Note to Physician.


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Referenced from: Professional Firefighter

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Note to Physician.

You are being asked to evaluate an individual who is applying for the Holland College Firefighting Program (Fire Fighter ApplicantFFA ). It is essential that the FFA undergo a medical assessment to determine whether the individual is medically fit to permit safe and effective performance in the program. The medical evaluation of the applicant shall include a medical history, examination, and any laboratory tests required to detect physical or medical condition(s) that could adversely affect his/her ability to safely perform the essential job tasks outlined on page 2 of this form. This evaluation is based on the guidance established by the NFPA Technical Committee on Occupational Safety and Health (*NFPA1582-2022). If YES is selected for any of the criteria below, when

indicated the corresponding detailed medical form must be completed.

{The physician’s examination must be completed within 12 months prior of the Program Start Date.}

Applicant Name:

Phone No:

Address:

Month/Year of Birth:

This questionnaire is to be completed by a physician following their medical examination of the above applicant.

Does the applicant suffer from any problems with ears or hearing which would require special consideration? If yes, see QF247-A.

Does the applicant suffer from Diabetes? If yes and Type 1, see QF247-C. If yes and Insulin Requiring Type2, see QF247-D. If yes and Non-Insulin Requiring Type 2, see QF247-E.

Does the applicant suffer from Epilepsy? If yes, see QF247-F.

Does the applicant suffer from any medical condition of the head, neck, nose or mouth which would require special consideration? If yes, see QF247-G.

Does the applicant suffer from any respiratory disease that would require special consideration? If yes, see QF247-H.

Does the applicant suffer from any cardiovascular or blood disease that would require special consideration? If yes, see QF247-I

Does the applicant suffer from any medical condition affecting the abdominal area, abdominal organs, gastrointestinal system, reproductive system, urinary system, endocrine and or metabolic disorders, systemic

diseases, tumors and or malignant diseases? If yes, see QF247-J.
Yes
No

Does the applicant suffer from any medical condition affecting the spine, skeleton or extremities? If yes, see QF247-K.

Yes
No
Does the applicant suffer from any medical condition requiring the chronic or frequent use of narcotics, sedatives, anticoagulants, beta-blockers, corticosteroids or anabolic steroids? If yes, see QF247-L. Does the applicant suffer from any neurological or psychological illness? If yes, see QF247-L
Yes
No
Yes
No

Does the applicant suffer from any skin disease? If yes, see QF247-M.

Does the applicant suffer from allergies?

Does the applicant suffer from any communicable disease?

Does the applicant suffer from claustrophobia?

Is there any factor not covered by the above questions which would affect the applicant’s suitability to successfully complete the firefighting program?

Note: Please refer to the outline of physical stressors for the programs that are outlined on the reverse side this medical form.

Physician declaration:

After completion of an examination of the individual named above, it is my opinion that the ‘applicant’ is

Medically Fit, or
NOT Medically Fit ,

to undergo a rigorous physical training program with full regard to all the stressors indicated on reverse side of this form.

Comments:

Date of Examination:

Physicians Signature:

Physician Contact Information: (Please Print)

Physician Name:

Business Phone No:

Clinic/Office Business Address:

Note to Physician:

Applicants will be subject to extensive medical evaluation and must meet stringent health requirements when they enter the firefighter profession. The purpose of the information in this medical report is to identify any potential health concerns so both the College and the applicant are fully informed. Please refer to the reverse of this form for a brief description of the physical stressors that impact a student while attending an APA program.

The personal information requested on this form is collected under the authority of Section 31(c) of the PEI Freedom of Information and Protection of Privacy Act. It will be used to assess the medical fitness of applicants to the Professional Firefighting program. If you have any questions about the collection or use of this information, please contact Holland College’s Chief Privacy Officer at privacy@hollandcollege.com or 902-566-9542, 140 Weymouth Street, Charlottetown, PE, C1A 4Z1.

