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APPLICATION FOR MEMBERSHIP IN THE 1977 POLICE OFFICERS AND FIREFIGHTERS PENSION AND DISABILITY FUND
State Form 4928 (R7 / 3-09) Approved by State Board of Accounts, 2009

INDIANA POLICE OFFICERS AND FIREFIGHTERS PENSION AND DISABILITY FUND 77 Police and Firefighters Fund 143 West Market Street Indianapolis, Indiana 46204-2899 Toll Free: 1-888-526-1687

PLEASE PRINT.
Name of applicant Department applying to

Check here if you have 77 Fund service

1. 2.

All signatures must be originals. DO NOT leave any answer blank

NEW INFORMATION - PLEASE READ 3. DO NOT use N/A to complete any answer. 4. Drug test results MUST be originals. IMPORTANT NOTICE

Indiana law forbids the initial hiring of a person as a public safety officer if the person is over thirty-five (35) years of age at the time of hire. IC 36-8-8-7(a) provides as follows: Section 7. (a) Except as provided in subsections (d), (e), (f), (g), and (h): (1) a police officer; or (2) a firefighter who is less than thirty-six (36) years of age and who passes the baseline statewide physical and mental examinations required under section 19 of this chapter shall be a member of the 1977 fund and is not a member of the 1925 fund, the 1937 fund, or the 1953 fund. In addition, IC 36-8-3-21(b) provides that, (a)n individual may not be employed by a unit after May 31, 1985, as a member of the units fire department or as a member of the units police department unless the individual meets the conditions for membership in the 1977 fund. GIVING AN INDIVIDUAL A CONDITIONAL OFFER OF EMPLOYMENT PRIOR TO AGE THIRTY-SIX (36) DOES NOT CONSTITUTE COMPLIANCE WITH THESE STATUTES. THIS APPLICATION MUST BE RECEIVED AND FULLY APPROVED BY PERF BEFORE THE APPLICANT MAY BE ACTUALLY HIRED BY THE DEPARTMENT. THE ENTIRE APPROVAL PROCESS MUST BE CONCLUDED BEFORE THE APPLICANT REACHES THE AGE OF THIRTY-SIX (36). IF THE APPLICANT REACHES THE AGE OF THIRTY-SIX (36) BEFORE THE ENTIRE HIRING PROCESS IS CONCLUDED, INCLUDING ALL APPROVAL BY PERF, THE APPLICANT IS INELIGIBLE FOR MEMBERSHIP IN THE 1977 FUND AND IS INELIGIBLE TO BE HIRED AS A MEMBER OF THE DEPARTMENT. THIS MEMBERSHIP APPLICATION WILL BE RETURNED TO THE LOCAL PENSION BOARD IF THE CANDIDATES COMPREHENSIVE MEDICAL HISTORY SECTION, THE PHYSICAL EXAMINATION (INCLUDING TESTING TO BE ADMINISTERED), AND TEST RESULTS SUBMITTED ARE NOT COMPLETE.

APPLICATION CHECKLIST These items must be completed before any individual can become a member of the 1977 fund: 1. 2. 3. 4. 5. 6. 7. 8. 9. Aptitude test has been administered and passed (local option for police officers). Agility test has been administered and passed. Conditional offer is extended and statement of understanding and authorization for release of medical information has been signed. Pension secretary has certified that the candidate passed the physical agility exam. The comprehensive medical history has been completed and the baseline statewide examination has been administered. The baseline statewide examination (physical and mental) forms have been signed by a licensed physician indicating that the baseline statewide medical and any additional local standards have been met (mental exam must be interpreted by a licensed physician or PhD-trained psychologist.) The appropriate specialist reports, if any, are identified and included in the application package. A local pension board member, the pension secretary, and the appointing authority have signed the certification forms indicating the baseline and any local standards have been met. The examination form, all medical testing results, and certification of successful completion of the physical agility, mental, and medical examinations must be forwarded to PERF. PERF must approve or deny the application with respect to the baseline physical standards. PERF also determines if the applicant has any Class 3 excludable conditions. PERF either approves or denies the application and issues the appropriate notifying letter. If the application is approved, the approval letter will also specify whether the applicant has any Class 3 excludable conditions. If the applicant is approved by PERF, an unconditional offer of employment is made and the effect of any Class 3 exclusions is explained. If the applicant is approved, the approval letter sent out by PERF must have the hire date completed and must be returned to PERF along with the member record (blue for police / pink for fire). If the applicant is denied, the Indiana Administration Adjudication Act appeal process may be used to challenge the denial. The appeal process may also be used with respect to the determination that a Class 3 excludable condition exists.

10. 11. 12. 13.

Page 1 of 21

PHYSICIANS NOTES
Part of State Form 4928 (R7 / 3-09)

NOTES

Page 2 of 21

CONDITIONAL OFFER OF EMPLOYMENT STATEMENT OF UNDERSTANDING
Part of State Form 4928 (R7 / 3-09)

_______________________________________________________________________________, is applying for the position of
Name - last, first, middle

________________________________________________ with the ________________________________________________.
Police officer or firefighter City / town

_______________________________________________________________________________________________________
Address of candidate - number and street, city, state and ZIP code

I, ___________________________________________, a candidate for a ____________________________________________
Name of candidate Name of position

position on the _____________________________ department, have received a conditional offer of employment for that position.
Police or fire

I understand that the offer is conditional on my successfully passing the statewide baseline medical examination and the statewide mental examination, as well as any local medical and mental examination requirements. If I do not pass these examinations and requirements, the offer of employment will be withdrawn. I further understand that, as a result of tests and examinations, certain diseases or conditions may be identified. These diseases or conditions, if identified, will prevent me form receiving certain Class 3 impairment benefits for a period of four (4) years and will disqualify me from receiving disability benefits from the 1977 Police Officers and Firefighters Pension and Disability Fund throughout my employment if the disability is related in any way to the identified disease(s) or condition(s). I have reviewed PERF Board rules 35 IAC 2-9 and 35 IAC 2-10 and the lists of diseases and conditions set forth herein. I affirm that I understand the effect the 35 IAC 2-9 and 35 IAC 2-10 may have on my eligibility for benefits in the 1977 Fund and also on my ability to qualify for Class 3 impairment benefits.

