BILL TO: Comprehensive Health Services, Inc Parkridge Blvd, Suite 200 Reston, VA (703) or (800)
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1 DHS FITNESS TESTING INSTRUCTIONS NOTE: Failure to comply with these instructions will result in a delay of the candidate s application process and may ultimately deter payment to your facility. 1.) 2.) 3.) 4.) 5.) Vitals Signs and Resting EKG must be completed and reviewed and the Supplemental Examination Form must be completed by the examining physician prior to the start of the fitness test. In addition, the Documentation of Routine Equipment Safety Check and Calibration form must be completed and signed by the fitness administrator. Consent for Fitness/ Performance Test must be signed by the examinee prior to start of the Fitness Test. Review all fitness instructions prior to administering the test, as all portions must be completed in accordance with the established protocol. Each task must be administered in the appropriate order as well as the appropriate Fitness Test CD must be used for the appropriate test. *** Note that the Immigration Enforcement Agent (IEA) Fitness protocol requires a 16 inch riser for the administration of the step test*** Customs and Border Protection Officers and Border Patrol agents must complete all fitness components regardless of failure. All failed components must be noted and explained in detail on the failure summary. Immigration Enforcements Agents must be stopped when a component is failed. Do not proceed to the next component. The failed component must be noted and explained in detail on the failure summary. * Upon completion of the test (whether pass or fail) all requested documentation must be mailed using the provided Fed-Ex envelope the same day as the exam. BILL TO: Comprehensive Health Services, Inc Parkridge Blvd, Suite 200 Reston, VA (703) or (800) If there are any questions regarding this test please do not hesitate to contact the Comprehensive Health Services, Inc option 3.
2 SUPPLEMENTAL EXAMINATION FORM Department of Homeland Security Customs and Border Protection Supplemental Examination Form LAST NAME FIRST NAME MIDDLE NAME SOCIAL SECURITY NUMBER Blood Pressure Resting EKG Interpretation (attach tracing): Conclusions: Based on my review of the Blood pressure and EKG interpreted above,, it is my opinion that the applicant : (mm/dd/yy) May safely engage in the required fitness test Is unable to safely engage in the required fitness test Comments: TYPED OR PRINTED NAME OF EXAMINING PHYSICIAN: SIGNATURE OF EXAMINING PHYSICIAN: DATE:
3 CONSENT FOR FITNESS/PERFORMANCE TEST The position for which you have applied and its associated training programs are physically demanding. Requirements include a wide variety of physically challenging tasks. Administration of pre-employment fitness/performance assessment helps ensure that all entrants to the occupation are able to meet the physical demands of the position. The physical tasks you will be performing during the assessment are strenuous and many, in certain circumstances, result in injury or other significant medical event: e.g., heart attack, stroke, etc. Although these events are quite rare, the response of the body, including that of the cardiovascular system to physical exertion cannot be predicted with complete accuracy. By signing below, you are indicating that you have been made aware of these possibilities and are consenting to this risk. Participant Agreement and Release I understand that the position requires a high degree of physical exertion and that my participation in the Fitness/Performance Testing subjects me to risk of physical injury including permanent disability, which may result in severe social and economic losses, and death. I also acknowledge that there may be other risks not known or not reasonably foreseeable at this time. I agree to assume full responsibility for any and all such injuries and I agree to hold the Contractor, the government agency and/or any of the government agency s officials, employees, agents, consultants, or independent contractors free from liability for any loss or injury. I further release, waive, and discharge the Contractor and the government and its officials, officers, employees, agents, consultants, or independent contractors from any and all liability to me, my heirs, and next of kin for any and all claims, demands, losses, or damages resulting from my participation in the Fitness/Performance Assessment. In administering this fitness test, I understand that the Contractor and the agency are relying on my representation of being in good health. I am responsible for advising the Test Administrator of any symptoms I may be experiencing during the fitness test, such as chest pain, dizziness, breathing difficulties, sudden headache, severe muscle pain, or similar problems. I understand that it is my responsibility to voluntarily stop the Fitness/Performance Test any time I experience these symptoms or feel the physical demands are too great. By executing this document, I expressly consent to my participation in the Fitness/Performance Test pursuant to the terms of this Test Release and Waiver. I have read and fully understand the above Test Release and Waiver and sign it voluntarily. Applicant Name and SSN: Applicant Name SSN Applicant Signature Date
4 DOCUMENTATION OF ROUTINE EQUIPMENT SAFETY CHECK AND CALIBRATION FORM Date: Facility Name/Number: Applicant s Name/SSN: Applicant Name SSN Step Test Responses 1. Was a pre-test visual inspection of the equipment performed? YES NO 2. Is the step test equipment aligned? YES NO 3. Is the step test equipment in working order? YES NO 4. Is the step test equipment in need of repair? YES NO Lift Test Responses 1.Was a pre-test visual inspection of the equipment performed? YES NO 2. Is the lift test equipment in working order? YES NO 3. Is the lift test equipment in need of repair? YES NO Equipment Safety Check and Calibration performed by: (Please print name) Please circle the appropriate responses and include this routine equipment safety check and calibration document with the applicant s Fitness Testing Scoring Sheet. If you have any questions or need to replace equipment please call option 3.
5 U.S. CUSTOMS AND BORDER PROTECTION Customs and Border Protection Officer Pre-employment Fitness Test Score Sheet (Please Print) APPLICANT INFORMATION Last Name: First: M.I.: Gender: Social Security Number: Date of Birth (MM/DD/YYYY): M F Age: Weight (pounds): Height (inches): Dominant Hand (R/L): TEST INFORMATION Part One: Test Administrator USE ONLY (below this line) CHS USE ONLY (below this line) Push-up Test No. completed in 1-minute Score: Side Step Test (Must complete two trials) No. of line touches/crosses (trial 1) (trial 2) Score: Sit-up Test No. completed in 1-minute Score: Lift/Lower Test 8 cycles completed in seconds Score: TOTAL: Part Two: Step Test Completed 5 minutes: Yes No If no, enter time test stopped minutes seconds Failure Reasons (select one): Failed to keep cadence for 3 consecutive sequences Failed to keep cadence for a total of 6 sequences Test stopped for applicant safety (explain below) Applicant voluntarily stopped (explain below) Other (explain below) TEST ADMINISTRATOR INFORMATION Test Date: Test Site Location (City/State): Print Name: Signature: Phone No: OFFICIAL CBP USE ONLY DO NOT WRITE BELOW THIS LINE Based on the Pre-employment Fitness Test results listed above, the applicant has: PASSED and has been found physically fit for further consideration for the CBP Officer position FAILED and is removed from consideration for the CBP Officer position Director, Physical Fitness: Signature: Date:
6 Name of Applicant (Last, First) Social Security Number Test Administrator Name (Last, First) Date of Statement (Same as Date Tested) Statement Regarding CBP Officer Pre-Employment Fitness Test Failure Sworn Statement I do so declare under penalty of law that this is an accurate and truthful documentation of the circumstances of the CBP Pre-Employment Fitness Test battery administered to the applicant named above. Test Administrator Signature Date Telephone Number X ( ) Clinic Code City State Zip CBP Form 523 (Back) (03/06)
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