1
Criminal Justice Training Academy
100 College Boulevard Niceville, Florida 32578 Office (850) 729-5378 Fax (850) 729-5263 Renée Johnson, Director Dear Applicant:
Thank you for your interest in the Basic Recruit Programs at Northwest Florida State College. Attached is an information packet and preliminary application form for the Law Enforcement and Correctional Officer Academies. Please read this cover letter and review the packet thoroughly. Most questions are answered within this packet.
Pay particular attention to the enclosed list of Basic Requirements. We cannot accept applicants into the Academy that have been convicted of a felony, a misdemeanor involving perjury or false statement, domestic violence related offenses, or moral character violations as defined by the Florida Department of Law Enforcement’s (FDLE) Criminal Justice Standards and Training Commission (CJSTC). If you are unsure of your eligibility, please see attachment in this packet and/or consult a member of the Training Center staff. The entire application must be filled out. Incomplete applications will not be considered for admittance to either recruit
program.
Your application must be printed or typed and be legible – only black and blue ink are acceptable. Your application and all other paperwork must be returned in person to the Public Safety Division office located in Building “F” on the Niceville Campus. At that time your fingerprints will be captured for submittal to FDLE and the Federal Bureau of Investigations (FBI). Seating preferences are assigned on a “first come, first serve” basis; therefore, it is important to submit your application in a timely manner. Applications will only be kept on file for twelve (12) months.
Medical Clearance: You must submit a completed FDLE Physical Fitness Assessment form (CJSTC-75B), an FDLE Chemical Agent Exposure Training Evaluation form (CJSTC-6A), and an NWF State College Physical Requirements/Limitations form all signed by a doctor, physician’s assistant or nurse practitioner. No one will be permitted to participate in the academy without these forms being completed and on file in the Public Safety Division office.
Background Investigation: A background investigation will be conducted. Please ensure your application is complete and accurate.
Portions of the packet require notary services. Notary service is available in the Public Safety Division offices; however, you must call in advance for an appointment.
Approximately three weeks prior to the start of the academy a letter will be mailed to all students who have submitted completed applications. The letter will inform you of the date/time/location of academy orientation (generally seven days prior to the start of the academy). You must contact our office upon receipt of the letter and confirm your continued interest in attending the academy. All students are required to attend academy orientation. During orientation you will receive additional information about the academy, to include how and when to register for courses, academy policies and procedures, and more. Again, YOU ARE REQUIRED TO ATTEND ORIENTATION.
Note: If you intend on attending the academy, it would be a good idea to go ahead and apply for financial aid.
Please feel free to contact us at 850-729-5378 if you have any questions or if we can be of assistance.
Phyllis Davis – Instructional Support Specialist, [email protected] Steven Hough – Training Coordinator, [email protected]
Jeff McGill-Training Coordinator, [email protected]
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Northwest Florida State College
Law Enforcement/Corrections Officer
Basic Recruit Training Program Requirements
Under Florida Department of Law Enforcement (FDLE) rules and Florida Statutes, in order to qualify for certification as a law enforcement/corrections officer, applicants must meet the following requirements:
Be at least 19 years of age Be a United States citizen
Have a high school diploma or a GED certificate
No convictions of any felony or a misdemeanor involving perjury or false statement Never received a dishonorable discharge from any of the Armed Forces
Have good moral character
Complete an application to Northwest Florida State College Pass Florida Basic Abilities Test (FBAT)
If new student, must attend academy orientation
Passed the Medical Exam required to be accepted into Academy Agree to be fingerprinted by the training center school.
Successful completion of background investigation
These are the minimum qualifications set by the State of Florida for taking the State Certification Exam and receiving certification. A candidate who has a number of felony arrests without a conviction and/or an extensive record of traffic violations showing a disregard for the law, may be eligible to take the State Exam, but will have little or no chance of being employed by any law enforcement or corrections agency. In addition, Federal Law prohibits any individual who has been convicted of a domestic violence charge (felony or misdemeanor) from carrying a firearm. This law prohibits an individual with such a conviction from becoming a law enforcement/corrections officer. Criminal Justice agencies in Florida are free to set their own additional requirements on candidates for employment such as physical requirements, drug use, and criminal history. Applicants must meet the standards of that particular agency they apply for. Passing the Basic Recruit Training Program does not guarantee employment with a Criminal Justice agency.
