camrose police service application

Receipt No.

Fo r O ffi ce U se O n l y

CAMROSE POLICE SERVICEEMPLOYMENT APPLICATION

MAIL COMPLETED APPLICATION TO:

CHIEF OF POLICECAMROSE POLICE SERVICE6220-48 AvenueCamrose, Alberta, T4V 0K6

For more information about opportunities with the Camrose Police Service, please see our website www.camrosepoliceservice.ca

1. An essential component in the selection process of the Camrose Police Service is a background investigation. Information gatheredwill be used to assess the suitability of the Applicant for a police career. There will be a security check on the Applicant and membersof their family.

2. All questions must be answered. If a question is not applicable, mark N/A. attach a note explaining the reason any question is leftblank.

3. All information supplied is subject to verification by investigation. False statements can disqualify or result in dismissal if employed.4. Complete this form by printing in ink. Neatness and legibility are of the utmost importance.5. If extra space is required, attach additional pages to this application.6. Postal codes must be supplied for each address given.7. No information received from inquiries concerning information in this application will be released to the applicant.

LAST NAME GIVEN NAME MIDDLE NAME

FULL ADDRESS CITY PROVINCE POSTAL CODE

EMAIL ADDRESS TELEPHONE NO. (RES.) TELEPHONE NO. (BUS.) TELEPHONE NO. (OTHER)

[ ] [ ] [ ] DATE OF BIRTH

YYYY M M D D

NAME CHANGE FROM: NAME CHANGE TO: DATE OF CHANGE YYYY YYYY YYYY

PROVINCE CLASS(ES) LICENCE NUMBER DATE OF ISSUE YYYY M M D D

Personal information on this Employment Application is being collected under the authority of the Freedom of Information & Protection of Privacy Act (FOIPP) Section 33(c). It will be used to determine your suitability, eligibility or qualifications for employment. Questions about the use or collection of this information should be directed to the FOIP Program Administrator.

All of the items below must be submitted with your application:

Copy of High School Diploma

Certified copy of High School Transcript

Driving Record Abstract – last three years(Out of Province Applicants must supply their Provincial Equivalent)

Completed Personal Disclosure Form

Copy of Birth Certificate and/or Canadian Citizenship or Legal Permanent Resident documentation

Copy of Certificate of Standard First Aid – certified w ithin the last 36 m onths

Copy of Certificate in Cardiopulmonary Resuscitation (CPR) “Level B” – certified w ithin the last 12 m onths

Applicants w ithout Standard First Aid or CP R , should check w ith the individual police agency he/ she is applying to for additional inform ation on how to m eet this requirem ent…

Copy of A-PREP (Alberta- Physical Readiness Evaluation for Police Officer Applicants) results – certified within the last 6 months Attached Y et To Be Arranged with Agency

Post-Secondary Documents (if applicable)

Copy of Hearing Report

Copy of Vision Report

Pardon (if applicable)

Other than the name(s) listed above, please list any name change(s), or name(s) you may have used in the past.

LICENCE DRIVER’S

The Human Resources Unit is constantly reviewing recruiting initiatives across Canada. To assist us with our future planning, please indicate how you learned about this employment opportunity:

Career Fair Newspaper Radio/T.V. College Posting Police Officer Other

http://www.camrosepoliceservice.ca/

Circle highest grade com pleted

NAME OF SCHOOL LOCATION

HIGH SCHOOL DIPLOMA 10 11 12 13

NAME OF SCHOOL LOCATION

EQUIVALENCY DIPLOMA

PROGRAM OR COURSE START DATE FINISH DATE YYYY MM YYYY MM

LENGTH OF COURSE

GRADE POINT AVERAGE CERTIFICATE, DIPLOMA, OR LICENCE AWARDED? (I F N OT – P LEASE P R OVI DE DETAI LS)

YES NO NAME OF SCHOOL LOCATION


LENGTH OF COURSE

GRADE POINT AVERAGE CERTIFICATE, DIPLOMA, OR LICENCE AWARDED? (I F N OT – P LEASE P R OVI DE DETAI LS)


UNIVERSITY


MAJOR/MINOR

LENGTH OF COURSE

GRADE POINT AVERAGE CERTIFICATE, DIPLOMA, OR DEGREE AWARDED? (I F N OT – P LEASE P R OVI DE DETAI LS)


UNIVERSITY


MAJOR/MINOR

LENGTH OF COURSE



UNIVERSITY


MAJOR/MINOR

LENGTH OF COURSE


YES NO


MAJOR/MINOR

LENGTH OF COURSE


YES NO

LANGUAGES SPOKEN

LANGUAGES WRITTEN

EDUCATION AND TRAINING P roof of education w ill be required prior to engagem ent

SCHOOL HIGH

COLLEGE, BUSINESS SCHOOL, OR TECHNICAL

SCHOOL

COLLEGE, BUSINESS SCHOOL, OR TECHNICAL

SCHOOL

I. Q. A. S.

(I nternational Qualifications Assessm ent Standards – Certificate - if applicable) For I nternational applicants only – P lease state the highest level education achieved. NAME OF SCHOOL LOCATION

2

ADDITIONAL EDUCATION INCLUDING COURSES, WORKSHOPS, AND SEMINARS. (ATTACH AN ADDITIONAL PAPER IF NECESSARY)

ADDITIONAL COMPUTER SKILLS, TRAINING, COURSES, ETC … (ATTACH AN ADDITIONAL PAPER IF NECESSARY)

HAVE YOU EVER WRITTEN THE ACT (A LB ER TA COM M UN I CA TI ON TEST), THE CAAT (CAN ADI AN ADU LT ACHI EVEM EN T TEST), OR THE W C T (W R I TTEN COM M UN I CA TI ON TEST)? YES (if Y ES – W here & W hen) NO

HAVE YOU EVER WRITTEN THE APCAT (A LB ER TA P OLICE A P P LICA N T COGN ITIVE A B IL ITY TEST)? YES (if Y ES – W here & W hen) NO

