IOWA LAW ENFORCEMENT ACADEMY

RESERVE OFFICER STATUS REPORTING FORM

APPOINTMENT TO RESERVE OFFICER STATUS

DATE OF APPOINTMENT

REMOVAL FROM RESERVE OFFICER STATUS (COMPLETE ONLY ITEMS

1, 2 AND 3)

DATE OF RESIGNATION OR TERMINATION

1. Agency Name and Address _

2. Full name of officer:

Last First Middle

3. Drivers License N o . State:

4. Home Address Street City State Zip Code

5. Telephone Number

6. Age Birth date Birth Place

1. Sex Race: Asian or Pacific Islander Black/Non Hispanic

For Statistical Purposes Only Caucasian/Non Hispanic Native American Indian

Hispanic Other/Misc

With our Signatures below we certify that all of the foregoing information is

correct.

Signature of Applicant: Date:

Signature of Hiring Authority: Date:

2/28/2017 LRB

IOWA LAW ENFORCEMENT ACADEMY

RESERVE OFFICER MINIMUM HIRING STANDARDS

1. Name of Agency:

2. Full Name of Reserve Officer:

3. Drivers License Number: State:

4. Is this reserve officer a citizen of the United States and a resident of Iowa? Yes: No:

5. Is this reserve officer at least eighteen years of age and not over 65 years of age? Yes: No:

6. Does this officer have a valid drivers’ license issued by the State of Iowa? Yes: No:

7. Is this officer addicted to drugs or alcohol? Yes: No: If yes, has the officer been

rehabilitated within one year or is presently undergoing treatment? Yes: No:

8. Has thorough background investigation been conducted on this officer to determine if he/she is

of good moral character? Yes: No:

9. Has a fingerprint search been conducted of state and national fingerprint files? Yes: No:

Date of DCI clearance: Date of FBI clearance:

10. Has this officer ever been convicted of any offense other than simple misdemeanor traffic

violations? Yes: No: If yes, attach a separate sheet(s) with explanation.

11. Is this person willing to use force if necessary to fulfill his/her duties? Yes: No:

12. Is this officer a high school graduate or possess a G.E.D. equivalency certificate? Yes: No:

13. Has this officer passed all required medical tests? Yes: No:

a. (Attach ILEA Minimum Medical Standards Form A or B)

With our signatures below we certify that all information is true and correct.

Signature of Hiring Authority Date

Signature of Reserve Officer Date

2/28/2017 LRB

IOWA LAW ENFORCEMENT ACADEMY

RESERVE OFFICER DUTIES

This form should be completed and given to the testing physician before physical examination.

CHECK THE APPROPRIATE BOX BELOW

THIS OFFICER WILL PERFORM POLICING DUTIES ALONE AND WITHOUT

DIRECT SUPERVISION (PHYSICAL PRESENCE) OF A CERTIFIED REGULAR

LAW ENFORCEMENT OFFICER AT ALL TIMES. FORM A WILL BE PREPARED

BY PHYSCIAN CONDUCTING MEDICAL EXAMINATIONS.

THIS OFFICER WILL PERFORM POLICING DUTIES ONLY WITH THE

DIRECT SUPERVISION (PHYSICAL PRESENCE) OF A CERTIFIED REGULAR

LAW ENFORCEMENT OFFICER AT ALL TIMES. FORM B WILL BE PREPARED

BY PHYSCIAN CONDUCTING MEDICAL EXAMINATIONS.

THIS OFFICER WILL NOT PERFORM POLICING DUTIES AS DEFINED IN

I.A.C. 501-10.100(8) AND (9). FORM B WILL BE PREPARED BY PHYSCIAN

CONDUCTING MEDICAL EXAMINATION.

NAME OF OFFICER:

AGENCY:

DUTIES THIS OFFICER WILL BE REQUIRED TO PERFORM

(If additional duties are performed please attach separate sheet)

ATTACH AND SUBMIT THIS INFORMATION WITH FORM A OR FORM B TO THE IOWA LAW

ENFORCEMENT ACADEMY.

Signature of Examining Physician Date

2/28/2017 LRB

FORM A

IOWA LAW ENFORCEMENT ACADEMY

MINIMUM MEDICAL STANDARDS FOR RESERVE OFFICERS

RESERVE OFFICERS WHO PERFORM POLICING DUTIES ALONE WITHOUT THE DIRECT SUPERVISION OF

A REGULAR CERTIFIED LAW ENFORCEMENT OFFICER MUST MEET THESE STANDARDS.