Under Florida Statutes Chapter 943, the certification process begins with a candidate successfully completing a Criminal Justice Standards and Training Commission (CJSTC) Basic Recruit Training Program. The candidate receives a Certificate of Completion upon graduation and applies to sit for the State Officer Certification Exam (SOCE). Upon successful completion of the SOCE, the candidate must become employed with a law enforcement or corrections agency. The candidate can then apply to CJSTC for certification. The candidate has four years from the beginning of the Basic Recruit Training Program to fulfill these requirements and become certified.
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Northwest Florida State College
Basic Recruit Academy
List of Moral Character offenses which may disqualify you from employment cited by sections of the Florida Statutes
117.03 False oath before a notary 316.1936 Fleeing/attempting to elude an officer 409.325 Public assistance fraud 784.011 Assault
552.22(3-7, 10) Explosives violations 785.05(2) Culpable negligence
784.03 Battery 790.10 Improper exhibition of a weapon/firearm 790.01(1) Carrying a concealed weapon 790.18 Poss/Sale of firearm w/ altered serial # 790.14 Furnishing weapons to minors 796.06 Renting space for prostitution or lewdness 790.24 Willful failure to report gunshot wounds 800.03 Exposure of sex organs
794.027 Failure to report sexual battery 806.13 Criminal mischief 796.07 Prostitution/lascivious 812.014(d) Petit theft
800.02 Unnatural/lascivious act 812.016 Possession of altered property 806.101 False fire alarms 812.14 Theft of utilities/cable services
810.08 Trespass to structure or conveyance 817.39 Distribution of fictitious court documents 812.081 Theft of trade secrets 817.563 Sale of counterfeit controlled substance 817.235 Removing/altering property id marks 827.05 Negligent treatment of children
817.49 False report of a crime 828.122 Fighting/baiting animals 817.565 Fraudulent urine drug test 831.30 Prescription fraud
827.04(2-3) Child abuse 832.041 Stop payment of check w/ intent to defraud 827.06 Persistent nonsupport of child/spouse 837.012 Perjury not in official proceedings
831.31(1)(b) Mfg. of counterfeit controlled sub. 843.02 Resisting an officer without violence 832.05(2-4) Passing worthless checks 843.13 Aiding inmates escape from training school 837.05 False report to law enforcement 847.011 Pornography offenses
839.20 Refusal to serve arrest warrant 847.06 Transport of obscenity into state 843.06 False imprisonment of an officer 856.021 Loitering or prowling
843.17 Publishing name and address of LE officer 870.02 Unlawful assemblies
847.13(2) Retail display of obscenity to minors 876.18 Burning a cross on another’s property 847.07 Wholesale promotion of obscenity 914.22(2) Witness tampering
870.01 Affrays and riots 944.35(7)a False reports concerning use of force 876.17 Burning a cross in a public place 944.35(3) Malicious battery on a prison inmate 944.37 Accept UA compensation from inmate 893.13 (1-2) Controlled substance violations
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Northwest Florida State College
Basic Recruit Academy Application
Date: ____________________
Please ensure all questions are answered completely, accurately and truthfully. If any item does not pertain to you, answer “N/A” (not applicable). Keep in mind all information will be checked and verified. Misstatements, falsifications or omissions may delay and/or terminate entrance into the Academy.
Last Name First Name Middle Name Maiden Name
Social Security #: _______________________________
List any other names you may have used. Include former names, aliases, and/or nicknames.
