of 1.5 miles. This test is measured in minutes and seconds.

Please understand that any physical/medical examination that you determine is necessary to complete this form will be at the expense of your patient and not the United States Park Police.

I have examined the individual named above and determined that he/she (check one):

Is cleared to participate in all aspects of the Physical Efficiency Battery.

Is not cleared to participate in all aspects of the Physical Efficiency Battery.

Physician Comments:

_______________________________ ___________________________________ _______________________________

Physician Printed Name and Stamp Physician Authorized Signature Date of Physician Signature

_________________________________________________________________ ___________________________________

Complete Mailing Address Office Phone Number (including area code)

NOTICES

PRIVACY ACT NOTICE

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing Federal Investigative forms.

Authority: The authority to collect information on the attached form is derived from one or more of the following:

Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.

Purposes and Uses: The information you supply will be used principally as a basis for review of your qualifications for employment purposes. As part of such a review, the Standard Form 87 (Fingerprint Chart) will be sent to the Federal Bureau of Investigation and may be retained there. This information and information developed through investigation may be furnished to designated officers and employees of agencies and departments of the Federal Government for employment purposes.

Effects of Nondisclosure: The Personal Qualification Statement requests specific information. It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Under 5 U.S.C. 8315, a false answer to questions relating to membership in the Communist Party, U.S.A., or other communist or fascist organizations could deprive you of your right to an annuity when you reach retirement age. Deliberately and materially making false or fraudulent statements on this form will be grounds for not hiring you or for firing you after you begin work. In addition, these violations will become part of your permanent record for future employment.

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PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) as part of the pre-employment qualification review phase of the application process to help us determine your eligibility for the position of a United States Park Police Officer. Your obligation to respond is optional; however, failure to provide the requested information may prevent or delay the determination of your pre-employment qualifications, adversely affecting your consideration for appointment as a United States Park Police Officer. The OMB Control Number, 1024-0245, is currently valid. We may not collect this information and you are not required to respond unless this number is displayed.

ESTIMATED BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Do not send your completed form to this address.

This Physician Consent Form is valid for six (6) months from the date of the physician signature.

RECORDS RETENTION - TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule Management and Accountability) (Item 10D) (N1-79-08-9))