police academy application instruction - Kellogg Community College

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12/2009 MICHIGAN COMMISSION ON LAW ENFORCEMENT STANDARDS 106 West Allegan Suite 600, Lansing MI 48909 (517) 322-1417 MEDICAL HISTORY STATEMENT NOTE: After the medical examination is completed, the Medical History Statement should be retained by the examining physician or the law enforcement agency. Do not forward this form to the Michigan Commission on Law Enforcement Standards unless requested by MCOLES. The Michigan Administrative code of 1979, as amended, requires that law enforcement officer applicants be examined by a licensed physician to ensure that the applicant is free of any physical defect or medical condition which might adversely affect job performance or endanger the life of the officer or others. Rules 28.14206(1)(c), 28.14207(f) and 28.14312(3) require that a declaration of the applicant’s medical history be made available to the examining physician. The information you provide in this statement is extrem ely important. It will be used by the examining physician to evaluate your medical fitness for the position of entry-lev el law enforcement officer. Therefore, please fill out the questionnaire completely and accurately. Please keep in mind that: (a) all statements are subject to verification, and (b) deliberate inaccuracies or incomplete statements may bar or remove you from employment. This statement was designed to explore those areas that bear directly upon the physical demands of the position for which you are applying. A thorough and accurate evaluation of this information will contribute to sound employment decisions benefiting both you and your potential employer. This statement is confidential. If hired, the information you provide will be a part of your medical record. When answering “Yes” or “No” questions, place an “X ” in the appropriate space. If you are unable to answer a question for any reason you will need to discuss the issue with the examining physician. Type or print only: Name: Last: First: Middle: Suffix (Jr, Sr, III): Social Security No.*: Date of Birth: Primary Phone No.: Alternate Phone No.: Residence Address (Street, City, State, Zip): I, the undersigned, do hereby consent to undergo a medical examination, including blood specimens, x-rays, skin tests, immunizations, and other examinations which the examiners may consider necessary to complete the medical evaluation. Signature: Today’s Date: AUTHORITY: 203 PA 1965 COMPLIANCE: Voluntary PENALTY: No License Activation/ Academy Enrollment * This information is confidentia l. Confidential information is protected by the Federal Privac y Act. If necessary, the Social Security Number will be used for identification purposes to ensure that proper records are obtained. Page 1 of 7
Page 1 and 2: 450 NORTH AVENUE, BATTLE CREEK, MI
Page 3 and 4: Physical Integrity Vision, Color Be
Page 5 and 6: 09/2009 Michigan Commission on Law
Page 7 and 8: Michigan Commission on Law Enforcem
Page 9 and 10: MOTOR VEHICLE OPERATION List all tr
Page 11: SCHOOL HISTORY Have you ever been s
Page 15 and 16: MEDICAL HISTORY STATEMENT 8. Have y
Page 17 and 18: MEDICAL HISTORY STATEMENT 84. Has y
Page 19 and 20: MEDICAL HISTORY STATEMENT MEN ONLY
Page 21 and 22: Fitness Test Application The fitnes
Page 23 and 24: MCOLES PREENROLLMENT FITNESS TEST
Page 25: The Michigan Commission on Law Enfo

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