Address: ____________________________________________________________________________________________________ City and State: ___________________________________________________ County: ____________________ Zip: __________ Home Phone: ________________________ Work Phone: ___________________________ Cell Phone: _____________________ Email Address: _____________________________________________________________________________________________ Emergency Contact: ______________________________ Relationship: ______________________ Phone: ___________________
Are you a U.S. Citizen? Yes No Date of Birth: _______________________________ State of Birth: _________________________________ Birth Country: ______________________________ Do you possess a valid driver’s license? Yes No State Issued: _______________________________ Driver’s License #: ______________________________ Expiration Date: ____________________________
Gender: Male Female Race: _____________________________________
Eye Color: ____________________________________ Hair Color: _________________________________
Education Level: High School Graduate GED Some College 2 year degree Bachelor’ Degree Master Degree
Other: ________________________________ List number of credits earned: ______________________
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Are you a certified law enforcement or corrections officer? If yes, what state? ___________________________ Have you ever been rejected by any law enforcement agency or law enforcement training school? Yes No
If yes, explain:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ Have you ever been in the military? Yes No If yes, Active or Reserves? _____________________ List all separations or discharges form the military. (Honorable, Dishonorable, Honorable Conditions, Medical, etc)
Also include a copy of your DD-214(Member Copy 4):
____________________________________________________________________________________________________________ Arrest History: If you answer yes to any of the following, please provide an explanation in the area below.
Have you ever been arrested, charged, or issued a notice or summons to appear for any criminal violation, as an adult or juvenile? Yes No
Have you ever received a ticket or been charged with a traffic violation? (Excluding parking tickets) Yes No
Have you ever been detained by any law enforcement officer for investigative purposes or to your knowledge have you ever been the subject or a suspect in any criminal investigation? Yes No
Explanation:
____________________________________________________________________________________________________________
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Northwest Florida State College
Criminal Justice Training Center
AGREEMENT TO OBEY INSTRUCTIONS, RELEASE, ASSUMPTION OF RISK AND AGREEMENT TO HOLD HARMLESS
I am aware that participating in the Northwest Florida State College Basic Recruit Program can be dangerous in nature involving many risks of injury. I understand that the dangers and risks of participating in the program include, but are not limited to, death, serious neck and spinal injuries, injuries to virtually all bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system, serious injury to virtually all internal organs, and serious injury or impairment to other aspects of the body, general health and wellbeing. I understand that the dangers and risks of participating may result not only in injury, but also in a serious impairment of my future abilities to earn a living, engage in other business, social and recreational activities, and generally to enjoy life.
I attest and affirm that I am physically fit and able to participate in the activities and I have not been advised or informed by anyone in the contrary. I will immediately bring to the attention of Northwest Florida State College and the Criminal Justice Training Center Staff, any medical or other problems that may affect my health and/or fitness and ability to participate in any activity related to the program.
Because of the dangers of participating in the program, I recognize the importance of following the instructions regarding the activities and agree to obey all such instructions.
In consideration of the Northwest Florida State College Board of Directors and other designated organizations for allowing me to use their facilities, I assume all risks associated with participation and release and agree to hold harmless the Board of Directors of Northwest Florida State College, their employees, agents,
representatives, and volunteers from any and all liability, actions, causes of actions, debts, claims, or demands of any kind and nature whatsoever including any medical treatment and expenses incurred as a result of any injury that I might receive while participating in the above activity related to the program.
The terms hereof shall serve as a release, assumption of risk, and hold harmless agreement not only for
ourselves, but also for our heirs, estates, executors, successors, administrators, assigns, and for all members of our family.
___________________________________ _________________________________
(Signature of Student) (Signature of Witness)
__________________________________ _________________________________
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Northwest Florida State College
Criminal Justice Training Center
I hereby authorize Northwest Florida State College and, in particular, the Criminal Justice
Training Center to release any and all records, test results, evaluations, and any information of a
privileged nature, which may have been accumulated or compiled by virtue of my attendance,
to the Florida Department of Law Enforcement, Division of Criminal Justice Standards and
Training.
Also to any state, county, or local law enforcement or corrections agency that has an official
need for such records.
I hereby release you, your organization, or others from any liability or damage, which may
result from furnishing the information requested above.
I have read and understand the above listed statement and authorize the release of my records.
Date: ___________________________, 20 ____.
