BOP Program Statement 3906.24 § 9

Since ICT II is administered to employees, any injury suffered during official business is covered

under the Federal Employees’ Compensation Act.

Students injured while attending ICT II must immediately report the injury to a Staff Training

Academy Instructor. The employee will be offered the opportunity to be evaluated by FLETC

Health Services. If seen by FLETC Health Services, and medically cleared, he/she returns to

his/her class to complete ICT II. If not cleared, the employee is returned to his/her duty station.

The employee must be medically cleared of injury before being scheduled to return to the STA to

attend ICT II.

If the employee declines the opportunity to be evaluated by FLETC Health Services, he/she will be

be required to continue with, and successfully complete, all required training components of ICT II.

REFERENCES

Program Statements

P3300.02 Employment (3/25/16)

P3330.02 Pre-employment (7/25/16)

P3906.22 Employee Development Manual (4/30/15)

P6701.01 Employee Health Care (8/30/13)

BOP Forms

BP-A0631 Applicant Physical Exam Report

ACA Standards (see Program Statement Directives Management Manual, sections 2.5 and 10.3)

 American Correctional Association 2nd Edition Standards for Administration of Correctional

Agencies: 2-CO-1C-01, 2-CO-1C-19.

■ American Correctional Association 4th Edition Standards for Adult Correctional Institutions:

4-4048, 4-4062.

■ American Correctional Association 4th Edition Standards for Adult Local Detention Facilities:

4-ALDF-7B-04

Records Retention Requirements

Requirements and retention guidance for records and information applicable to this program are

available in the Records and Information Disposition Schedule (RIDS) on Sallyport.

P3906.24 2/24/2017 8

BP-A0631

Nov 16 APPLICANT PHYSICAL EXAM REPORT U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

THIS INFORMATION IS FOR OFFICIAL AND MEDICALLY PRIVILEGED USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS

Examining Facility Date of Examination

Last Name - First Name - Middle Name Date of Birth

Height Weight Blood Pressure Temp. Resp. Rate Pulse Rate

Distant Vision W/O Corr. Lenses Distant Vision With Corr. Lenses Color Vision (Test used)

Right 20/ Right 20/

Left 20/ Left 20/

Hearing 500 1000 2000 3000 4000 6000 8000

Right

Left

Hearing Aid: Yes/No

Head/Eyes/Ears/Nose/Throat/Neck

Chest Heart

Abdomen

Extremities

Vascular

Neurologic

Skin

Back (Describe any limitations)

Other / Mental Health Status

Summary/Conclusions/Findings

Typed or Printed Name of Examiner Signature Date

APPLICANT Last Name - First Name - Middle Name Date of Examination

CENTRAL OFFICE MEDICAL REVIEW:

Medically Qualified NOT Medically Qualified

Typed or Printed Name of Physician Signature Date

COMPLETE BELOW SECTIONS ONLY AFTER BEGINNING ICT I

A. TB SKIN TEST RESULTS: mm Name/Sig. of reader: Date:

If 2-step test: mm Name/Sig. of reader: Date:

Follow-up with healthcare provider, if indicated. Result:

Name/Signature of IOP: Date:

(only review/sign if required follow-up with healthcare provider)

B. PRE-TRAINING ASSESMENT, BY MEDICAL PROVIDER (HSD)

Ordinarily, new employees shall be sent to FLETC to participate in the ICTP within 120 days after entrance on

duty. However, a cursory screening, WITHIN 30 DAYS OF DEPARTURE, shall be required for final clearance to ensure

there are no acute conditions present which would preclude participation in the physical components.

1. Are you or do you believe you are pregnant? Yes No N/A

2 Have you recently given birth or are breastfeeding? Yes No N/A

3. Have you been injured since your pre-employment exam? Yes No

4. Have you had any illness or surgery since your pre-employment exam? Yes No

5. Do you feel you are able to fully participate in the Yes No

physical ability test as shown in the film when you were interviewed?

I certify that the above statements are true.

Employee Signature: Date:

MEDICAL PROVIDER TO COMPLETE:

Medically cleared to proceed to ICT II

(Only sign if cleared. IF “NO,” then comment in “Explanation” section at bottom of page)

Provider Signature: Date:

C. INSTITUTION FINAL PRE-TRAINING REVIEW, BY HUMAN RESOURCES (HR)

Proceed to ICT II training at FLETC

(Only sign if cleared. IF “NO,” then comment in “Explanation” section at bottom of page)

Typed or Printed Name of HR Staff Signature Date

IF a condition(s) is present that will preclude participation in the physical components of training,

then make entries as needed below. Once issue(s) is resolved, HR may complete item “C” above.

Explanation (may make multiple entries as needed): HSD or HR Staff Name: Date: