Large Applicant Class Scheduling | Public Safety Medical

Name of Department *

Name of Person Making Request *

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 (unless provided above)

E-mail of Chief of Department (unless provided above)

Phone Number of Chief of Department (unless provided above)

Do you want to receive an emailed copy of this submission?

Yes

No

Who Should be Contacted to Schedule Appointments? *

"Person Making Request" Above

The Chief Named Above

The Candidate(s)

Please Indicate the Number of Applicants you Wish to Schedule *

Who Should Receive Appointment Confirmation (check all that apply) *

"Person Making Request" above

Other

Please Provide the Name of the "Other" Person that should get the Appointment Confirmation *

Please Provide E-Mail for the "Other" Person that should get the Appointment Confirmation *

Do You Want the Applicants to Pay for Any Portion of the Evaluation? *

Yes

No

Please Indicate Your Preference on What the Applicants 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

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

Attach PO if Possible

Maximum file 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 *

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. *

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

By What Date Do You Need to Have the Exam Results in Hand? *

When is Your Pension Board Meeting to Review Test Results? *

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

File Upload

Maximum file size: 2MB

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

All Pre-Exam Paperwork and the MMPI testing (if applicable) is Completed at Public Safety Medical

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

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