Students Name: _______________________________________________________________
(Last name) (First name) (M.I.)
______________________________________________ _________________________
Applicant’s Signature Date
SSN: _______________________________________________________________________
____________________________________________________________________________ Address
____________________________________________________________________________
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Northwest Florida State College
Criminal Justice Training Center
Statement of Military Service
____ I have never served with any branch of the Armed Forces of the United States of America. - Or -
____ I am currently an active member of the Armed Forces of the United States of America, the Armed Forces reserve of the United States of America, or the National Guard.
- Or -
____ I have served, but I am no longer serving, as a member of any branch of the Armed Forces of the United States of America (attach a copy of DD-214, member copy 4).
This document shall constitute an official statement within the purview of Section 837.06 of the Florida State Statutes, and is subject to verification by the Criminal Justice Training Center and/or the Florida Criminal Justice Standards and Training Commission.
_________________________
(Applicant’s signature)
Sworn to and subscribed by me this ___ day of __________, 20___ A.D.
_________________________ Notary Public, State of Florida My commission expires:
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Northwest Florida State College
Criminal Justice Training Center
Criminal History Statement
(Please read carefully before signing)
I fully understand that in order to qualify as a candidate for participation in the course of study for Law Enforcement Officer or Correctional Officer, I must comply with the Rules and Regulations of the Florida Department of Law Enforcement Criminal Justice Standards and Training Commission. I understand that if I have a sealed or expunged record that I may not be eligible for employment or appointment as a Criminal Justice Officer.
I therefore attest to the following:
1. I have not been convicted of any felony. I have not been convicted of a misdemeanor involving perjury or false statement, nor have I received a dishonorable discharge from any of the Armed Forces of the United States of America; and
2. I have not, after July 1, 1981, pled guilty or nolo contendere or have been found guilty of any felony, or
any misdemeanor involving perjury or false statement, notwithstanding suspension of sentence or withholding of adjudication.
3. I have not been convicted of a misdemeanor crime involving domestic violence, including the use,
attempted or threatened use of physical force, as one of the “defined parties” in the Omnibus
Consolidated Appropriations Act of 1997, a part of which is an amendment to the Gun Control Act of 1968.
4. I am of “good moral character” as defined in Florida Administrative Code 11B-27.0011.
In the State of Florida, County of _____________, before me personally came ___________________, who being duly sworn deposes and says: I hereby certify that to the best of my knowledge and belief, the information that I have entered on this form is true.
_________________________
(Applicant’s signature)
Sworn to and subscribed by me this ___ day of __________, 20___ A.D.
_________________________ Notary Public, State of Florida My commission expires:
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Northwest Florida State College
Release and Indemnity Agreement
In consideration of being permitted to utilize the firing range and driving range located at Northwest Florida State College (the “Institution”), the undersigned (the “Releasor”) hereby releases, waives, discharges and covenants not to sue the State of Florida, Northwest Florida State College or any of their employees, instructors, or associate-instructors. Also to release them from all liability to the Releasor, for all loss, damage, liability and cost on account of injury to person or property, whether caused by the negligence, intentional conduct or
omission of the Institution, or anyone else, while the Releasor is at the Institution.
Releasor agrees to indemnify the Institution from any loss, liability, damage or cost the Institution may incur due to the activities of Releasor at the Institution, whether caused by the negligence, intentional conduct or omissions of the Releasor.
Releasor expressly agrees that this release, waiver, and indemnity agreements is intended to be as broad and inclusive as permitted by the laws of the State of Florida and that if any portion of the agreement is held invalid, it is agreed that the balance, notwithstanding, continue in full legal force and effect.
Releasor further states that he/she has carefully read the above release and knows the contents of the release and signs this release, as the releasor’s own free act.
Dated this ____________ day of ___________________, 20 ______.
_____________________________________ Releasor Signature
_____________________________________ Print name of Releasor
_____________________________________ _____________________________________ _____________________________________ Print address of Releasor
Florida Department of Law Enforcement
PHYSICAL FITNESS ASSESSMENT
Incorporated by Reference in Rule 11B-35.001(11)(c)12., F.A.C.