HAVE YOU EVER APPLIED FOR A POSITION WITH THIS OR ANY OTHER POLICE AGENCY? YES (if Y ES – W here & W hen) NO

LIST ALL APPLICATIONS TO THIS OR ANY OTHER POLICE AGENCIES

POLICE AGENCY APPLICATION DATE

YYYY MM DD STATUS (describe reason for non-selection)

HAVE YOU EVER TAKEN A POLYGRAPH OR COMPUTER VOICE STRESS ANALYSIS EXAMINATION? YES NO

AGENCY WHERE POLYGRAPH OR COMPUTER VOICE STRESS ANALYSIS EXAMINATION WAS COMPLETED YYYY MM DD

REASON FOR POLYGRAPH OR COMPUTER VOICE STRESS ANALYSIS EXAMINATION

HAVE YOU EVER BEEN FINGERPRINTED? YES NO

REASON FOR FINGERPRINTING

3

EMPLOYER’S NAME TELEPHONE NUMBER

[ ] EMPLOYER’S ADDRESS POSTAL CODE

NAME OF IMMEDIATE SUPERVISOR TELEPHONE NUMBER

[ ] START DATE FINISH DATE POSITION HELD

YYYY MM YYYY MM

DUTIES/RESPONSIBILITIES

REASON FOR LEAVING





YYYY MM YYYY MM


REASON FOR LEAVING





YYYY MM YYYY MM


REASON FOR LEAVING

EMPLOYMENT HISTORY Begin with your most recent employer and continue in reverse time order.

Provide history for the last ten (10) years if applicable. Provide an explanation for all gaps in employment.

MOST RECENT

2nd

3rd

4





YYYY MM YYYY MM


REASON FOR LEAVING





YYYY MM YYYY MM


REASON FOR LEAVING

EMPLOYMENT HISTORY (Continued)

4th

5th

IF YOU WERE ASKED TO RESIGN, OR WERE FIRED FROM A JOB, OR HAD A GAP IN EMPLOYMENT, PLEASE PROVIDE DETAILS AND EXPLANATIONS.

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NAME GIVEN NAMES RELATIONSHIP

FULL ADDRESS POSTAL CODE

TELEPHONE NO. (RES.)

[ ]

TELEPHONE NO. (BUS.)

[ ]

OCCUPATION YEARS KNOWN




[ ]


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REFERENCES Please list five (5) adults, not related to you and not previous employers,

whom we may contact as references to provide competent judgment of your personal character, temperament, and work habits.

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NAME

MAIDEN NAME / OTHER NAMES USED

DATE OF BIRTH EMPLOYER’S NAME YYYY M M D D

CURRENT ADDRESS FROM TO YYYY MM DD YYYY MM DD

CITY PROVINCE COUNTRY POSTAL CODE

PREVIOUS ADDRESS FROM TO YYYY MM DD YYYY MM DD






PROVINCE CLASS(ES) LICENCE NUMBER DATE OF ISSUE YYYY M M D D

TYPE ISSUING INSTITUTION CURRENT BALANCE OWING EXPIRATION DATE YYYY M M




FILE MANAGER

DATE SENT (Fax) YYYY MM DD DATE RECEIVED (Fax) YYYY MM DD

CREDIT HISTORY Please complete the following information.

DRIVER’S LICENCE

CARDS CREDIT

2

3

4

OFFICE USE ONLY

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SECURITY CLEARANCE DECLARATION FILE MANAGER

O FFIC E U S E O N L Y

This page contains detailed information regarding you, your family, and associates. This information is required to determine your eligibility for employment. THIS INFORMATION WILL BE HELD IN STRICTEST CONFIDENCE. Please print legibly. Ensure that all sections are completed. Additional sheets should follow suggested format. LAST NAME FIRST NAME MIDDLE NAME PREFERRED FIRST NAME

MAIDEN / OTHER NAMES USED

FULL ADDRESS CITY PROVINCE POSTAL CODE TELEPHONE NUMBER

[ ] DATE OF BIRTH SEX PLACE OF BIRTH (INCLUDE CITY / COUNTRY BORN)

YYYY M M D D

Male Female

MARITAL STATUS

Single Married Common-law / Domestic Partner Separated Divorced

If you checked married, common-law or domestic partner, please give full name and date of birth of your partner.

SURNAME / MAIDEN NAME / OTHER NAMES USED FIRST NAME MIDDLE NAME DATE OF BIRTH YYYY M M D D

YOU MUST PROVIDE A PHOTOCOPY OF ONE OF THE FOLLOWING DOCUMENTS:

DRIVER’S LICENCE PASSPORT CITIZENSHIP

HAVE YOU APPLIED FOR EMPLOYMENT/CONTRACT WORK/VOLUNTEER WORK WITH ANY POLICE SERVICE IN THE PAST?

YES NO

POSITION APPLIED FOR DIVISION / SECTION

IN CHRONOLOGICAL ORDER, MOST RECENT FIRST, PLEASE PROVIDE THE ADDRESSES OF EVERY LOCATION WHERE YOU HAVE LIVED IN THE LAST 10 YEARS, AND THE NAMES OF PERSONS WHOM LIVED WITH YOU. PLEASE ESTIMATE THE AGE IF THE EXACT DATE(S) OF BIRTH CANNOT BE OBTAINED. USE NEXT PAGE OR ATTACH ADDITIONAL SHEETS IF REQUIRED.

ADDRESS CITY PROVINCE POSTAL CODE FROM TO YYYY M M D D YYYY M M D D

NAME OF PERSON(S) WHO SHARE ADDRESS WITH YOU TELEPHONE NUMBER

[ ]

TELEPHONE NUMBER

[ ]

TELEPHONE NUMBER

[ ]

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

DATE OF BIRTH YYYY M M D D




NAME OF PERSON(S) WHO SHARED ADDRESS WITH YOU TELEPHONE NUMBER

[ ]

TELEPHONE NUMBER

[ ]

TELEPHONE NUMBER

[ ]

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female




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TELEPHONE NUMBER

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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female






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TELEPHONE NUMBER

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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female






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TELEPHONE NUMBER

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TELEPHONE NUMBER

[ ]

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female






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TELEPHONE NUMBER

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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female






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TELEPHONE NUMBER

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TELEPHONE NUMBER

[ ]

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female




SECUR I TY CLEA R AN CE DECLAR ATI ON (Con tin ued)

Attach an additional sheet(s) if required – follow ing the suggested form at.

