12 NCAC 09I .0105           MEDICAL FORMS

The following Commission-approved forms shall be used by agencies and Commission-accredited delivery sites during the application for criminal justice certification or Commission-approved training course enrollment:

(1)           Form F-1, Medical History Statement, shall include the following:

(a)           Applicant's name, date of birth, address, and telephone number;

(b)           Current medications, allergies, and past medical history;

(c)           Occupational history;

(d)           Applicant's signature; and

(e)           Name and signature of a physician, physician assistant, or nurse practitioner who holds a current license in the United States to practice medicine, as issued by a state medical board.

(2)           Form F-2, Medical Examination Report, shall include the following:

(a)           Name, date of birth, employing agency, height, weight, and last four digits of the Social Security Number for the person being examined;

(b)           Results of Vision Acuity;

(c)           Results of Hearing Acuity;

(d)           Results of Cardiovascular Examination;

(e)           Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and

(f)            Name, signature, and medical license number of the examining medical professional.

(3)           Form F-2A, Tuberculosis Questionnaire, shall include the following:

(a)           Applicant's name, date of birth, and employing agency;

(b)           Tuberculosis Risk Questions and individual's response; and

(c)           Tuberculosis Symptoms Questions and individual's response.

(4)           Form F-2B, Medical Examination Report Addendum, shall include the following;

(a)           Name, date of birth, and employing agency of individual being examined;

(b)           Additional Exam Notes, if any;

(c)           Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and

(d)           Name, signature, and medical license number of examining medical professional.

(5)           Form F-31, Request for Accommodation, shall include the following:

(a)           Name, signature, and date of birth of requesting student;

(b)           Accredited delivery site, and name of certified School Director;

(c)           Reason for Accommodation; and

(d)           Proposed Accommodation.

(6)           Web Form WF-5, CJ Standards Specialized Training Student Injury Report for SMI, Instructor Courses, shall include the following:

(a)           Course name, course dates, and training location;

(b)           Injured student's name, date of birth, and academy ID number;

(c)           Date of the injury;

(d)           Details of the injury, including what the injury is, when and where it took place, and how the injury occurred;

(e)           Whether the student was able to return to training on the same day as the injury occurred; and

(f)            Whether the student was transported to a hospital or other medical facility for assessment or treatment of the injury.

History Note:        Authority G.S 17C-6;

Eff. February 1, 2026.