Signature of candidate

Date (month, day, year)

Page 3 of 21

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Part of State Form 4928 (R7 / 3-09)

This information is for official and medically confidential use only and will not be released to unauthorized persons.

_______________________________________________________________________________, is applying for the position of
Name - last, first, middle

________________________________________________ with the ________________________________________________.
Police officer or firefighter City / town department

_______________________________________________________________________________________________________
Address of candidate - number and street, city, state and ZIP code

I, ___________________________________________, a candidate for a position within the department, agree to assist and cooperate with the department, the administrators of the 1977 Police Officers and Firefighters Pension and Disability Fund (1977 Fund), and any representative thereof in obtaining the following personal information: All written or printed information concerning any diagnosis, treatment, or prognosis regarding my physical or mental health; including, but not limited to, all mental and physical health records and alcohol and drug abuse records. I hereby authorize and request all persons to whom this request (original or copy) is presented, having information relating to or concerning me, to furnish the above described information to any duly appointed administrator or representative of the 1977 Fund and any officer or individual of the department. I further authorize the department, or the administrators of the 1977 Fund to release this information, as well as the results of any physical examinations performed in connection with this form, to the appropriate local pension board. I am aware that this information may be of a personal nature and may otherwise be protected by my constitutional, statutory, or common law privileges. I understand that information released and complied pursuant to this authorization shall be treated in a confidential manner. Therefore, I expressly waive all privileges which may attach to such disclosure and shall hold no individual, organization(s), or corporation(s) liable for legal actions for disclosing any of the information herein to the department, a 1977 Fund representative, or a local pension board. I am also aware that this authorization is subject to revocation at any time, except to the extent a person or institution has already legally acted in reliance on this authorization. If not previously revoked, this authorization will expire on the earlier of: the date I am extended an unconditional offer of employment to become a member of the department; or the date I am officially advised that I am ineligible for membership in the 1977 Fund. I understand that this information is required to complete my application to become employed as a member of the department and that misrepresentation, falsification of information, or failure to assist and cooperate with the department or the administrators of the 1977 Fund in obtaining the requested information will be considered cause for disqualification from consideration. Further, I authorize investigation of all statements contained in this form. I understand that omission of facts called for in this application form is also cause for disqualification from further consideration. I have read the above, understand it, and certify that I will fully and truthfully answer all questions to the best of my knowledge. Dated this ______, day of ____________________________________, 20______.
Signature of candidate Social Security Number of candidate

Subscribed and sworn to me this ______, day of ____________________________________, 20______.
Signature of notary public (must be an original signature - no rubber stamps) Printed name of notary public Date commission expires (month, day, year) County of residence

NOTARY SEAL

Page 4 of 21

GUIDELINES FOR PHYSICIANS
Part of State Form 4928 (R7 / 3-09)

This information is designed to help physicians complete the following forms. The medical conditions outlined in these forms may impact on an individuals ability to perform the essential functions of the job for a first class police officer or firefighter. The application of these guidelines requires a careful consideration of the job duties of a police officer or firefighter and the medical conditions that might affect a persons capability to conduct those duties. Firefighting and emergency response are very difficult jobs. People in these jobs must perform functions that are physically and psychologically demanding. These functions must often be performed under very difficult conditions. Studies have shown that firefighting and police functions at times require working at near maximal heart rates for prolonged periods of time. Heavy protective equipment (including respirators) and the heat from fire also contribute to the physical load that firefighters must endure. The available health data on firefighters and police officers is limited. Given the delay between exposure and onset of many occupational illnesses (i.e., latency), current or past health studies of firefighters and police officers may not reflect future health risks. However, it appears that firefighters and police officers have increased risk for injuries, pulmonary disease, cardiovascular disease, cancer, and noise-induced hearing loss. The increased risk for injuries is expected given the demands and circumstances for this work.

BASIC ESSENTIAL JOB FUNCTIONS
I. BASIC ESSENTIAL FUNCTIONS FOR POLICE OFFICERS II. Patrol assigned area on foot or drive a vehicle searching for suspicious activity or situations, or checking for persons in need of service. Monitor radio and other communication devices to receive assigned runs and to maintain awareness of activities in assigned areas or by other officers. Assist citizens with problems such as lost children, injured persons, animal bites, civil disputes, locked doors, vehicle inspections and verifications, or abandoned vehicles. Refer persons to appropriate social service agencies when situation warrants. Respond to assigned run by driving, walking, or running to specified location, assess situation, determine need for other assistance, and take appropriate action. Move people away from danger, including carrying unconscious people, and providing emergency aid to injured people. Investigate accidents, extract victims, provide emergency aid, gather evidence, record observations and statements of witnesses and victims, request assistance from other officers or agencies as needed, direct the removal of the vehicles involved, and ensure the area is clear. Search crime scenes, take prescribed actions to preserve and protect evidence, and record findings and observations. Interview victims, suspects, and witnesses, and record responses and observations. Pursue, apprehend, search, and arrest suspects using only necessary force, advise suspects of rights, and transport suspect to detention area. Using appropriate equipment and weapons, restrain people from physically striking or injuring others. Drive a vehicle at high speed when situation warrants due to nature of emergency. Stop drivers of vehicles when traffic violations are observed, verify license and registration data, advise driver of safe driving practices, and issue citations or make arrests as warranted. Direct vehicular and pedestrian traffic when congestion occurs or as directed. Report as directed to scenes of general emergencies and take appropriate action to protect life and property, such as directing traffic, quarantining an area, assisting individuals in leaving an area, preventing looting, and requesting appropriate assistance. Maintain visibility in the community by meeting and talking with citizens, provide information, visit local businesses, and make presentations to school, neighborhood, and civic organizations. Write reports and complete forms as required by operating procedure, and make oral reports to appropriate personnel. Testify in court, prepare for such testimony by reviewing reports and notes, meet with attorneys, and obtain appropriate evidence. Participate in training on law enforcement procedures, including firearms, criminal justice, and court procedure, emergency medical aid, and related subjects. Maintain uniforms, equipment, and weapons. Maintain personal physical fitness. Perform related duties as assigned.