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[ ]

TELEPHONE NUMBER

[ ]

TELEPHONE NUMBER

[ ]

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female






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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

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TELEPHONE NUMBER

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RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

Male Female

RELATIONSHIP SEX

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TELEPHONE NUMBER

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TELEPHONE NUMBER

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RELATIONSHIP SEX

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RELATIONSHIP SEX

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SURNAME / MAIDEN NAME / OTHER NAMES USED FIRST NAME MIDDLE NAME COMMON NAME USED DATE OF BIRTH YYYY M M D D

RELATIONSHIP ADDRESS CITY PROVINCE POSTAL CODE TELEPHONE NUMBER

[ ] SURNAME / MAIDEN NAME / OTHER NAMES USED FIRST NAME MIDDLE NAME COMMON NAME USED DATE OF BIRTH

YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D


[ ]

FAMILY MEMBERS SECUR I TY CLEA R AN CE DECLAR ATI ON

(Con tin ued) Attach an additional sheet(s) if required – follow ing the suggested form at.

Applicants must list all names, relationship, sex, date of birth, address and phone number of the applicant’s immediate relatives AND of the immediate relatives of the current and/or former spouse, domestic partner, common-law, or significant other. Attach additional sheets if required.

Immediate relatives include parents, stepparents, guardians, current and/or former spouse, domestic partner, common-law, or significant other, as well as, children, stepchildren, adopted children, brothers, sisters, step-brothers/sisters, adopted brothers/sisters, who are age 12 or over. This includes individuals who are alive or deceased.

•

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SURNAME / MAIDEN NAME / OTHER NAMES USED FIRST NAME MIDDLE NAME COMMON NAME USED DATE OF BIRTH YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D



YYYY M M D D


[ ]

FAMILY MEMBERS SECUR I TY CLEA R AN CE DECLAR ATI ON

(Con tin ued) Attach an additional sheet(s) if required – follow ing the suggested form at.

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1. Have you ever been convicted of any criminal offence in Canada or in any other country forwhich a pardon, or the equivalent, of a pardon was or was not granted? (Attach Pardon Document)

YES NO

2. Are you now, or have you ever been investigated, arrested, or charged in Canada or in anyother country for an offence of any kind? If yes – explain on separate sheet.

YES NO

3. Have you ever been found guilty of an offence in Canada or in any other country when youwere under the age of 18? If yes – explain on separate sheet.

YES NO

4. Are you associated with any companies, or businesses, not listed on your application?

Owner Director Controlling Share Holder Other

YES NO

5. Are you a member of any clubs or organizations?

If yes – explain which

YES NO

6. If you answered yes to the previous question, do you hold a position in that club or organization?

President Chair Director Other _

YES NO

7. In the past 10 years, have you been involved in any lawsuits or civil actions? YES NO

If you have answered “YES” to any of the above questions, attach an additional sheet providing complete details regarding the specific incident, including what occurred, when, where, and why. If pardoned, attach Pardon documentation.

STATEMENT OF CONSENT

I HEREBY CONSENT THAT any and all information pertaining to a Criminal Record registered in my name with the National Repository for Criminal Records in Canada may be provided to authorized persons at the Camrose Police Service. I recognize that an employee of the Camrose Police is in a position of trust within the community and I hereby consent to the Camrose Police Service performing a VS (Vulnerable Sector) search of my name in the National Repository for Criminal Records. I understand that a VS search is a search that will check for pardoned sex offences. I further consent, if requested, to attend the Identification Section of the Camrose Police Service for fingerprint confirmation. I further agree to absolutely release, discharge, and absolve the Camrose Police Service, the City of Camrose and its employees from all claims, losses, or damages including indirect or consequential, occasioned by me during, or as a result of any investigation for a Criminal Record.

Dated this day of _, 20_ SIGNATURE

PRINTED NAME OF WITNESS WITNESS SIGNATURE



13

REPORTAlberta VISION

Examination MUST have been completed within 12 months of application.

NAME OF APPLICANT SURNAME GIVEN NAMES INITIAL

ADDRESS OF APPLICANT

CITY PROVINCE POSTAL CODE DATE OF BIRTH YYYY M M D D

VISION STANDARDS FOR POLICE OFFICER APPLICANTS

OPTOMETRIST / OPHTHALMOLOGIST

NAME OF OPTOMETRIST/OPHTHALMOLOGIST DATE OF EXAMINATION YYYY M M D D

ADDRESS OF OPTOMETRIST / OPHTHALMOLOGIST

TELEPHONE NUMBER

[ ]

UNCORRECTED VISUAL ACUITY – NORMAL

At least 20/40 (6/12) with both eyes open

APPLICANT STANDARD

YES NO

FARSIGHTEDNESS – NORMAL Not greater than +2.00 D, spheroequivalent in the least hyperopic eye

APPLICANT STANDARD

YES NO

BEST CORRECTED VISUAL ACUITY – NORMAL

At least 20/20 (6/6) with both eyes open

APPLICANT STANDARD

YES NO

COLOUR VISION – NORMAL Pass Ishihara (Book or Titmus) without any colour corrective (e.g. X-Chrom, Chromagen) lenses

APPLICANT STANDARD

YES NO

NOTE: Farnsworth Vision Test – is recommended for unsuccessful Ishihara Tests APPLICANT STANDARD

YES NOPass Farnsworth D-15 without any colour corrective (e.g. X-Chrom, Chromagen) lenses