Name:

Agency:

Drivers License #: State: Date of Birth: Age:

1. Does the above individual have uncorrected vision of not less (worse) than 20/100 in each eye, corrected to 20/20 in each eye?

Yes No Date Tested:

Uncorrected Vision: Corrected Vision:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

2. Does the above individual have color vision consistent with the occupational demands of law enforcement? Passing any of the

following color vision tests indicates the applicant has color vision consistent with the demands of law enforcement:

Pseudoisochromatic plate tests such as but not limited to Tokyo Medical College, Ishihara, Standard Pseudosochromatic Plates,

Dvorine, American Optical HRR Plates, American Optical; panel tests such as Farnsworth Dichotomous D-15 Test, or any

other test designed and documented to identify extreme anomalous trichromatic, dichromatic or monochromatic color vision.

Individuals with extreme anomalous trichromatism or monochromasy color vision, as determined through testing, are not

eligible to be hired as law enforcement officers in the state of Iowa.

Please circle the name of the test used above.

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

3. Does the above individual have normal hearing in each ear? (Hearing is considered normal when tested by an audiometer.

Hearing sensitivity thresholds are within 25db measured at 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz, averaged together.) If this

individual is unable to meet these hearing standards, please contact the Academy for information regarding further testing

options.

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

4. Has the above individual been examined by a licensed physician or surgeon and determined to meet the physical requirements

necessary to fulfill the responsibilities of a law enforcement officer?

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

Signature of Reserve Officer Date

With your signature you certify that all the foregoing information is correct. The above signed individual hereby authorizes any

physician, doctor or audiologist named above to release to the Iowa Law Enforcement Academy such limited information

necessary only to verify the answers set forth above. A copy of this release shall have the same effect as the original. 2/28/2017 LRB

FORM B

IOWA LAW ENFORCEMENT ACADEMY

MINIMUM MEDICAL STABNDARDS FOR RESERVE OFFICERS

RERSERVE OFFICERS WHO PERFORM POLICING DUTIES WITH THE DIRECT SUPERVISION OF A

REGULAR CERTIFIED LAW ENFORCEMENT OFFICER MUST MEET THESE STANDARDS.

Name:

Agency:

Drivers License #: State: Date of Birth: Age:

1. Does the above individual have uncorrected vision of not less (worse) than 20/100 in each eye, corrected to 20/20 in each eye?

Yes No Date Tested:

Uncorrected Vision: Corrected Vision:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

2. Does the above individual have color vision consistent with the occupational demands of law enforcement? Passing any of the

following color vision tests indicates the applicant has color vision consistent with the demands of law enforcement:

Pseudoisochromatic plate tests such as but not limited to Tokyo Medical College, Ishihara, Standard Pseudosochromatic Plates,

Dvorine, American Optical HRR Plates, American Optical; panel tests such as Farnsworth Dichotomous D-15 Test, or any

other test designed and documented to identify extreme anomalous trichromatic, dichromatic or monochromatic color vision.

Individuals with extreme anomalous trichromatism or monochromasy color vision, as determined through testing, are not

eligible to be hired as law enforcement officers in the state of Iowa.

Please circle the name of the test used above.

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

3. Does the above individual have normal hearing in each ear? (Hearing is considered normal when tested by an audiometer.

Hearing sensitivity thresholds are within 25db measured at 500 Hz, 1000 Hz, 2000 Hz, and 3000 Hz, averaged together.) If this

individual is unable to meet these hearing standards, please contact the Academy for information regarding further testing

options.

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

4. Has the above individual been examined by a licensed physician or surgeon and determined to meet the physical requirements

necessary to fulfill the responsibilities of a law enforcement officer?

Yes No Date Tested:

Signature of Doctor: * with your signature you certify that all of the forgoing information is true and correct.

Signature of Reserve Officer Date

With your signature you certify that all the foregoing information is correct. The above signed individual hereby authorizes any

physician, doctor or audiologist named above to release to the Iowa Law Enforcement Academy such limited information

necessary only to verify the answers set forth above. A copy of this release shall have the same effect as the original. 2/28/2017 LRB