BASIC ESSENTIAL FUNCTIONS FOR FIREFIGHTERS Respond to alarms by reporting to assigned vehicle, riding in or on assigned vehicle to the scene of the emergency or fire. Lift, carry, drag, lay, and connect hose lines from hydrants and equipment to scene. Carry resuscitators, tools, and other equipment from vehicle to scene. Raise and climb ladders, crawl and walk on roofs and floors, open holes and windows with axes, bars, or hooks for access or ventilation. Combat fires by holding nozzles and directing streams of fog, chemicals, or water and move into fire area, including into confined spaces and up stairs. Communicate by voice or radio with other firefighters and other emergency personnel to relay observations, equipment needs, and other relevant information. Move people away from danger, including carrying unconscious people or holding a life net. Provide emergency medical treatment to injured people. Remove objects from buildings, place protective covers over objects, and monitor assigned areas for signs of recurrence. Conduct fire drills, critique drill participants on emergency procedure, and instruct groups on such procedures. Participate in training on firefighting, emergency aid, emergency procedures, and related subjects. Maintain departmental equipment and structures, which includes cleaning and washing walls and floors, hanging and drying fire hose, cleaning equipment, and performing preventative maintenance on motorized equipment. Maintain personal physical fitness. Perform related duties as assigned. Page 5 of 21

GUIDELINES FOR PHYSICIANS (continued)
Part of State Form 4928 (R7 / 3-09)

ENVIRONMENTAL FACTORS THAT AFFECT JOB FUNCTIONS
I. ENVIRONMENTAL FACTORS FOR POLICE OFFICERS The (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) II. essential job functions for a police officer are performed in and affected by the following environmental factors. An officer must: Operate both as a member of a team and independently at incidents of uncertain duration. Face exposure to infectious agents such as hepatitis B or HIV. Perform complex tasks during life-threatening emergencies. Work for long periods of time, requiring sustained physical activity and intense concentration. Face life or death decisions during emergency conditions. Tolerate exposure to grotesque sights and smells associated with major trauma. Make rapid transitions from rest to near maximal exertion without warm-up periods. Use firearms, self-defense equipment and body armor. Be able to physically protect him/herself. Be able to communicate with people effectively.

ENVIRONMENTAL FACTORS FOR FIREFIGHTERS The (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) essential job functions for a firefighter are performed in and affected by the following environmental factors. A firefighter must: Operate both as a member of a team and independently at incidents of uncertain duration. Spend extensive time outside exposed to the elements. Experience frequent transition from hot to cold and from humid to dry atmospheres. Tolerate extreme fluctuations in temperature and perform physically demanding work in hot (up to 400° F), humid (up to 100%) atmospheres while wearing equipment that significantly impairs body cooling mechanisms. Work in wet, icy, or muddy areas. Perform a variety of tasks on slippery, hazardous surfaces such as on roof tops or from ladders. Work in areas where sustaining traumatic or thermal injury is possible. Face exposure to carcinogenic dusts such as asbestos, and toxic substances such as hydrogen cyanide, acids, carbon monoxide, or organic solvents either through inhalation or skin contact. Face exposure to infectious agents such as hepatitis B or HIV. Perform complex tasks during life-threatening emergencies. Work for long periods of time, requiring sustained physical activity and intense concentration. Face life or death decisions during emergency conditions. Tolerate exposure to grotesque sights and smells associated with major trauma and burn victims. Make rapid transitions from rest to near maximal exertion without warm-up periods. Operate in environments of high noise, poor visibility, limited mobility, at heights, and in enclosed or confined spaces. Use manual or power tools in the performance of duties. Rely on sense of sight, hearing, smell, and touch to help determine the nature of the emergency, maintain personal safety, and make critical decisions in confused, chaotic, and potentially life-threatening environments. Wear personal protective equipment that weighs approximately fifty (50) pounds while performing the essential functions of the job. Perform physically demanding work while wearing protective pressure breathing equipment with 1.5 inches water column resistance to exhalation at a flow of forty (40) liters per minute. Be able to communicate with people effectively.

Please do not leave any questions blank unless the form instructs you to skip questions.

Page 6 of 21

COMPREHENSIVE MEDICAL HISTORY
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the candidate.
Name of candidate Date of birth (month, day, year) Occupation Age Sex

DO NOT ANSWER ANY QUESTION WITH N/A.
Home telephone number

(
Male Female
What is your present health?

)

Are you having pain or discomfort at this time?

Good

Fair

Poor
Business telephone number

Yes

No

Name of employer

(

)

RELATION Father Mother Brothers and Sisters Spouse Children

AGE

A. (1) FAMILY HISTORY OF APPLICANT STATE OF HEALTH IF DEAD, CAUSE OF DEATH

AGE AT DEATH

Has any blood relation (grandparent, parent, brother, sister) had: (check each item) Yes No Relationship Tuberculosis Hypertension (high blood pressure) Diabetes Kidney trouble Heart trouble Stroke Muscular disease
Please explain any yes answers

(check each item) Stomach or intestine trouble Rheumatism (arthritis) Asthma Epilepsy Cancer Mental illness

Yes

No

Relationship

A. (2) PERSONAL HISTORY OF APPLICANT (past medical history)
Did you have any unusual, complicated, or prolonged childhood illnesses? If so, please explain.