DEPTH PERCEPTION – NORMAL Stereo acuity of 80 seconds of arc or better

APPLICANT STANDARD

YES NO

LATERAL PHORIA FAR – NORMAL No more than 5 eso or 5 exo

APPLICANT STANDARD

YES NO

If No – please provide additional information, which documents that the person is unlikely to experience double vision when fatigued or functioning in reduced visual environments…

LATERAL PHORIA NEAR – NORMAL No more than 6 eso or 10 exo

APPLICANT STANDARD

YES NO

If No – please provide additional information, which documents that the person is unlikely to experience double vision when fatigued or functioning in reduced visual environments…

14

PERIPHERAL VISION Peripheral visual field limits with a 5 mm white target at 33cm (or a target with similar angular size with respect to the candidate’s viewing distance) should be no less than the limits given below. In addition, no blind spots should be present within these limits other than the physiological blind spot. Limits for the various meridians are:

• Temporal (0º meridian) 75º • Nasal (180º meridian) 45º• Superior-temporal (45º meridian) 40º • Nasal-inferior (225º meridian) 35º• Superior (90º meridian) 35º • Inferior (270º meridian) 55º• Superior-nasal (135º meridian) 35º • Inferior-temporal (315º meridian) 70º

APPLICANT STANDARD

YES NO

OCULAR DISEASE – NORMAL Free from diseases that impair visual performance as indicated by the standards above, or will produce sudden, unpredictable incapacitation of the visual system.

APPLICANT STANDARD

YES NO

CORRECTIVE SURGERY HAVE YOU EVER HAD CORRECTIVE SURGERY? YES NO

PROCEDURE TYPE – Please indicate which procedure from the list below… DATE OF PROCEDURE

YYYY M M D D

Corneal Refractive Allowed; however, the candidate must meet additional requirements and must provide specific Surgery documentation on vision stability and night vision using Recruit Selection Standards approved

forms available through any Alberta Municipal Police Service, or from the Manager of First Nations Policing for the Alberta Solicitor General and Public Security.

Pseudophakic Intra-Ocular Allowed; however, the candidate must meet additional requirements and must provide specificLenses documentation on Alberta Police Recruit Selection Standards approved forms…

Phakic Intra-Ocular Lens Certain designs are allowed; however, the candidate must meet additional requirements and Implants (Piol) must provide specific documentation on vision stability and night vision using the Alberta Police

Recruit Selection Standards approved forms…

Orthokeratology, Corneal Not allowed.Transplants, and Intra-Stromalcorneal Rings

NIGHT VISION – Only required if an Applicant had Corrective Surgery Obtain minimum scores on at least 2 of the 3 following tests (all testing is done binocularly with, or without, any spectacle or contact lens correction):

1. Bailey-Lovie Low Contrast Acuity in Room Illumination: minimum acuity of 0.20logMAR

2. Bailey-Lovie High Contrast Acuity in Dim Illumination: minimum acuity of 0.30logMAR

3. Bailey-Lovie Low Contrast Acuity in Dim Illumination: minimum acuity of 0.58logMAR

APPLICANT STANDARD

YES NO

SIGNATURE OF DOCTOR DATE YYYY M M D D

SIGNATURE OF APPLICANT DATE YYYY M M D D

Note: All vision test results will be verified by a Pre-Employment Occupational Health and Safety Medical prior to employment.

15

REPORTAlberta HEARING

Examination MUST have been completed within 12 months of application.




HEARING STANDARDS FOR POLICE OFFICER APPLICANTS

AUDIOLOGIST / OTOLARYNGOLOGIST

NAME OF AUDIOLOGIST/OTOLARYNGOLOGIST: DATE OF EXAMINATION

YYYY M M D D

ADDRESS OF AUDIOLOGIST/OTOLARYNGOLOGIST:

TELEPHONE NUMBER

[ ]

PURE TONE THRESHOLDS

IN HL 500 1000 2000 3000 4000

RIGHT EAR

LEFT EAR

PLACE A LARGE “X” IN THE APPROPRIATE BOX

I certify that the above named individual Meets Does Not Meet the hearing requirements for a Police Officer applicant as indicated in Unaided Criteria .

SIGNATURE OF TECHNICIAN/NURSE/DOCTOR DATE YYYY M M D D

SIGNATURE OF APPLICANT DATE YYYY M M D D

Note: All hearing test results will be verified by a Pre-Employment Occupational Health and Safety Medical prior to employment.

16

ALBERTA POLICE RECRUIT SELECTION STANDARDS SUPPLEMENTARY HEARING INFORMATION FOR AUDIOLOGISTS

The auditory requirements of a police constable’s routine duties are such that the constable’s life may depend on the ability to hear, localize and understand a variety of environmental and speech sounds, including soft sounds. The constable should hear well enough to avoid undue risk to bystanders and to herself/himself and to protect the public from harm

The hearing requirements of the Alberta Police Recruit Selection Standards were developed based on task and job analysis and an expert opinion. The standard is based on the recognition that, for the police constable, hearing acuity, word discrimination and sound localization are important dimensions of hearing competency required to perform job- related tasks safely and effectively.

Alberta Police Recruit Selection Standards – Hearing Standards Unaided Criteria I

Pure-tone threshold measured under audiometric earphones shall not exceed 25dB HL in each ear at the following frequencies: 500, 1000, 2000, 3000 and 4000 Hz.

Unaided Criteria II

For each ear, pure-tone thresholds measured under audiometric earphones shall not exceed a four-frequency average (500, 1000, 2000, 3000 Hz) of 25dB HL, thresholds at none of these single frequencies shall exceed 35 dB HL and thresholds at 4000 Hz shall not exceed 45 dB HL. In addition, speech recognition scores shall be 88% or better in each ear at 50dB HL in quiet, using half lists (25 test words) of recorded monosyllabic words presented under standard audiometric earphones. The lists of Northwestern University Test No. 6 are to be used for word discrimination testing, to achieve consistency across test sites. Furthermore, speech recognition scores measured with both ears open in sound field shall be 68% or better at a 5+ signal-to-noise (S/N) ration, when a half-list (25 test words) of recorded monosyllabic words is presented at 50 dB HL. For measurement, both the word list and competing speech noise shall be presented at 0° azimuth (i.e. from one speaker located directly in front of the candidate).