Training School: Original Agency: Copy 1 of 2 Applicant: Copy Created 11/8/2007
CJSTC
75B
1. Applicant’s Name:
Last First MI
2. Applicant’s Address:
3. Enter Last Four Digits of Social Security Number: 4. Training School:
5. The Applicant Is Requesting Admission Into a Basic Recruit Training Program for One of the Following Disciplines: Law Enforcement Correctional Correctional Probation
6. Student Participation in Basic Recruit Training Program Activities. A student enrolled in a basic recruit training program (BRTP) is required to participate in the following
activities:
A. Defensive tactics and firearms high-liability training is a component of the curriculum mandated by the Criminal Justice Standards and Training Commission. Firearms
training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires sustained physical exertion and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).
B. Physical Fitness Conditioning and Physical Fitness Testing: A BRTP student shall participate in physical fitness conditioning and a fitness test and includes the
following measures:
• Vertical Jump • One Minute Sit Ups • 300 Meter Run • Maximum Push Ups • 1.5 Mile Run/Walk
C. The training center director has attached the training schools physical fitness conditioning program: Yes
**********TO BE COMPLETED BY THE APPLICANT*********
7. Medical Conditions Regarding OC/CS Contamination. A BRTP student should be aware of the following personal considerations that may restrict participation in the chemical
agent contamination of the BRTP and could possibly be aggravated to a severe degree during the contamination: Recent eye surgery, heart problems, panic disorder or stress, respiratory disorder, emphysema (loss of elasticity/thinning of lung tissues), bronchial asthma, x-ray evidence of pneumoconiosis (black lung), evidence of reduced pulmonary (lung) function, chronic obstructive pulmonary disease, coronary (heart) artery disease, cerebral (brain) blood vessel disease, severe or progressive hypertension (high blood pressure), epilepsy, grand malor petite mal (seizures), pernicious anemia (severe reduction in red blood cells), diabetes (any form), pueumomediastinum gap (air in the sac surrounding lungs), history of skin allergies, or any condition for which the student is presently taking medication.
8. BRTP Student Certification. I certify that I have reviewed the above information and I do or do not have any medical restrictions that would prevent me from
participating in the basic recruit training program activities outlined in item numbers 6, 6A, and 6B above.
9. Student’s Printed Name:
10. Student’s Signature:_____________________________________ Date:
11. Prior Exposure to OC or CS. For a student who has had prior chemical agent exposure that includes chemical agent contamination and working through the effects of chemical
agent contamination in a training environment, please attach the supporting documentation of prior exposure and check one of the following boxes:
I certify that I have OR I have not been exposed to oleo-resin capsicum (OC) and/or orthochlorobenzal-malononitrile (CS) in the manner described in item number 11
above.
**********TO BE COMPLETED BY THE EXAMINING PHYSICIAN*********
12. Physician Attestment. The above applicant is seeking entry into a law enforcement, correctional, or correctional probation basic recruit training program.
Rule 11B-35.001(11)(c)12., F.A.C., requires a complete physical examination at a level of specificity sufficient to determine whether there are any medical or physiological restrictions that would prevent the applicant from performing the required activities described in items 6, 6A, and 6B above. Disabilities, impairment, or limitations identified by the examination that would prevent the applicant from performing the required activities should be reported to the training school indicated in item number 4 above.
I hereby attest that I have examined the above named applicant and find him or her CAPABLE of participating in the basic recruit training program activities indicated in item numbers 6, 6A, and 6B above.
I hereby attest that I have examined the above named applicant and find him or her NOT CAPABLE of participating in the basic recruit training program activities indicated in item numbers 6, 6A, and 6B above
13.
Physician, Certified Advanced Registered Printed Name Examination Date Nurse Practitioner, or Physician Assistant’s Signature
14.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number Licensing State 15.
Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address
**********TO BE COMPLETED BY THE TRAINING CENTER DIRECTOR OR DESIGNEE*********
16. Training Center Director or Designee’s Printed Name:
FORM CJSTC-75B Page 2 of 2
INSTRUCTIONS FOR COMPLETING FORM CJSTC-75B
A basic recruit student approved to enter a basic recruit training program (BRTP) shall review and complete form CJSTC-75B to indicate the presence of any medical conditions that may prevent participation in the Physical Fitness Program and Chemical Agent Contamination of the BRTP. A copy of the Physical Fitness Program for law enforcement, correctional, or correctional probation discipline shall be attached to this form for the student to review.
1. Applicant’s Name. Enter the applicant’s last name, first name, and middle initial. 2. Applicant’s Address. Enter the applicant’s current address, city, state, and zip code.
3. Applicant’s Social Security Number. Enter the last four digits of the applicant’s social security number as in this example: 000-00-1234. 4. Training School Name. Enter the name of the Commission-certified criminal justice training school where the applicant is enrolled.
5. Basic Recruit Training Program Discipline. Place a check mark in one of the box(es) for the law enforcement, correctional, or correctional probation discipline for which the
applicant is requesting admission.
6. Student Participation in Basic Recruit Training Program Activities. Defensive Tactics (includes chemical agent contamination), Firearms, and Physical Fitness Conditioning and Physical Fitness Testing: High-liability training in defensive tactics, firearms, and chemical agent contamination is a component of the curriculum mandated
by the Criminal Justice Standards and Training Commission and participation in the activities is a requirement for successfully completing a BRTP. There is no pass or fail at this
time. The test results for each of the five required tests will be recorded on the Academy Physical Fitness Standards Report, form CJSTC-67A as “I” if the student did not perform
the test component or “D” if the student was dismissed from the basic recruit training program.
A. Defensive Tactics and Firearms Training. Firearms training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires
sustained physical exertion and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).
B. Physical Fitness Conditioning and Physical Fitness Testing. The Physical Fitness Test includes the following measures and are defined as follows:
• Vertical Jump. This measures leg power by measuring how high a person jumps.
• One Minute Sit Ups. This measures abdominal, or trunk, muscular endurance. While lying on his or her back, the student will be given one minute to do as many
bent-leg sit ups as possible.
• 300 Meter Run. This measures anaerobic power, or the ability to make an intense burst of effort for a short time period or distance. This component consists of
sprinting 300 meters as fast as possible.
• Maximum Push Ups. This measures the muscular endurance of the upper body. This component consists of doing as many push ups as possible until muscular
failure. Males are required to perform the standard push-up and females have the option to perform the standard or modified push-up.
• 1.5 Mile Run/Walk. This measures aerobic power or cardiovascular endurance (stamina over time). To complete this component, the student runs or walks a distance
of 1.5 miles as fast as possible.
C. A physical fitness conditioning program developed by the training school shall be attached to form CJSTC-75B prior to the student’s examination by a physician, certified advanced registered nurse practitioner, or the physician’s assistant.
7. Medical Conditions Regarding Chemical Agent Contamination. The student shall review the listed medical conditions and list other conditions that may restrict him or her from
participating in Chemical Agent Contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS).
8. Basic Recruit Training Program Activities Certification. The student shall check the appropriate box to indicate if he or she does or does not have a medical condition that
would restrict participation in the BRTP activities indicated in item numbers 6, 6A, and 6B of this form.
9. Student’s Printed Name. The student shall print his or her first name, last name, and middle initial.
10. Student’s Signature and Date. The student shall provide a signature and date to verify the information provided by the student is true and correct.
11. Prior Exposure to Chemical Agent Contamination. The student shall Indicate in the appropriate box if he or she has been previously exposed to chemical agent contamination
to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzal-malonotrite (CS), and shall attach supporting documentation of such contamination.
12. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Attestment. The physician shall check the appropriate box to indicate if the student is
capable or not capable of participating in the BRTP activities indicated in item numbers 6, 6A, and 6B of this form.
13. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Signature, Printed Name, and Examination Date. The physician shall complete this
item to verify his or her attestment to item number 12 of this form.
14. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number and Licensing State. The physician shall complete this item to
verify his or her valid license number and licensing state.
15. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address. The physician shall print his or her complete professional
address.
16. Training Center Director or Designee’s Printed Name, Signature and Date. The training center director or designee who signs this form shall print his or her legal first and last
Capsaicin D-Limonene Secondary Butanol Propylene Glycol
Dipropylene Glycol Monomethyl Ether
Note: *Skin
M a terial Safety Data Sheet
May be used to comply with OSHA's Hazard Communication Standard, 29CFR 1910. 1200. Standard must be consulted for specific requirements.
SECTION 1
-Manufacturer's NameDefense Technology / Federal Laboratories
Address Emergency
Telephone No.
Postal Box 248 (800) 424-9300
City, State, and ZIP Other
Information Calls Date Signature of Person
Responsible for Preparation (Optional) Prepared
SECTION 2 - HAZARDOUS INGREDIENTS / IDENTITY
O S H A A C G I H CAS
Hazardous Component(s) (chemical & common name(s)) O t h e r E x p o s u r e %
P E L TLV Limits (optional) N O .
SECTION 3 - PHYSICAL & CHEMICAL CHARACTERISTICS
Vapor Specific
Boiling
211° F 370° F 0.947 Pressure (mm H g ) NG
Point Gravity (H2O = 1)
Vapor
Density (Air = 1)
Solubility Reactivity in
in Water Slight Water
Appearance Melting
a n d O d o r Point
SECTION 4 - FIRE & EXPLOSION DATA
Flash Method Flammable Limits L E L UEL
110° F Closed Cup
Point Used in Air % by Volume Lower Upper
Auto-lgnition Extinguisher
Use dry chemical, CO2, or water spray.
Temperature Media
Special Fire
Cool containers if exposed to fire or high heat.
Fighting Procedures
Unusual Fire and
Product packaged in aerosol form may cause containers to burst when exposed to extreme heat.
Explosion Hazards
Dark Brown Liquid, Aromatic Odor NG
NG Casper, Wyoming 82602 (877) 248-3835 11/01/01 PEPPER MACE® NG ppm NG ppm 100 ppm NG ppm 100* ppm 404-86-4 5989275 78922 57-55-6 34590948 QUICK IDENTIFIER
Common Name: (used on label and list)
NG ppm NG ppm 100 ppm NG ppm 100* ppm
QUICK IDENTIFIER
Common Name: (used on label and list)
SECTION 5 - PHYSICAL HAZARDS (REACTIVITY DATA)
S t a b i l i t y U n s t a b l e Conditions Stable t o A v o i d Incompatibility (Materials to Avoid) Hazardous Decomposition ProductsAvoid exposure to extreme heat.
Hazardous thermal decomposition products may form such as Carbon Monoxide, Carbon Dioxide and other toxic and corrosive gases.
Hazardous May Occur Conditions
Polymerization Will Not Occur to Avoid
SECTION 6 - HEALTH HAZARDS
1. Acute 2. Chronic
See Signs and Symptoms
---S i g n s a n d
May cause superficial keratitis, conjunctivitis and irritation to the stomach and digestive system.
S y m p t o m s o f E x p o s u r e
Medical Conditions Generally
Dermititis. Aggravated by Exposure C h e m i c a l L i s t e d a s C a r c i n o g e n or Potential Carcinogen I.A.R.C. O S H A Y e s
National Toxicology Yes Yes
No
Program M o n o g r a p h s N o No
Emergency and
Remove to fresh air. If breathing is difficult, administer oxygen. If breathing has stopped, administer CPR.
F i r s t A i d P r o c e d u r e s
1. Inhalation
Burning sensation, irritation and nausea.
ROUTES
2. EyesBurning sensation and irritation.
OF
3. SkinENTRY
Liquid and vapors can cause irritation.4. Ingestion
SECTION 7 - SPECIAL PRECAUTIONS AND SPILL / LEAK PROCEDURES
P r e c a u t i o n s t o b e T a k e nPackaged product is under pressure. Do not puncture, incinerate or store at temperature above 130° F.
i n H a n d l i n g a n d S t o r a g e
Other
Irritating to eyes, nose and skin. Avoid inhaling vapors and contact with skin.