Year

Nature of Problem

HOSPITALIZATIONS (for non-surgical reasons) Name of Physician and City

Describe Any Long-lasting or Residual Effects

Page 7 of 21

COMPREHENSIVE MEDICAL HISTORY (continued)
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the candidate.

DO NOT ANSWER ANY QUESTION WITH N/A.

Year

A. (2) PERSONAL HISTORY OF APPLICANT (past medical history) (continued) OPERATIONS / SURGERIES Type of Surgery Name of Hospital Name of Surgeon and City

Year

Nature of Injuries

SERIOUS INJURIES / ACCIDENTS (no hospitalization required) Name of Physician and City Describe Any Long-lasting or Residual Effects

Have you traveled extensively or resided outside of the United States and Canada? If so, please explain.

Military Service

Dates (month, day, year)

Branch of Service

Any duty outside of the United States?

Any serious illnesses or injuries sustained while in military service should be listed on the previous page.
List any medications to which you are allergic or which you do not tolerate well.

List any non-medication allergies or sensitivities.

Medication

List any and all medications that you are currently taking or that you take on a regular basis. Dosage Reason for Medication Prescribing Physician

Name of Personal Physician(s)

Address (number and street, city, state, and ZIP code)

Telephone Number

Are you presently under a physicians care or the care of any other health care provider for any reason? If so, please explain.

Do you have any impairment, disabilities, functional limitations, or restrictions on activities as a result of physical, medical or an emotional condition that may interfere with your ability to perform the essential functions of the job for which you are applying? The essential functions of the job are listed on page 4. If so, please explain.

Page 8 of 21

COMPREHENSIVE MEDICAL HISTORY (continued)
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the candidate.

DO NOT ANSWER ANY QUESTION WITH N/A.
A. (3) REVIEW OF SYSTEMS

Have you had in the past or do you currently have any of the following conditions? (check each item) GENERAL Feel too hot or too cold Tremors or shaking of hands Chills or night sweats Presently following a specific diet In the past year, had unexplained weight loss/gain Frequent or recurrent infections Any unexplained or significant bleeding Use any type of braces, supports, or other orthopedic devices that may affect your ability to perform the essential functions of the job for which you are applying? Unexplained or unusual discharge SKIN Change in skin character or texture Unusual growth on skin Change in color or size of mole Swelling or lump in neck, armpits, groin, or breasts HEENT Wear glasses or contacts Difficulty with vision not corrected by glasses/contacts Blurred vision Double vision Pain or inflammation in eyes Color blindness Decrease in hearing ability Frequent earaches or discharge from the ears Buzzing or ringing in the ears Sudden attacks of dizziness or fainting Frequent or severe nosebleeds Nasal discharge Nasal obstruction Persistent change or loss in sense of smell or taste Gums bleed easily Persistent sore or rough places on lips or tongue Frequent or severe sore throats Hoarseness that lasted more than one week RESPIRATORY Frequent colds Wheezing or whistling in the chest Chronic cough Cough up blood Short of breath walking at normal pace or level surface CARDIOVASCULAR Chest pain Pressure or heaviness in chest Chest pain radiating to neck, jaw, or down either arm Yes No CARDIOVASCULAR (continued) Irregular heartbeat (palpitation, heart flutter) Ankles swell Sleep propped up in bed Pain in either leg on walking GENITOURINARY Get up at night to urinate Trouble starting or stopping your stream when you urinate Frequency, burning, or pain when you urinate Blood or pus in urine Swelling or lumps in your testicles Sore on penis Now pregnant Lump in breasts GASTROINTESTINAL Difficulty swallowing Frequent nausea or vomiting Stomach pain Excessive gas, belching, or bloating Intolerance of fatty foods Recent change in bowel habits Diarrhea lasting more than one week Blood in bowel movements Black or tarry bowel movements Constipation MUSCULOSKELETAL Pain in muscles Pain in joints Swelling of any joints Frequent backaches HEMATOLOGICAL Bruise easily Bleed excessively after a cut or dental procedure NEUROLOGICAL Persistent numbness, tingling, weakness, or paralysis in any body part Frequent headaches severe enough to limit activities Sensation of dizziness Sensation of lightheadedness or faintness Periods of unconsciousness Seizures/convulsions (fits, spells, or falling out) Persistent drowsiness through the day Become suddenly sleepy or sleep attacks during the day Have episode of sudden muscle weakness during the day Yes No

Page 9 of 21

COMPREHENSIVE MEDICAL HISTORY (continued)
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the candidate.

DO NOT ANSWER ANY QUESTION WITH N/A.
A. (3) REVIEW OF SYSTEMS (continued)
NOTE: If you wear contact lenses, please identify below the type of contact you wear (soft, hard)

Please explain any affirmative responses to the questions in Section A. (3). and how long you have worn contacts.

Do you have the history of any other significant physical conditions, medical problems, or emotional disorders than those listed above? If so, please fully explain.

A. (4) PERSONAL AND SOCIAL HISTORY
1. Have you ever smoked? If no, go to question 3. 2. Complete the appropriate columns if youve ever smoked.

Yes
Do you smoke now?

No No

Amount smoked at present

Amount smoked when you stopped

Total years smoking

Cigarettes (number/day) Pipe (pipefuls/day) Cigars (number/day)

Yes

3. How much of the following do you usually drink each day?

Cups of coffee ____________
4. Have you ever drunk alcoholic beverages? If no, go to question 9.

Cups of tea ____________
Amount drunk when you stopped

Soft drinks ____________
If stopped, when? Total years drinking

Yes
Do you drink now?

No No No No

5. Complete the appropriate columns if youve ever drunk alcoholic beverages. Liquor (ounces/week) Beer (bottles/week) Wine (glasses/week)

Amount drunk at present

Yes Yes Yes Yes

6. Are you always able to stop drinking when you want to?

7. Has drinking ever created problems for you with your job, family, social life or other obligations?

Yes

No

8. Have you ever gone to anyone for help about your drinking?

Yes

No

9. Do you or have you taken any illegal drugs? 10. Do you or have you ever used smokeless tobacco? 11. Describe your previous occupations.

If yes, please explain. If yes, please describe.

No

12. Have you ever had any occupational illness, injury, or significant occupational exposure? If so, please explain.

I certify that I have reviewed the information and answered the questions set forth in Sections A (1), A (2), A (3), and A (4) of this application, and that I have answered truthfully and to the best of my ability.
Signature of candidate Printed name of candidate Date (month, day, year)

Page 10 of 21

PHYSICAL EXAMINATION
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.

B. (1) GENERAL (Check the appropriate column for each entry) Normal Abnormal Number and describe abnormalities in detail. General appearance Skin Head and neck Eyes: Conjunctiva Pupils Fundi Ear, nose, throat: External ear Tympanic membrane Septum Teeth, gums Throat, tonsils, tongue Trachea Lymph nodes Thyroid: Size Nodules Breasts Chest: Contour Expansion Lungs: Rales Ronchi Wheeze Dullness Heart: Rate Rhythm Inspection/ palpitation Sounds Murmur Vessels: Pulse Bruits Varicosities Abdomen: Scars Tenderness Masses Hernia Genitalia Pelvic Prostate (if indicated) Rectum (if indicated) Spine: Mobility Alignment Extremities: Joints Deformity Edema Neurological: Gait Coordination Reflexes Sensory Cranial nerves Other

Page 11 of 21

PHYSICAL EXAMINATION (continued)
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.

B. (2) TESTS (Each of the following tests must be administered to the candidate. Test results should be recorded below or attached.)
Vital signs

Blood pressure ____________ Visual acuity uncorrected corrected

Pulse ____________

Respiration ____________

Height (inches) ____________

Weight (pounds) ____________ Yes Yes No No

Visual testing (using a Snellen chart or other comparable chart)

Distant ___/___ ___/___ ___/___ ___/___ ___/___ ___/___
right left both right left both

Near ___/___ ___/___ ___/___ ___/___ ___/___ ___/___
right left both right left both

Color vision (ability to identify red, green, and yellow colors)

Peripheral vision (at least 140° in the horizontal meridian of each eye without correction)

Audio testing - should be performed in an ANSI approved soundproof booth (ANSI S3.1-1991) with equipment calibrated to ANSI standards (ANSI S 3.6-1989). If a booth is unavailable, the test room sound pressure levels should not exceed those specified in the Federal OSHA noise regulations (29 CFR 1910.95); (July 1, 1992 Edition). Pulmonary function testing - A minimum of three (3) acceptable Forced Vital Capacity (FVC) maneuvers must be performed and recorded. The best two (2) FVC maneuvers must reveal results that are within 5% of each other. The best Forced Expiratory Volume in One Second (FEVI) are recorded and the FEVI/FVC ratio is then calculated. Additional spirometric functions may be performed if desired or indicated. Chest x-ray - Posterior-anterior / lateral views - with interpretation by a radiologist required. Other diagnostic imaging, if indicated. 12-lead ECG (resting) test - with interpretation by a cardiologist or other qualified physician. Other diagnostic testing, if indicated. Laboratory testing (minimum) Complete blood count Blood chemistries - fasting glucose, BUN, creatinine Liver function - SGPT (ALT), SGOT (AST), GGT, LDH, alkaline phosphotase, total protein, albumin, bilirubin (total) Urinalysis - SG, blood, protein, glucose, ketones, bilirubin and nitrates required, microscopic evaluation required if any significant abnormalities above have resulted HIV testing - if screening test positive, confirm testing with Western Blot analysis HIV antigen Syphilis serology Urine drug screen - must test for at least marijuana, cocaine, opiates, amphetamines, PCP, benzodiazepines, and barbiturates. Testing must be performed in accord with the acceptable standards within the field of forensic toxicology and should adhere to all proper chain of custody procedures. TBc skin test - applied and interpreted - not to be done if there is a past history of positive PPD or pulmonary TBc

I, __________________________________________________, a licensed physician, certify that I have performed the above tests on
Name of physician

___________________________________________________, candidate for appointment to the ______________________________
Name of candidate Police or fire

department of _______________________________________.
Name of city / town

I further certify that I had administered or have had administered the above-listed test and examinations to appropriately complete this questionnaire, and that I further certify that I have attached hereto copies of the results of all of the tests identified herein.
Signature of licensed physician (must be an original signature - no rubber stamps) Date (month, day, year)

Note to physician completing the medical examination: Please do not leave any questions in your examination blank. Answer all of the questions and include all of the original testing results with this examination form. Thank you.
PHYSICIAN IDENTIFYING INFORMATION (please print)
Name of physician Address (number and street, city, state, and ZIP code) Telephone number Number issued by Medical Licensing Board

(

)

Page 12 of 21

STATEWIDE BASELINE STANDARDS
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.