Unaided Criteria IA

Pure-tone thresholds measured under audiometric earphones shall not exceed 40 dB HL in each ear at the following frequencies: 500, 1000, 2000, 3000; and shall not exceed 55 dB HL at 4000 Hz.

If the standards are met the applicant can proceed to Aided Criteria with a Completely in Canal (CIC) hearingaid.

If the application does not meet hearing standards, accommodation with a CIC is not allowed.

Aided Criteria

NOTE: Individual assessments by an audiologist are recommended for candidates with any type of hearing aid, who then must decide whether the candidate is able to perform within the CSS Hearing Performance Standard criteria established for the sound field.

For each ear, narrow-band or warbled-tone thresholds measured in a calibrated sound field at 0° azimuth shall not exceed a four-frequency average (500, 1000, 2000 and 3000 Hz) of 25 dB HL; thresholds at none of these single frequencies shall exceed 35 dB HL, and threshold at 4000 Hz shall not exceed 45 dB HL. Measurements shall be made monaurally in an audiometric sound field with the aided (non-test) ear plugged or, when necessary, effectively masked. (Measurements of aided threshold may also be expressed as real-ear aided response, using probe- microphone measurements with sound pressure levels appropriately converted to hearing levels). In addition, speech recognition scores in sound field shall be 88% or higher in each aided ear (with the non-test ear plugged or appropriately masked) using half-lists (25 words) or recorded, monosyllabic words (Northwestern University NU-6 lists) presented at 50 dB HL in quiet at 0° azimuth. Furthermore, monaurally or binaurally aided speech recognition scores measured in sound field shall be 68% or higher at a +5 dB S/N ration, when NU-6 half lists are presented at 50 dB HL. Both the word list and competing speech noise shall be presented at 0° azimuth. Hearing aids worn shall be adjusted to those settings used in the “Hearing Acuity” portion of this criterion.

17

ALBERTA POLICE RECRUIT SELECTION STANDARDS

AUTHORIZATION FOR RELEASE OF INFORMATION




I, , the undersigned, hereby authorize any person, employer, organization, or physician to provide any information, opinion, reports, records, documents or copies thereof in any form, which may be requested in connection with my application for employment with the Camrose Police Service and any subsequent training.

Personal information about me will be used to assess my qualifications and suitability in relation to my application as a police officer as well as research purposes. I consent to the collection, use, disclosure, transmittal, and examination of all information compiled by the Camrose Police Service.

Personal information about me that is obtained during the selection process, or any subsequent training and employment, may be disclosed to any law enforcement agency for the purpose for which it was obtained or for any other reason.

I agree to waive any right of action against any person or organization providing information or opinions in compliance with this authorization.

I hereby acknowledge and declare the terms of this authorization for release of information are fully understood by me.

SIGNATURES SIGNATURE OF APPLICANT: DATE:

YYYY M M D D

NAME OF WITNESS: SIGNATURE OF WITNESS: DATE:

YYYY M M D D

NOTE: The Witness must be 18 years or older

18


Computer Volice Stress Anlaysis (CVSA)

EXAMINATION CONSENT




I, , the undersigned, hereby voluntarily, without threats, promises of immunity or reward and without duress, coercion of force, agree to take a truth

vertification examination (i.e., CVSA), to be given to me by a Member of Camrose Police Service.

I fully realize I am not obligated to say anything and that anything I say may be given in evidence.

SIGNATURES SIGNATURE OF APPLICANT: DATE:

YYYY M M D D

NAME OF WITNESS: SIGNATURE OF WITNESS: DATE:

YYYY M M D D

NOTE: The Witness must be 18 years or older

19

Alberta Police Recruit Selection Standards

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20

Alberta AA--PPRREEPP

Participant Information Form

In preparation for taking part in the A-PREP, please follow these instructions:

1. Complete the attached PAR-Q form which identifies the presence of medical conditions that could pose a riskduring exercise.• If you are over 40 years of age AND not accustomed to regular strenuous (vigorous) exercise OR

If you answer “Yes” to any of the PAR-Q questions, you must be cleared by a physician using thePARmed-X and Medical Physician Clearance Forms before taking part in the A-PREP.

• Take the PARmed-X and Medical Physician Clearance Form to the physician so that the physician is awareof what you will be doing when performing the A-PREP and that you may be required to run more than 7 stages of the Leger Shuttle Run. Bring your completed PARmed-X and Medical Physician Clearance form with you on the day of testing.

Note: If untruthful or misleading answers are given, the applicant may be found unsuitable for employment, or ifaccepted for employment, could be subsequently dismissed.

2. Applicants who possess two or more of the following major coronary risk factors MUST receive a physician’sclearance (PARmed-X and Medical Physician Clearance) before participating in the A-PREP; family history of a heartattack or sudden death before 55 years of age; currently smoke cigarettes; have high blood pressure, havediabetes mellitus; have high blood cholesterol or are in a sedentary occupation and are physically inactive.

3. Complete the Informed Consent and the Declaration documents which provide information about the A-PREPtest and any risks associated with participation.

4.

In preparation for testing, be aware of the following:

• Proper Attire: You will attend the testing facility in proper business attire; no casual business attire will beaccepted.

• Smoking: Do not smoke for two hours prior to the test.

• Food & Beverages: Do not eat a heavy meal during the two hours prior to the test and refrain from drinkingcaffeine or alcoholic beverages at least two hours prior to the test. It is recommended that you eat a lightbalanced meal approximately 45 minutes to 1 hour before testing.

• Exercise: Do not exercise vigorously in the 24 hours prior to the test.

