Online Forms

Seniors on Patrol Self-Screening Questionnaire

2. First Name*

3. Middle Name*

4. Last Name*

6. Could you operate a marked vehicle both day and night, using depth of field and peripheral vision; in congested traffic and in unsafe road conditions that can include fog, smoke, rain, ice and show; while operating a radio, maintaining visual surveillance of your surroundings and finding unfamiliar locations simultaneously?*

   1. Yes
   2. No

8. Could you communicate clearly and understandably on a law enforcement radio (both talking and listening to the radio?)*

   1. Yes
   2. No

10. Could you flee on foot over uneven terrain; balance on uneven or narrow surfaces?*

    1. Yes
    2. No

12. Could you kneel to perform first aid while using the police radio to request assistance?*

    1. Yes
    2. No

14. Can you remain on your feet for extended periods of time, walking and/or standing in a relatively fixed position?*

    1. Yes
    2. No

16. Could you conduct visual and audio surveillance for extended periods of time?*

    1. Yes
    2. No

18. Could you tolerate walking on foot patrol, and physically checking the doors and windows of buildings to ensure they are secure?*

    1. Yes
    2. No

20. Can you communicate effectively with people of all ages and backgrounds, giving information and directions?*

    1. Yes
    2. No

22. Would you be able to read, learn, and remember new and updated detailed, complex information (example: changes in policy, procedure, etc.) and apply the information in a logical manner?*

    1. Yes
    2. No

24. Can you read maps and be able to orient yourself to geographic locations as your assignment changes?*

    1. Yes
    2. No

26. Can you adequately describe persons, vehicles, and objects, using such data as size, shape, and color AND effectively communicate such information on a cell phone or radio?*

    1. Yes
    2. No

28. Would you be able to control your temper if you were taunted or physically pushed by others?*

    1. Yes
    2. No

30. Could you observe an incident which takes place in your presence, and then later describe verbally and/or in writing what took place, where and when it occurred, who was involved, and what was said?*

    1. Yes
    2. No

32. Could you bend, stretch, contort, push, pull, twist, carry, walk with weight, or lift up to 35 pounds?*

    1. Yes
    2. No

Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field