Primary Medical Form for Professional Firefighting Program

Admission/Office of the Registrar 140 Weymouth Street

Charlottetown, PE ~ C1A 4Z1

Tel: 902-629-4217 (1-800-446-5265)

Fax: 902-629-4239

Information for Physicians Regarding the Physical Requirements of Atlantic Police Academy Professional Firefighting Program

(…page 2)

Firefighting entails a unique set of conditions that need to be considered in evaluating the medical fitness of applicants. These may include (depending upon the duties of the particular FF position):

unpredictable periods of maximal physical exertion (e.g., climbing stairs with over 50 pounds of PPE and 20 to 40 pounds of equipment);
use of encapsulating and insulated personal protective equipment (PPE) that can result in significant fluid loss and dehydration;
exposure to extreme environmental temperatures;
during emergency responses with limited access to food, water, and medications for prolonged periods of time;
emergency response driving with the responsibility for others in the vehicle;
critical, time -sensitive complex problem solving in hazardous environments;
unpredictable meal schedules;
control of one’s emotions under stress;
functioning as a team where sudden incapacitation can result in mission failure or risk of injury or death to civilians or other team members.

15 Essential Job Tasks of Firefighters

Wearing personal protective equipment (PPE) and self-contained breathing apparatus (SCBA) while performing firefighting tasks (e.g., hose line operations, extensive crawling, lifting and carrying heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue operations, and other emergency response actions under stressful conditions, including working in extremely hot or cold environments for prolonged time periods
Wearing the respirators required by the jurisdiction (e.g., N-95, half-face elastomeric, PAPR, SCBA), which includes a demand-valve-type positive-pressure facepiece or filter respirator, achieving a successful fit-test and tolerating increased respiratory workloads
Exposure to toxic fumes, irritants, particulates, biological (i.e., infectious) and nonbiological hazards, or heated gases, despite the use of PPE and SCBA
Climbing at least six flights of stairs or walking a similarly strenuous distance and incline in jurisdictions without tall buildings while wearing PPE and SCBA, commonly weighing 40 -50 lb (18 -23 kg) and carrying equipment/tools weighing an additional 20 -40 lb (9 -18 kg)
Wearing PPE and SCBA that is encapsulating and insulated, which will result in significant fluid loss that frequently progresses to clinical dehydration and can elevate core temperature to levels exceeding 102.2°F (39°C)
Working alone while wearing PPE and respirators required by the jurisdiction, searching, finding, and rescuedragging or carrying victims to safety in hazardous conditions and low visibility
While wearing PPE and SCBA, advancing water-filled hose lines up to 1 3/4 in. (45 mm) in diameter from fire apparatus to occupancy [approximately 150 ft (50 m)], which can involve negotiating multiple flights of stairs, ladders, and other obstacles
While wearing PPE and SCBA, climbing ladders, operating from heights, walking or crawling in the dark along narrow and uneven surfaces that might be wet or icy, and operating in proximity to electrical power lines or other hazards
Unpredictable, prolonged periods of extreme physical exertion as required by emergency operations without benefit of a warm-up period, scheduled rest periods, meals, access to medication(s), or hydration
Operating fire apparatus or other vehicles in an emergency mode with emergency lights and sirens
Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous environments, including hot, dark, tightly enclosed spaces, that is further aggravated by fatigue, flashing lights, sirens, and other distractions
Ability to communicate (i.e., give and comprehend written or verbal orders) while wearing PPE and respirators required by the jurisdiction under conditions of high background noise, poor visibility, and drenching from hose lines or fixed protection systems (e.g., sprinklers)
Functioning as an integral component of a team, where sudden incapacitation of a member can result in mission failure or in risk of injury or death to members of the public or other team members
Working in shifts, including during nighttime, that can extend beyond 12 hours
Performing emergency medical service (EMS) tasks, such as cardiopulmonary resuscitation (CPR) or lifting or moving patients, while wearing PPE and respirators required by the jurisdiction

Source: NFPA 1582 2022 Edition

(*NFPA (National Fire Protection Association), 1 Batterymarch Park, Quincy, MA 02269-9101)

Source: https://sam.hollandcollege.com/shared/QMS/Forms/QF201-250/QF247-FireFighterPrimaryMedicalForm.pdf