Based on the foregoing tests and examinations, I have determined that ___________________________________________________ Name of candidate either does or does not have the following conditions as indicated:
(Check each item) 1. Vision testing as follows: a. Far vision acuity (1) Corrected binocular vision worse than 20/30; (2) Corrected vision of the worse eye worse than 20/50; or (3) Uncorrected binocular vision worse than 20/100, with the exception that long-term successful users of soft contact lenses do not have to meet this uncorrected standard. b. Color vision - an inability to identify red, green, and yellow colors. c. Peripheral vision - uncorrected field-of-vision less than one hundred forty degrees (140°) in the horizontal meridian in each eye. 2. Hearing deficits - A hearing deficit in the pure tonal thresholds (five hundred (500) Hertz, one thousand (1,000) Hertz, two thousand (2,000) Hertz, and three thousand (3,000) Hertz) in the unaided worst ear: a. of more than twenty-five (25) decibels in three (3) of the four (4) frequencies; b. of more than thirty (30) decibels in any one of the first three (3) frequencies; or c. an average loss within the four (4) frequencies of more than thirty (30) decibels. 3. Communicable diseases: Any communicable disease or condition that poses a significant risk of substantial harm to the health and safety of the candidate, co-workers, or members of the public with whom the candidate will come in contact during the course of employment. 4. Suddenly incapacitating diseases or condition: Any disease or condition (physical or mental) that could incapacitate the candidate without sufficient warning to allow the candidate to take preventive measures, thereby imposing a significant risk of substantial harm to the health or safety of the candidate, co-workers, or members of the public with whom the candidate will come in contact during the course of employment (unless such disease or condition can be controlled by medication and the candidate affirms he or she takes the appropriate medication). 5. Alcoholism or illegal use of drugs as follows: a. Any history of alcoholism, unless the candidate has successfully rehabilitated for a period of at least one (1) year, successfully passes an examination for alcohol usage, and the candidate affirms he or she is no longer engaging in the use of alcohol and has successfully rehabilitated for a period of at least one (1) year preceding his or her application for employment. b. Any history of illegal drug use or evidence of drug abuse, unless the candidate has successfully rehabilitated for a period of at least one (1) year, successfully passes an examination for the use of drugs or drug abuse, and the candidate affirms he or she is no longer engaging in drug abuse and has successfully rehabilitated for a period of at least one (1) year preceding his or her application for employment. YES NO

The determination of whether a candidates condition poses a significant risk of substantial harm will be based on an objective individualized assessment of this applicants present ability to safely perform the essential functions of the job considering reasonable accommodations to the extent required under the Americans with Disabilities Act. Factors to be considered include the following: 1. The duration of the risk, 2. The nature and severity of the potential harm, 3. The likelihood that the potential harm will occur, 4. The imminence of the potential harm. Relevant evidence may include input from the applicant, the experience of the applicant in previous similar positions, opinions of medical doctors, rehabilitation counselors, or physical therapists who have expertise in the disability involved, or direct knowledge of the applicant.
Signature of licensed physician (must be an original signature - no rubber stamps) Date (month, day, year)

Page 13 of 21

PHYSICIANS EXPLANATION OF STATEWIDE BASELINE STANDARDS AND CONDIDATES AFFIRMATIONS
Part of State Form 4928 (R7 / 3-09)

Complete this section only if answered yes on the previous page.

DO NOT ANSWER ANY QUESTION WITH N/A.

Communicable diseases Physicians explanation: (Identify the communicable disease or condition and describe its risk to the health and safety of the candidate, co-workers, or members of the public with whom the candidate will come in contact during the course of employment.)

Suddenly incapacitating diseases or conditions Physicians explanation: (Identify the suddenly incapacitating disease or condition and describe the risk to the health or safety of the candidate, co-workers, or members of the public with whom the candidate will come in contact during the course of employment; indicate if disease or condition can be successfully controlled by medication and identify the medication.)

Candidates Affirmation I, ________________________________________________, affirm that I take the appropriate medication, as identified above, to control the above described suddenly incapacitating disease or condition.
Signature of candidate Date (month, day, year)

Alcoholism Physicians explanation: (Determine and describe whether the candidate has successfully rehabilitated for a period of at least one (1) year and successfully passes an examination for alcohol usage [attach examination results].)

Candidates Affirmation I, ________________________________________________, affirm that I am no longer engaging in the use of alcohol and have been successfully rehabilitated for a period of at least one (1) year preceding the date of my application for employment.
Signature of candidate Date (month, day, year)

Illegal use of drugs Physicians explanation: (Determine and describe whether the candidate has successfully rehabilitated for a period of at least one (1) year and successfully passes an examination for the use of drugs or drug abuse [attach examination results].)

Candidates Affirmation I, ________________________________________________, affirm that I am no longer engaging in drug abuse and have been successfully rehabilitated for a period of at least one (1) year preceding the date of my application for employment.
Signature of candidate Date (month, day, year)

Page 14 of 21

EXCLUDABLE CONDITIONS
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.
Name of candidate