GOVERNMENT ISSUED PHOTO IDENTIFICATION IS REQUIRED WHEN YOU SHOW UP FOR THE TEST.

Please complete pages 22 - 30. Send copies of these pages with your application package. Retain the original documents and bring them with you to the A-PREP test.

You may schedule your A-PREP test with one of the testing centers once your application has been submitted and accepted. The following agencies have A-PREP testing equipment: Edmonton Police Service, Calgary Police Service, Lethbridge Regional Police Service and Medicine Hat Police Service. Due to their size, Edmonton and Calgary test on a regular basis.

21

5.

Arrive at the test site at least 15 minutes prior to your test appointment time to allow your blood pressure tonormalize. LATE ARRIVALS MAY NOT BE TESTED!

The Camrose Police Service has high standards with respect to behavior and deportment. Your conduct and ability to encourage teamwork will be monitored. Failure to comply with these standards may affect your competitiveness. Put forth a full effort in all activities.

Equipment: It is recommended that you bring a water bottle with you.

Exercise Attire: You will change into exercise attire at the testing venue. Bring running shoes, T-shirt andshorts, or appropriate fitness pants, with you to conduct the test. No baggy/dragging pants, hats or tank topswill be permitted during the testing for safety purposes. Further to this, no “short shorts”, tattered clothing orclothing with offensive wording/logos will be accepted.

•

•


AAPPPPLLIICCAANNTT CCOONNSSEENNTT FFOORR AA--PPRREEPP TTEESSTTIINNGG AANNDD RREELLEEAASSEE OOFF IINNFFOORRMMAATTIIOONN

I, the undersigned, do hereby acknowledge:

1. My consent to perform an aerobic shuttle run and a simulated foot pursuit which consists ofrunning 100 m (328 ft) while climbing stairs, climbing a 1.52 m (5 ft) fence, engaging in a“resistor control” simulation with a weight machine, performing an “arm restraint” simulationwith a weight machine and dragging a 68 kg (150 lb) “victim” 15m (50 ft);

2. My consent to the tests being supervised by a qualified fitness appraiser who has beentrained to administer these fitness assessment protocols;

3. My understanding that I may ask questions or request further information or explanationabout the tests;

4. My understanding that there exists the possibility of certain changes occurring during andafter my performance of the fitness tests including abnormal blood pressure, fainting,transient light-headedness, leg cramps, muscle strains, nausea, and, in rare instances, heartattacks, or heart rhythm disturbances;

5. My obligation to immediately inform the fitness appraiser of any unusual pain, discomfort,fatigue or any other symptoms that I incur during or after the testing;

6. My understanding that I may stop any further testing if I so desire and also that the testingmay be terminated by the fitness appraiser;

7. That if I am over 40 years of age AND not accustomed to regular strenuous/vigorousexercise, I have been cleared for participation in the fitness testing by a Certified ExercisePhysiologist or by my physician who completed the clearance form from the PARmed-X forthat purpose;

8. That I do not have two or more of the following major coronary risk factors, or if I do, I havereceived medical clearance (PARmed-X) before reporting to participate in the A-PREP: familyhistory of a heart attack or sudden death before 55 years of age; currently smoke cigarettes;have high blood pressure, have diabetes mellitus; have high blood cholesterol or work in asedentary occupation and am physically inactive;

That I have read, understood and completed the Physical Activity Readiness Questionnaire (PAR-Q) and my answers to all questions were “No”, or if I answered “Yes” to any question, I was subsequently cleared for participation in the fitness testing by a Certified Exercise Physiologist or by my physician who completed the clearance form from the PARmed-X for that purpose

22


AAPPPPLLIICCAANNTT CCOONNSSEENNTT FFOORR AA--PPRREEPP TTEESSTTIINNGG AANNDD RREELLEEAASSEE OOFF IINNFFOORRMMAATTIIOONN

PPaaggee 22 ooff 22

RELEASE OF INFORMATION:

I, the undersigned, have been informed about the tests and standards employed in the assessment of fitness, and direct that the information determined during my assessment on these standards is to be provided to the ___________________ Police Service, and all or any oftheir respective servants, agents and employees, for consideration in the evaluation of my application for employment as a police officer.

RELEASE AND INDEMNITY:

I, the undersigned, in consideration of my being given the opportunity to participate in the Alberta Police Recruit Selection process, do hereby release, indemnify and forever discharge the ___________________ Police Service, the Alberta Association of Chiefs of Police(AACP), the Alberta Solicitor General and Public Security , Her Majesty the Queen in Right of Alberta and all of their respective servants, agents and employees, from any and all actions, cause of action, claims, demands, prosecutions and remedies for any and all damages, losses, injuries, and expenses of any nature or kind howsoever arising out of the vision, hearing, and fitness testing engaged in by myself as part of the aforesaid police constable applicant selection process.

And for the aforesaid consideration I further agree not to make any claim or to take any proceedings against any other person or corporation who might claim contribution or indemnity from Her Majesty, the AACP, the ___________________ Police Service and all of theirrespective servants, agents and employees, or from any one or more of them. And for the aforesaid consideration I further agree that this Release and Indemnity shall apply to and be binding on my heirs, administrators, executors and assigns and each of them.

Name of Participant (Please Print) Signature of Participant Date

Name of Witness (Please Print) Signature of Witness Date

© Queen's Printer for Alberta, 2009 Confidential

23


AA--PPRREEPP PPeerrffoorrmmaannccee DDeeccllaarraatt iioonn

TTOO BBEE CCOOMMPPLLEETTEEDD BBYY CCAANNDDIIDDAATTEE::

Surname: (please print) Given Names: (please print) Identification Number:

Address: (Town/City only)

Are there any factors which you feel may affect your ability to perform the A-PREP today?

