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

USPP Form 10-2201E (Rev: 04/2018) OMB Control No. 1024-0245

National Park Service Expiration Date 09/30/2018

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

Authority: U.S.C. Title 54, 5 U.S.C. 3301, 3302, 3307, 3309, 3313, and Executive Order 9397.

Purpose: The information collected on this form will be used to review your qualifications for employment in connection with the pre-employment qualification determination phase of the United States Park Police application process.

Routine uses:  In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other government agencies, authorized organizations and individuals. The disclosure is only permitted as described under the routine uses for the system of records notice “OPM/GOVT–5 Recruiting, Examining, and Placement Records” when is compatible with the purpose for which the records were compiled.

Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to review your qualifications for employment.

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.

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