The following Commission-approved forms shall be used by agencies and Commission-accredited delivery sites during the application for criminal justice certification or Commission-approved training course enrollment:

1. (1) Form F-1, Medical History Statement, shall include the following:

   1. (a) Applicant's name, date of birth, address, and telephone number;
   2. (b) Current medications, allergies, and past medical history;
   3. (c) Occupational history;
   4. (d) Applicant's signature; and
   5. (e) Name and signature of a physician, physician assistant, or nurse practitioner who holds a current license in the United States to practice medicine, as issued by a state medical board.

2. (2) Form F-2, Medical Examination Report, shall include the following:

   1. (a) Name, date of birth, employing agency, height, weight, and last four digits of the Social Security Number for the person being examined;
   2. (b) Results of Vision Acuity;
   3. (c) Results of Hearing Acuity;
   4. (d) Results of Cardiovascular Examination;
   5. (e) Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and
   6. (f) Name, signature, and medical license number of the examining medical professional.

3. (3) Form F-2A, Tuberculosis Questionnaire, shall include the following:

   1. (a) Applicant's name, date of birth, and employing agency;
   2. (b) Tuberculosis Risk Questions and individual's response; and
   3. (c) Tuberculosis Symptoms Questions and individual's response.

4. (4) Form F-2B, Medical Examination Report Addendum, shall include the following;

   1. (a) Name, date of birth, and employing agency of individual being examined;
   2. (b) Additional Exam Notes, if any;
   3. (c) Certification that the individual being examined does or does not have any conditions, physical, emotional, or mental, that suggest further medical examination; and
   4. (d) Name, signature, and medical license number of examining medical professional.

5. (5) Form F-31, Request for Accommodation, shall include the following:

   1. (a) Name, signature, and date of birth of requesting student;
   2. (b) Accredited delivery site, and name of certified School Director;
   3. (c) Reason for Accommodation; and
   4. (d) Proposed Accommodation.

6. (6) Web Form WF-5, CJ Standards Specialized Training Student Injury Report for SMI, Instructor Courses, shall include the following:

   1. (a) Course name, course dates, and training location;
   2. (b) Injured student's name, date of birth, and academy ID number;
   3. (c) Date of the injury;
   4. (d) Details of the injury, including what the injury is, when and where it took place, and how the injury occurred;
   5. (e) Whether the student was able to return to training on the same day as the injury occurred; and
   6. (f) Whether the student was transported to a hospital or other medical facility for assessment or treatment of the injury.

History Note: Authority G.S 17C-6;
Eff. February 1, 2026.