Please check one: ‘‘‘‘ NO ‘‘‘‘ YES – If YES, please provide explanation on the lines below:

I am aware that the information provided above will be reviewed by the person conducting the A-PREP and/or by an authorized representative of any Alberta municipal police service to which I apply, and/or by an authorized representative of the Alberta Association of Chiefs of Police (AACP) and/or by an authorized representative of the Alberta Solicitor General and Public Security. My signature, below, acknowledges that I understand, and consent to, this disclosure and use of information:

Signature of Participant Date

TToo bbee ccoommpplleetteedd bbyy ccaannddiiddaattee aanndd aapppprraaiisseerr ii ff ccaannddiiddaattee hhaass rreessppoonnddeedd ““ yyeess”” aabboovvee::

‘‘‘‘ After discussing my circumstances, outlined above, with the Appraiser, I have decided to continue with the A-PREP testing today. I have made this decision freely and voluntarily, after being informed that I may participate in the testing on another date, at my option, without penalty or adverse consequence. I understand that the results of the testing which will be performed today will become part of my application file and will be available to the AACP, the AACP – licensed assessment agency and/or all police agencies to which I apply.

‘‘‘‘ After discussing my circumstances with the Appraiser, I choose not to participate in the A-PREP today.

Name of Participant (Please Print) Signature of Participant Date

Name of Appraiser (Please Print) Signature of Appraiser Date

NNOOTTEE TTOO CCAANNDDIIDDAATTEESS:: IIff aannyy ffaaccttoorrss aarriissee dduurriinngg yyoouurr ppeerrffoorrmmaannccee ooff tthhee AA--PPRREEPP tthhaatt mmaayy aaffffeecctt yyoouurr ppeerrffoorrmmaannccee,, pplleeaassee aaddvviissee aann AApppprraaiisseerr iimmmmeeddiiaatteellyy.. PPeerrssoonnaall iinnffoorrmmaattiioonn iiss ccoolllleecctteedd ffoorr tthhee ppuurrppoossee ooff aasssseessssiinngg qquuaalliiffiiccaattiioonnss aanndd ssuuiittaabbiilliittyy aass aa ppoolliiccee ooffffiicceerr.. QQuueessttiioonnss ccoonncceerrnniinngg ccoolllleeccttiioonn oorr ddiisscclloossuurree ooff tthhiiss iinnffoorrmmaattiioonn sshhoouulldd bbee aaddddrreesssseedd ttoo tthhee AAllbbeerrttaa AAssssoocciiaattiioonn ooff CChhiieeffss ooff PPoolliiccee..

© Queen's Printer for Alberta, 2009

24

The Physical Activity Readiness Questionnaire for EveryoneThe health bene�ts of regular physical activity are clear; more people should engage in physicalactivity every day of the week. Participating in physical activity is very safe for MOST people. Thisquestionnaire will tell you whether it is necessary for you to seek further advice from your doctorOR a quali�ed exercise professional before becoming more physically active.

YES NOPlease read the 7 questions below carefully and answer each one honestly: check YES or NO.

1) Has your doctor ever said that you have a heart condition OR high blood pressure ?

4) Have you ever been diagnosed with another chronic medical condition (other than heart diseaseor high blood pressure)? PLEASE LIST CONDITION(S) HERE:

5) Are you currently taking prescribed medications for a chronic medical condition?

7) Has your doctor ever said that you should only do medically supervised physical activity?

2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you dophysical activity?

3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue(muscle, ligament, or tendon) problem that could be made worse by becoming more physicallyactive? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. PLEASE LIST CONDITION(S) HERE:

GENERAL HEALTH QUESTIONS

If you answered NO to all of the questions above, you are cleared for physical activity.Go to Page 4 to sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.

Delay becoming more active if:You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

You are pregnant - talk to your health care practitioner, your physician, a quali�ed exercise professional, and/orcomplete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a quali�ed exercise professional before continuing with any physical activity program.

Copyright © 2015 PAR-Q+ Collaboration01-01-2015

PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:

Start becoming much more physically active – start slowly and build up gradually.

Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/).

You may take part in a health and �tness appraisal.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e�ort exercise, consult a quali�ed exercise professional before engaging in this intensity of exercise.

If you have any further questions, contact a quali�ed exercise professional.

2015 PAR-Q+

25

1. Do you have Arthritis, Osteoporosis, or Back Problems?

1a. Do you have di�culty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

If the above condition(s) is/are present, answer questions 1a-1c If NO go to question 2

2. Do you have Cancer of any kind?If the above condition(s) is/are present, answer questions 2a-2b

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart RhythmIf the above condition(s) is/are present, answer questions 3a-3d

If the above condition(s) is/are present, answer questions 5a-5e

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

If NO go to question 3



4. Do you have High Blood Pressure?If the above condition(s) is/are present, answer questions 4a-4b


4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?(Answer YES if you do not know your resting blood pressure)


2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer ofplasma cells), head, and neck?

2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?


3b. Do you have an irregular heart beat that requires medical management?(e.g., atrial �brillation, premature ventricular contraction)

3c. Do you have chronic heart failure?

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

5a. Do you often have di�culty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?

5b. Do you often su�er from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability,abnormal sweating, dizziness or light-headedness, mental confusion, di�culty speaking, weakness, or sleepiness.

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications a�ecting your eyes, kidneys, OR the sensation in your toes and feet?

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, orliver problems)?

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

2015 PAR-Q+YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

FOLLOW-UP QUESTIONS ABOUT YOUR MEDICAL CONDITION(S)

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Copyright © 2015 PAR-Q+ Collaboration

01-01-201526

If the above condition(s) is/are present, answer questions 7a-7d

If the above condition(s) is/are present, answer questions 8a-8c

If the above condition(s) is/are present, answer questions 9a-9c

If you have other medical conditions, answer questions 10a-10c




If NO read the Page 4 recommendations

2015 PAR-Q+

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO


GO to Page 4 for recommendations about your current medical condition(s) and sign the PARTICIPANT DECLARATION.

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary HighBlood Pressure


7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia


8b. Do you commonly exhibit low resting blood pressure signi�cant enough to cause dizziness, light-headedness, and/or fainting?

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysre�exia)?

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event


9b. Do you have any impairment in walking or mobility?

