Applicant Scheduling | Public Safety Medical

Name of Department *

Name of Person Making Request *

Is this your first appointment this year? *

Yes

No

Have you used Public Safety Medical in the past?

Yes

No

How many employees do you have in your Department? *

How did you hear about us? *

Used your services in the past

Indiana Fire Chiefs Association

Indiana Association of Chiefs of Police

Referred by another Fire or Law Enforcement Agency

E-mail communication from Public Safety Medical

Special Event

OtherOther

Please Provide your Department's Mailing Address *

Title of Person Making Request *

Direct Phone Number of Person Making Request *

E-mail of Person Making Request *

Name of Chief of Department *

Direct Phone Number of Chief of Department *

E-mail of Chief of Department *

Do You Want the Applicant(s) to Pay for Any Portion of the Evaluation? *

Yes

No

Please Indicate Your Preference on What the Applicant(s) Should Pay. *

50% of Medical and Psychological Evaluation

50% of Medical Evaluation Only

50% of Psychological Evaluation Only

OtherOther

Your Applicant Results are sent to you via secure e-mail. Please contact Jane with questions at 317.964.2353.

Who Should Receive the Results? (check all that apply) *

"Person Making Request" above

The Chief Named Above

Someone Else other than the applicant

Direct Phone Number of Chief (if not already provided)

Name to Whom Results should be Sent *

Title of Results Contact *

E-mail of Results Contact *

Direct Phone Number of Results Contact *

Invoices Should Be Sent To:

Name to Send Invoice To: *

Title *

E-mail *

Phone *

Do You Require a Purchase Order? *

Yes

No

Please attached PO if Possible

Maximum upload size: 2MB

Billing Preference *

E-mail scan

Regular mail (snail mail)

Mailing Address *

Is this the Same Person who will be Paying the Bill? *

Yes

No

Payables Contact Person *

Payables Contact Phone Number *

Payables Contact E-mail Address *

Number of Applicants to be Scheduled (up to 5)

If more than 5 applicants, please call Alexis in Special Services at 317.964.2339.

Enter Number of Applicants You are Scheduling *

Choose from drop-down list

Position that Applicant(s) are Applying For *

Choose from drop down list

Please List "Other" Position

Results will be prepared within 12 business days of the appointment.

If applicable, has a Conditional Offer of Employment Been Made to the Applicant(s)? *

Yes

No

Not applicable

Please Provide Date that a Conditional Offer will be Made. *

Please Indicate When you need the Appointment (please ensure the date you select is at least 12 BUSINESS DAYS from your pension board meeting to review results) *

First Available Date

A Specific Date

Click in Box Below to Select a Specific Date on the Calendar *

Please Indicate Type of Evaluation.

What Type of Applicant Evaluation Do You Need? *

Indiana PERF (1977 Police Officers’ and Firefighters’ Pension Fund)

Ohio Police & Fire Pension Fund

Another Pension Fund

Non-Pension Fund

Are these Applicants Transferring from Another Department? *

Yes

No

Some are and some are not

Please Indicate How Many are Transferring and How Many are Not Transferring in the Space Below. *

Will Any of these Applicants be Volunteers? *

Yes

No

Please provide the name of the Pension Fund

All services are performed in one location in one day.

Which of the Following Do You Want Performed? *

Medical and Psychological Evaluation

Psychological Evaluation Only

Medical Evaluation Only

Please Select (or type in) Any Additional Testing that You Would Like Performed. (All Applicant Testing for Departments not on a Pension will be Based Upon Indiana's 1977 Fund Testing Requirements.)

Treadmill Stress Test

Hepatitis B Titer

Muscular Fitness Evaluation

OtherOther

What is your anticipated hire date? *

Has your pension board meeting been scheduled?

Yes

No

When is Your Pension Board Meeting to Review Test Results?
Please be sure that the Pension Board Meeting date entered above is at least 12 business days from the date requested for the evaluation(s). *

Please Attach any Relevant Documents (under File Upload Below) or Provide Other Notes.

File Upload

Maximum upload size: 20MB

Applicant(s) can only pay by credit or debit card (if applicable).

Please Provide the Following Information on Each Applicant.

Applicant #1 Name *

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #1 Date of Birth *

Enter as MM/DD/YYYY

Applicant #1 Gender

Male

Female

Applicant #1 Please Type in any Dates the Applicant WILL be Available for Scheduling *

Applicant #2 Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #2 Date of Birth *

Enter as MM/DD/YYYY

Applicant #2 Gender

Male

Female

Applicant #2 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #3 Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #3 Date of Birth *

Enter as MM/DD/YYYY

Applicant #3 Gender

Male

Female

Applicant #3 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #4 Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #4 Date of Birth *

Enter as MM/DD/YYYY

Applicant #4 Gender

Male

Female

Applicant #4 Please Type in any Dates the Applicant WILL be Available for Scheduling

Applicant #5 Name

Enter First Name, Middle Initial, Last Name (if Unknown, type "Unknown")

Applicant #5 Date of Birth *

Enter MM/DD/YYYY

Applicant #5 Gender

Male

Female

Applicant #5 Please Type in any Dates the Applicant WILL be Available for Scheduling

Do You Currently Provide Annual Physical Exams to Your Personnel?

Yes

No

Would You Be Interested in Being Contacted By Public Safety Medical to Learn About our Annual Physical Exam Process?

Yes

No

If this Form was Completed by a PSM Employee, Please Enter Your E-mail.

PLEASE CLICK "SUBMIT" AT BOTTOM OF SCREEN

STOP: PSM USE ONLY

PSM USE ONLY

Notes:

reCAPTCHA