Form ATF F 2300.10 ATF F 2300.10 Special Agent Medical (Preplacement/Incumbent)

OMB No. 1140-0056 (xx/xx/xxxx)

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

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

1. Name (Please print or type)

5. Sex
Male

6. Home Address

7. Home Telephone Number

Female

8. Work Telephone Number

9. Field Office

10. Field Office Mailing Address

11. Personal Telephone Number

12. Current Employer

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?
Yes
No

Yes

No

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

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

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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
No
yes, specify when, where and give details.)

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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,
Yes
No
give complete address of doctor, hospital, clinic, and give details.)
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
Yes
No
and type of discharge: whether honorable, other than honorable, for unfitness or unsuitability.)
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?

No

Yes No

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

Yes

No
ATF Form 2300.10
Revised ( )

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

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27. Have You Experienced Any of the Following? (If yes, please explain below)
Difficulty hearing
Yes
No
Loud, constant noise or music within the last 14 hours
Dizziness
Yes
No
Do you wear a hearing aid?
Loud, impact noise in past 14 hours
Yes
No
Do you use hearing protective equipment?
Are you in a hearing conservation program?
Yes
No
Ankles or feet swelling
Chest pains
Yes
No
Palpitations (rapid or skipped heart beat)
Leg pains
Yes
No
Past history or diagnosis of heart disease
Heart murmur
Yes
No
Heart attack or stroke
Coronary bypass surgery/other heart surgery
Yes
No
Abnormal treadmill
Abnormal EKG (Resting)
Yes
No
Cold hands or feet when others are comfortable in same
Numbness in feet/hands
Yes
No
room
Phlebitis or blood clots
Yes
No
High blood pressure
Bronchitis, tuberculosis
Yes
No
Problems with breathing, wheezing, persistent cough,
Asthma
Yes
No
/shortness of breath
Heat/sun stroke
Yes
No
Past history or diagnosis of lung disease or surgery
Thyroid disease
Yes No
Diabetes
Blood disorder
Yes
No
Pituitary gland problem
Back pain
Yes No
Anemia
Joint pain or swelling
Yes
No
Back surgery
Lack of coordination
Yes
No
Tingling in head/hands/legs
Tremors/shakiness
Yes
No
Epilepsy (seizure)
Persistent stomach/abdominal pain
Yes
No
Loss of sensation
Vomiting blood
Yes
No
Stomach ulcers
Trouble walking
Yes
No
Trouble using hip/knee/shoulder
Loss of strength/muscle weakness
Yes
No
Loss of joint/limb movement
Arthritis
Yes
No
Any limb or finger amputations
Skin problems, urticaria
Yes
No
Gout
Kidney disease
Yes
No
Urinary pain/infection/bleeding
Are you left handed?
Yes
No
Localized weakness/numbness
Persistent diarrhea/constipation
Yes
No
Are you right handed?
Liver disease
Yes
No
Blood in stool
Gall bladder problems
Yes
No
Hepatitis
Psychiatric/psychologic consult
Yes No
Hernia
Periods of nervousness
Yes
No
Feelings of depression
Ringing or buzzing in ears
Yes
No
Fainting
Syncope

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Explanation:

28. Your Current Physical Activity or Exercise
Program Intensity

29. Frequency of

30. Duration of

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

31. Activities

Days Per Week
Minutes Per Session
Low
Moderate
High
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
Cigarette Pipe Cigar
Currently
Past (Number of years since you quit)

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

38. For How Many Years?
ATF Form 2300.10
Revised ( )

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

Name of Clinic

RN

Telephone Number (Include area code)

MD/DO

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Part V - 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:
Lab Components Fasting Blood

Comprehensive
Metabolic Panel

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Labs (blood & urine)
Cholesterol Total
Glucose
Blood Lead & ZPP
Triglycerides
Urea Nitrogen (BUN)
Height, weight, vitals
HDL - cholesterol
Creatinine
LDL - cholesterol
BUN/Creatinine
EKG (12 lead with interpretation)
PPD Mantoux (TB skin test)
Chol/HDL Sodium
Audiometry (500 Hz - 8000 Hz)
Bilirubin
Potassium
Vision screening (Near & Far;
Transferase Chloride
Corrected & Uncorrected)
GGT
Protein, Total
Color vision (14 plate Ishihara)
LDH, Total
Globulin
Peripheral vision (nasal & temporal)
Alanine Transminase Albumin/Globulin Ratio
Tonometry
Alkaline Phosphatase
Depth Perception (seconds of arc)

AST (SGOT)

General Physical Exam
General Medical history
Attach copies of all test results

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

4. Intraocular Pressure
Puff

Left mm/hg
Shiotz

Depth Perception (Require documentation of:)
Type of Tester

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

Type Of Test
Titmus
Ishihara Plate
Other (Specify)
5. Peripheral Vision (Require numerical values)

Right mm/hg

# Correct

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

Part VI - Diagnosis and Physical Findings (To be completed by Health Care Provider)
3. Color Vision (Require documentation of:)

2. Head and Neck
Abnormal

Type of Test:

CBC
(included Diff/Plat)

of

Total Tested Arc
Seconds of Arc
Shepard - Fry %

Nasal

Nasal

Total

Total

ATF Form 2300.10
Revised ( )

6. Uncorrected Vision (Snellen Units)

Right 20/
Right 20/
8. Comment on Heent Abnormalities:

9. Frequency

7. Corrected Vision (Snellen Units)

Right 20/
Right 20/

Left 20/
Left 20/

500 Hz

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

Baseline

Annual

Left 20/
Left 20/

6000 Hz

8000 Hz

Right Ear
Left Ear
10. Audiogram:
Calibration Method:

Termination (Attach current and baseline audiogram)

Oscar

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

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Weight

Blood Pressure
mm/hg (sitting)

Date Read

Degrees of Induration

(sitting)

Temperature (If indicated)

Date of Last Chest X-ray

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12. Tuberculosis
Date Administered

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Comments:

Pulse

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

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:

ATF Form 2300.10
Revised ( )

Part VIII - Diagnosis and Physical Findings (To be completed by Health Care Provider)
15. Musculoskeletal
Upper Extremities (strength):
Normal
Abnormal
Lower Extremities (range of motion):
Normal
Abnormal
Flexibility
Normal
Abnormal

Upper Extremities (range of motion):
Normal
Abnormal

Lower Extremities (strength):
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 No

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

Yes

No

Yes

Sit Ups

No

Push Ups

Yes

No

One and One Half Mile (1.5) Time Run

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.

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Please Comment on “Cannot Participate” Responses:

Abnormal

Mental/Emotional Affect (describe if abnormal)

Normal

Abnormal

G -U System

Normal

Abnormal

Abdomen, Viscera

Normal

Abnormal

Skin (scar/unique markings)

Normal

Abnormal

Lymphatic

Normal

Abnormal

Other

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Comments:

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Normal

Part IX - 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 X - 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

ATF Form 2300.10
Revised ( )

When Exam is Complete, UPS Within Two Days To:

Program Support Center
U.S. Department of Health and Human Services
299 Main Street, Suite 446
Salt Lake City, UT 84111

ATF Use Only

Action Taken:

Hired or Retained
Non-selected For Appointment, or Eligibility Objected to
Action Taken to Separate
Human Resources Officer’s Signature
Human Resources Officer’s Name (Print or type)

Date

Privacy Act Information

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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

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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.

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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 ( )