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12months OR have you had a diagnosed concussion within the last 12 months?

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

10c. Do you currently live with two or more medical conditions?

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

01-01-2015

6. Do you have any Mental Health Problems or Learning Di�culties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome

If the above condition(s) is/are present, answer questions 6a-6b If NO go to question 7


6b. Do you ALSO have back problems a�ecting nerves or muscles?

YES NO

YES NO

27

2015 PAR-Q+

PARTICIPANT DECLARATION

NAME ____________________________________________________

SIGNATURE ________________________________________________

SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ____________________________________________________________________

DATE _________________________________________

WITNESS ______________________________________


For more information, please contact

Key References

www.eparmedx.comEmail: [email protected]

1. Jamnik VK, Warburton DER, Makarski J, McKenzie DC, Shephard RJ, Stone J, and Gledhill N. Enhancing the e�ectiveness of clearance for physical activity participation; background and overall process. APNM 36(S1):S3-S13, 2011.2. Warburton DER, Gledhill N, Jamnik VK, Bredin SSD, McKenzie DC, Stone J, Charlesworth S, and Shephard RJ. Evidence-based risk assessment and recommendations for physical activity clearance; Consensus Document. APNM36(S1):S266-s298, 2011.

Citation for PAR-Q+Warburton DER, Jamnik VK, Bredin SSD, and Gledhill N on behalf of the PAR-Q+ Collaboration.The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) and Electronic Physical ActivityReadiness Medical Examination (ePARmed-X+). Health & Fitness Journal of Canada 4(2):3-23, 2011.

If you answered NO to all of the follow-up questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

If you answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging in a �tness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a quali�ed exercise professional to work through the ePARmed-X+ and for further information.

It is advised that you consult a quali�ed exercise professional to help you develop a safe and e�ective physical activity plan to meet your health needs.

You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.

As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.

If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal e�ort exercise, consult a quali�ed exercise professional before engaging in this intensity of exercise.

All persons who have completed the PAR-Q+ please read and sign the declaration below.

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/�tness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that the Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best to wait until you feel better.

You are pregnant - talk to your health care practitioner, your physician, a quali�ed exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.

Your health changes - talk to your doctor or quali�ed exercise professional before continuing with any physical activity program.

You are encouraged to photocopy the PAR-Q+. You must use the entire questionnaire and NO changes are permitted.The authors, the PAR-Q+ Collaboration, partner organizations, and their agents assume no liability for persons who undertake physical activity and/or make use of the PAR-Q+ or ePARmed-X+. If in doubt after completing the questionnaire, consult your doctor prior to physical activity.

The PAR-Q+ was created using the evidence-based AGREE process (1) by the PAR-Q+ Collaboration chaired by Dr. Darren E. R. Warburton with Dr. Norman Gledhill, Dr. Veronica Jamnik, and Dr. Donald C. McKenzie (2). Production of this document has been made possible through �nancial contributions from the Public Health Agency of Canada and the BC Ministry of Health Services. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada or the BC Ministry of Health Services.

01-01-201528


A-PREP (Alberta – Physical Readiness Evaluation for Police)

MEDICAL PHYSICIAN CLEARANCE FORM



DATE OF BIRTH CITY PROVINCE POSTAL CODE YYYY M M D D

Dear Doctor

The Applicant who has made this appointment with you has applied for employment with the __________________________Police Service. As a prerequisite, Applicant must demonstrate a minimum level of physical ability/fitness. This is to be accomplished by successfully completing a test called the Alberta – Physical Readiness Evaluation for Police (A-PREP).

The A-PREP is designed to simulate a critical incident where a police officer chases, controls, and restrains a suspect. The test was developed by exercise scientists and is based on extensive research, including a thorough job analysis. The first component of the A-PREP is a circuit type test where the Applicant performs a simulated foot pursuit. During this circuit, the Applicant must run 100 m. (328 ft) while climbing 4 sets of stairs, and climb a 1.52 m (5 ft) fence twice. The Applicant must then engage in a “resister control” simulation with a weight machine by pulling and then pushing a 34 kg. (75 lb.) weight. The Applicant then performs an “arm restraint” simulation with a weight machine. The arm restraint requires gripping two handles and depressing the grips, then bring two arms together. It requires 14.5 kg. (32 lb.) of force to depress each grip and 16 kg. (35 lb.) of force to retract each arm. Finally, the Applicant must drag a 68 kg. (150 lb.) “victim” 15 m (50 ft). The Applicant is allowed a maximum of 2 minutes and 10 seconds to complete this phase of the A-PREP. An applicant who fails any one of the circuit components fails the overall test.

Following the A-PREP evaluation, the Applicant is required to engage in the Leger 20 Metre Aerobic Shuttle Run, which provides an evaluation of aerobic fitness. The Leger 20 Metre Aerobic Shuttle Run was selected to assess aerobic fitness because of the documented reliability of the test and the validity of the test compared with directly measured VO2max values. A warm-up is included within the test and only the last portion of the test may require maximal effort. The objective is to follow the progressively faster pace back and forth over a 20 metre course. If the Applicant completes stage 7.0, the Applicant will receive a “Meets Standard” rating. The CD instructions will be stopped at stage 7.0. To minimize the health risk, we are requesting this medical examination to determine whether the Applicant is healthy enough to undertake both components of the A-PREP.

29

Blood Pressure recorded by physician: mmHG.

To minimize the health risk, we are requesting this medical examination to determine whether the Applicant is healthy enough to undertake the A-PREP

I certify that the above named individual �� Is

�� Is Nothealthy enough to take the A-PREP.

DATE OF EXAMINATION EXAMINING PHYSICIAN

NAME OF PHYSICIAN:

YYYY M M D D

ADDRESS OF PHYSICIAN: TELEPHONE NUMBER

[ ]

SIGNATURE OF PHYSICIAN: SIGNATURE OF APPLICANT:

Examining Ph ysician’s Office Stamp:

30