Precautions
Steps to be Taken in Case
Extinguish all flames then soak up material in absorbent material and shovel into waste container.
Material is Released or Spilled
Waste Disposal
Dispose of in accordance with local, state and federal regulations.
Methods ( Consult Federal, State, and Local Regulations )
SECTION 8 - SPECIAL PROTECTION INFORMATION / CONTROL MEASURES
Respiratory ProtectionUse chemical respirator, NIOSH approved.
( Specify Type )
Mechanical Special
Local Other
Ventilation
Exhaust ( General )
Protective Eye Protection
Use solvent-resistant rubber gloves Use chemical-resistant goggles.
Gloves
Other Protective
Use solvent-resistant type with full jacket.
C l o t h i n g o r E q u i p m e n t Work/Hygienic Practices
Avoid absorption of product on clothing. If absorbed in clothing, remove and launder at once.
I M P O R T A N T
Do not leave any blank spaces. If required information is unavailable, unknown, or does not apply, so indicate. Pungent fumes may be emitted on exposure to temperatures above 175° F.
Liquid can cause nausea and a burning sensation.
Flush eyes with cool water for at least 15 minutes. Wash with cool water and soap. Drink a glass of water and induce vomiting.
Yes Yes Yes No No
PEPPER MACE®
Northwest Florida State College
Criminal Justice Training Center
I am aware of the physical requirements listed below and I have no physical limitations which would preclude my participation in the high-liability training areas of the Northwest Florida State College Basic Recruit Program.
Applicant’s Name: _____________________________ Social Security #: _______________________ Applicant’s Signature: _____________________________ Date: ____________________ Basic Recruit Program students are required to perform in the subject areas of Physical Training, Defensive Tactics, Firearms Training, and Medical First Aid as indicated below. Please initial the appropriate block which identifies the student’s ability to participate in each of the areas listed.
Yes No
Arrest Techniques: Requires the individual to bend at waist and knees (squat and kneel). Student must have full range of motion of both arms and manipulative dexterity of the hands to properly handcuff and control an
individual.
Self-Defense: Requires the individual to have joint structures which are completely flexible and free of anomalies. The individual will be required to kick, punch, and block or parry blows.
Flexibility Exercise: Requires the individual to participate in a variety of exercises focusing on all major muscle groups. The exercises consist of active stretching of the muscle groups through ballistic and non-ballistic movements.
Physical Conditioning: Requires the individual to participate in a variety of physical activities involving strength, flexibility, and cardiovascular endurance. This may consist of, but not limited to, push-ups, pull-ups, sit-ups, leg lifts, and 1 ½ mile run.
Cardiopulmonary Resuscitation: Requires the individual to possess enough physical strength and endurance to compress the chest of an adult 1 ½” to 2” at a rate of 80 compressions per minute for five minutes. Must possess the vital capacity to inflate the lungs of a training manikin with a minimum of 0.8 liters. In addition, must have the strength to roll a 150 pound manikin to a proper position to administer back blows and abdominal thrusts.
Firearms Training: Requires the individual to be capable of 8 – 10 hour blocks of training in firearms, outdoors in prevailing weather conditions. Training may necessitate carrying 3’ x 4’ targets and frames, shooting up to 300 rounds of handgun ammunition (per training block), up to 50 rounds of shotgun ammunition per training block, and being in direct contact with chemical agents, to wit: Chloracetophenone gas (a.k.a. CN gas), Ortho-chlorobenzylidene Malononitrile (a.k.a. CS gas, or tear gas) gas, Oleoresin Capsicum (a.k.a., pepper spray), and smoke. Training may also require running, jumping, kneeling, rolling, squatting, crawling, and shooting during a timed, highly stressful reactionary course.
Physician’s Signature: _______________________________ Date: ________________________ Physician’s Name (printed): _________________________________________________________________ Physician’s License Number and State of Licensure: ______________________________________________ Physician’s Comments:
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