Atlanta Police Department

Health Screening Certification

Ordinance 00-0-0995, approved July 21, 2000, authorized up to four hours of Health Screening Leave one time per calendar year for permanent full-time employees of the City of Atlanta who undergo screening for one or more of the illnesses listed below. Please have your physician or physician’s assistant complete the appropriate portion of this form as documentation required for approval of this leave.

This is to certify that _________________________, employee of the

Name of Employed

City of Atlanta, has undergone screening on _________________________

Date of Screening

For cardiovascular disease, cancer, HIV, diabetes, pneumonia/influenza, or any

of the related disease processes.

Name of Physician or Physician’s Assistant	Signature

Address	Phone Number

Health Screening Leave Approved:

Supervisor/Department Representative

Date

APD Form 258

JMcGirt

2005-03-24

AJordan

Atlanta Police Academy