I have determined that, based upon the above test and examinations, __________________________________________________ either does or does not have the conditions as indicated (please explain all affirmative responses to each item on Addendum A).
(Check each item) 1. A history of myocardial infarction. 2. Angina pectoris or other evidence of coronary artery disease. 3. Arteriosclerotic heart disease. 4. Hypertrophy or dilation of the heart as evidenced by examination. 5. Pericarditis, endocarditis, or myocarditis unless the examining physician determines that the condition is now stable and unlikely to recur. 6. Functional arrhythmias. 7. Diabetes requiring insulin or oral hypoglycemics. An individual with diabetes whose condition is effectively controlled by diet alone would not be considered to have an excludable condition. A candidate with a history of glucosuria or albuminuria must be considered to have an excludable condition unless a report from the physician that treated the candidate can be obtained which assures the absence of diabetes mellitus. 8. Pancreatitis. 9. A history of a chronic bowel disorder such as Crohns disease and ulcerative colitis. A candidate with a history of a bowel obstruction within the preceding ten (10) years shall be considered to have an excludable condition unless the candidate is able to obtain a letter from the treating physician to the examining physician explaining the nature of the obstruction and what was done to cure it. 10. Any hepatitis, chronic or acute, with impairment of liver function. 11. Cirrhosis or varices. 12. Inguinal or femoral hernia, hiatal hernia, if symptomatic, or ventral hernia, if symptomatic. 13. Interabdominal tumor or mass. 14. Any previous gastric resection unless there is sound x-ray evidence provided that there is little chance of recurrence of the condition which caused the first surgery. 15. Active gastric or duodenal ulcer unless the candidate is able to provide x-ray evidence that the ulcer is currently healed. A history of a gastric or duodenal ulcer shall be treated the same as any such active ulcer unless the candidate is able to provide x-ray evidence that the ulcer is currently healed. 16. Any evidence of rectal or prostatic malignancy. 17. Evidence of existing renal calculus or ureterovesical calculus, if symptomatic. 18. A person who has had a nephrectomy but with a functional remaining kidney will not be considered to have an excludable condition, provided there is no evidence of reduced renal function in the remaining kidney. 19. Any chronic nephritis or nephrosis, hydronephrosis, pyelonephrosis, pyelitis, pyelonephritis, or polycystic disease of the kidneys. 20. Urinary tract disease, whether or not the urinary tract has any significant abnormalities at this time, or whether any organic disease is present, or other related disorders adversely affecting the kidneys, excluding urinary tract infections. Yes No (Check each item) Yes 21. A history of kidney stones. If there is a history of kidney stones, urological consultation must be sought in order to provide an estimate of the likelihood of the recurrence of long term incapacitating symptoms. A candidate exhibiting a high likelihood of recurrence must be considered to have an excludable condition. 22. Any proteinuria which is a result of renal disease. 23. Any malformation of the urinary tract organs, congenital or acquired. 24. Polycystic kidney. 25. Any current fistula, either congenital or acquired, including tracheostomy. 26. Any history of subarachnoid hemorrhage, cerebral aneurysm, or any cerebral vascular disease including any previous stroke within the preceding ten (10) years. 27. Hydrocephalus. 28. Abnormalities from recent head injury, such as severe cerebral concussion or contusion. 29. Any acute or chronic pathological condition in either eye or the adnexa of the eye. 30. Nystagmus of the eye, uncorrected strabismus, glaucoma, and aphakia, whether it is unilateral or bilateral, and active chorioretinitis should be considered for further examination by a qualified eye specialist to determine the likelihood and degree of future impairment. 31. Cataract, retinitis pigmentosa, and any papilledema or tumor. 32. Any retinal exudate, hemorrhage or edema, or detachment of the retina. 33. Inflammatory disease of the retina, the globe, or the other structures within the globe. 34. Heterophoria, hyperphoria, esophoria, or exophoria should be considered for further examination by a qualified eye specialist to determine the likelihood and degree of future impairment. 35. Bronchiectasis. 36. Bronchial asthma. 37. Emphysema or chronic obstructive pulmonary disease. 38. Pulmonary fibrosis. 39. Pleurisy with effusion or empyema. 40. Any spontaneous pneumothorax unless the examining physician determines that the condition is not likely to persist or recur. 41. Any evidence or history of tuberculosis, sarcoidosis, or congenital cystic disease of the lung, active histoplasmosis, or any other lung pathology unless the examining physician determines that the condition is now stable and unlikely to recur. 42. Tumor or cyst of the lung, pleura, or mediastinal. 43. Any disease of the blood forming organs or of the blood. 44. Anemia with the hemoglobin lower than twelve (12) grams per hundred cubic centimeters. 45. Polycythemia, leukemia, or any other progressive diseases of the blood system. 46. Hemophilia. No

Page 15 of 21

EXCLUDABLE CONDITIONS (conditions)
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.
Yes No (Check each item) 62. Disease of the adrenal gland, pituitary gland, parathyroid gland, or thyroid gland of clinical significance. 63. Nutritional deficiency disease or metabolic disorder. 64. Any malignant tumor of any type unless completely eradicated for at least ten (10) years. 65. Alcohol or drug abuse within five (5) years. 66. Anorexia nervosa or bulimia within three (3) years. 67. Auto immune disorders, including, but not limited to, the following: a. Rheumatoid arthritis and myasthenia gravis. b. Dermatomyositis. c. Scleroderma. 68. Lupus erythematosus. 69. Multiple sclerosis. 70. Amyotrophic lateral sclerosis (Lou Gehrigs disease). 71. Muscular dystrophy. 72. Obesity of such a degree so as to interfere with normal activities, including respiration. 73. Peripheral atherosclerosis or arteriosclerosis, including any of the following peripheral vascular diseases: a. Intermittent claudication. b. Buergers disease. c. A phenomenon of repeated thrombophlebitis. 74. Acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV) positive, as determined by a blood test. 75. Sexually transmitted diseases should be considered for further examination by a qualified medical specialist to determine the likelihood and degree of future impairment. 76. Narcolepsy. 77. Heart bypass surgery within the preceding ten (10) years. 78. Primary pulmonary hypertension. 79. Organ transplant. 80. Pacemaker implant. 81. Any disqualifying condition under 35 IAC 2-9-6 that has been accommodated by the local appointing authority. Yes No

(Check each item) 47. High blood pressure, evidenced by any of the following: a. Any blood pressure reading above one hundred fifty (150) millimeters mercury (for systolic). b. Any blood pressure reading above ninety (90) millimeters mercury (for diastolic). c. Use of antihypertensive medication. However, if systolic and diastolic readings without medication are produced at levels lower than one hundred fifty (150) millimeters mercury (for systolic) and ninety (90) millimeters mercury (for diastolic) on three (3) consecutive days, high blood pressure shall not be an excludable condition. 48. If peripheral edema is present, the cause shall be determined and the disqualifying disorder identified. 49. Aneurysm and arteriovenous malformation. 50. Any active disease of bones and joints, including active arthritis, osteomyelitis, or marked deformity of the spinal column, including, but not limited to, the following: a. History of laminectomy. b. Amputation or deformity of a joint or limb. c. Joint reconstruction. d. Ligamentous instability. e. Joint replacement. 51. Herniation of an intervertebral disk. 52. Neurofibromatosis. 53. Neuropathy or neuralgia, including sciatica. 54. Recurrent syncope. 55. Any seizure disorder within the preceding ten (10) years. 56. Parkinsonism. 57. Huntingtons disease (chorea). 58. Ankylosing rheumatoid spondylitis. 59. Malignant melanoma or, if it had been removed, any evidence of metastatic disease. 60. Hodgkins disease, lymphadenopathy, lymphomas, or lymphosarcomas. 61. Addisons disease, splenomegaly, or adenopathy secondary to systemic disease or metastasis.

