Attachment 13: Certification of Physical Qualifications Form

15 June 2026

SIR No. 69M215-25-R-00012

Attachment 13

CERTIFICATION OF PHYSICAL QUALIFICATIONS

Federal Aviation Administration
William J Hughes Technical Center for Advanced
Aerospace Armed Security Guard Services

EMPLOYEE NAME:

DATE OF BIRTH:

ADDRESS:

CONTRACTOR:

CONTRACT NO.:

YES

NO

The individual named above has submitted to drug testing and screening. The results will be sent to the Contractor via separate correspondence.

YES

NO

The individual named above is physically fit to perform guard duties and is in good general health without any physical defects or abnormalities.

YES

NO

The individual named above possesses binocular vision correctable to 20/30 (Snellen) and is not colorblind.

YES

NO

The individual named above has the ability to hear normal conversation at 20 feet and whispered conversation at 10 feet without the benefit of a hearing aid.

YES

NO

The individual named above possesses hearing (corrected with a hearing aid or uncorrected) at 500, 1000, 2000, and 3000 Hertz (Hz) at a level that is less than or equal to 25 decibels.

YES

NO

The individual named above possesses hearing (corrected by a hearing aid or uncorrected) at 4000 and 5000 Hz at a level that is less than or equal to 45 decibels.

Attachment 13

YES

NO

The individual named above possesses a hearing (corrected with a hearing aid or uncorrected) difference between the individual’s ears in the 500-3000 Hz range that is less than or equal to 15 decibels.

YES

NO

The individual named above possesses hearing (corrected with a hearing aid or uncorrected) that is not affected by an ear disorder that affects equilibrium

Physician’s Typed or Printed Name

Physician’s Signature

Date

License Number

Address

Phone Number

CERTIFIED BY:

COR Signature

Date

Printed or Typed Name
Phone Number