Signature of licensed physician (must be an original signature - no rubber stamps)

Date (month, day, year)

PHYSICIAN IDENTIFYING INFORMATION (please print)
Name of physician Address (number and street, city, state, and ZIP code) Telephone number Number issued by Medical Licensing Board

(

)

Page 16 of 21

EXCLUDABLE CONDITIONS - ADDENDUM A
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.
EXPLANATION

Please record explanations below for all affirmative responses to items listed as an excludable condition. Please print or type. Attach additional sheets, if necessary. ITEM NUMBER

Page 17 of 21

EXCLUDABLE CONDITIONS - SPECIALISTS INFORMATION
Part of State Form 4928 (R7 / 3-09)

This section is to be completed by the examining physician.

DO NOT ANSWER ANY QUESTION WITH N/A.

If any items are answered affirmatively, has the appropriate specialists report been obtained and included in the candidates application package? (Please complete the following for each of the items answered affirmatively.) Specialists report included? Yes No Item number of excludable condition Name and address (number and street, city, state, and ZIP code) of specialist

Page 18 of 21

CERTIFICATION - BASELINE STATEWIDE MENTAL EXAMINATION
Part of State Form 4928 (R7 / 3-09)

Indiana law mandates administering a mental examination to all candidates to determine if the candidate is mentally suitable to be a member of the department. The mental examination prescribed is the Minnesota Multiphasic Personality Inventory (MMPI). (This section is required to be completed before PERF can process the candidates application; copies of the results of the mental examination are not required to be sent to PERF.)

I, ________________________________________________________________________, a licensed (physician / PhD psychologist),
Name of physician / psychologist

have interpreted the results of the statewide mental examination (the MMPI) and have determined that the named applicant, ________________________________________________________________, has passed the standards established by the local board.
Name of candidate

Signature of physician / psychologist (must be an original signature - no rubber stamps)

Date (month, day, year)

PHYSICIAN / PSYCHOLOGIST IDENTIFYING INFORMATION (please print)
Name of physician / psychologist Address (number and street, city, state, and ZIP code) Telephone number Number issued by Medical Licensing Board

(

)

CERTIFICATION BY LOCAL BOARD
Part of State Form 4928 (R5 / 12-07)

The ___________________________________________________________________________ Board (Board) has determined that
Name of local board

______________________________________________________:
Name of candidate

(1) passes the local physical and mental standards, if any, established by the appointing authority for the department; (2) has been determined to be mentally suitable to be a member of the department after being tested using the baseline statewide mental examination (MMPI); (3) has successfully met all minimum criteria for the baseline physical examination; and (4) has been determined to meet the physical requirements to be a member of the department by virtue of having passed said physical and mental standards. The Board certifies that the statewide mental examination prescribed by the PERF board was appropriately administered and that the results of the examination were interpreted by a licensed physician or a licensed PhD psychologist. The Board has attached hereto copies and certification of the results of the physical agility examination required by law, and certification of the results of the baseline statewide mental examination. The Board further certifies that the candidate has satisfied any aptitude, physical agility, or physical and mental standards established by the appointing authority.
Signature of board member (must be an original signature - no rubber stamps) Telephone number Date (month, day, year)

(
Signature of pension secretary (must be an original signature - no rubber stamps)

)
Date (month, day, year)

Telephone number

(
Page 19 of 21

)

CERTIFICATION BY APPOINTING AUTHORITY
Part of State Form 4928 (R7 / 3-09)

The appointing authority for the ________________________________________________ certifies that it has adopted standards
Name of city / town department

for physical agility tests and has administered the tests to _______________________________________________, who successfully
Name of candidate

passed the standards. These results have been certified to the local board.

The appointing authority further certifies that it caused to be administered the baseline statewide physical examinations required by law, that the examination was administered by a licensed physician, and that the candidate successfully met all standards and passed said examination. The appointing authority further certifies that no medical examination was performed upon the candidate prior to a conditional offer of employment. The appointing authority further certifies that, at the time of the conditional offer of employment, the candidate completed the attached State of Understanding. The appointing authority certifies that, with respect to the statewide baseline standards, reasonable accommodations have been made to enable the candidate to successfully perform the essential functions of the job and/or eliminate or effectively reduce the direct threat that would be caused by the presence of the following disease(s) or condition(s):

In addition to the statewide required standards, the appointing authority has established the following additional standards as a condition of employment:

The appointing authority further certifies that _________________________________________________ has passed the locally
Name of candidate

prescribed standards and the test results for these standards have been certified by the local board.

Signature of appointing authority (must be an original signature - no rubber stamps)

Telephone number

Date (month, day, year)

(

)

Page 20 of 21

SPOUSE INFORMATION
Part of State Form 4928 (R7 / 3-09)

* This agency is requesting disclosure of your Social Security Number in accordance wirh IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Name of member

Social Security Number *

Marital status (please check one)

Married
Name of spouse

Single

Social Security Number *

Date of birth (month, day, year)

Signature of member

Date (month, day, year)

Printed name of member

Page 21 of 21