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JOB OPPORTUNITY FULL-TIME FIREFIGHTER/EMT-PARAMEDIC Lateral Entry Accepted Recruitment Open Until Filled THE POSITION: Washington Township, Montgomery County, Ohio, is seeking a driven and energetic staff for the Fire Department. Under the direction of a Fire Lieutenant or Battalion Chief, performs all functions associated with fire suppression, EMS, fire prevention and station and equipment maintenance activities. QUALIFICATIONS: In addition to the online application, you must attach the following materials in order for it to be considered a complete application: cover letter, resume, job experience questionnaire, certifications, college degree and if applicable, a full copy of any military discharge paperwork. Required certifications listed below must be attached to your online application by the application deadline. If a certification is currently in progress, it must be supplied by the time of polygraph. Applicant must possess and attach currently valid copies of the following: Ohio Firefighter II Ohio Paramedic Fire Safety Inspector Hazardous Materials Operation Advanced Cardiac Life Support American Heart CPR or equivalent NIMS ICS-100 NIMS ICS-700 Greater Miami Valley EMS Council protocol testing (within one month of hire date) Washington Township Driver/Operator (within six months of hire date) Washington Township Squad Leader (within six months of hire date) CPAT certificate or passed the Washington Township physical agility test from Kettering Sports Medicine. Valid certificates must be dated one year or newer at the time of the second interview. Must possess and maintain a valid driver license and remain insurable under the Township vehicle insurance plan. Preferred qualifications would include an Associate degree in Fire Science or related field. One year or more of experience in firefighting and/or paramedic work environment. Fire or EMS Instructor certification. COMPENSATION & BENEFITS: Salary range is $55,640 to $73,219, plus education and paramedic and is a non-exempt, union position. Entry rate is contingent upon candidate’s experience, qualifications, and related skills, knowledge, and ability. Excellent benefits. APPOINTMENT PROCEDURE: The selection process will include a review of all submitted materials. The appointment procedure may include written/video tests, assessment centers, interviews, and polygraphs. Candidate will be required to complete a criminal background check, driver’s license review and personal background investigation. The Fire Chief may waive certain requirements to ensure an adequate candidate pool. Complete the application online at http://www.washingtontwp.org/jobs and click on any of the red Apply Here buttons. Make sure to click on the additional information at the bottom of the posting to get additional application information and questionnaire. For first consideration, requested materials must be received online by 4:00 p.m. Friday, March 16, 2018. Incomplete application submittals will not be called or considered.

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JOB OPPORTUNITY

FULL-TIME FIREFIGHTER/EMT-PARAMEDIC Lateral Entry Accepted ● Recruitment Open Until Filled

THE POSITION:

Washington Township, Montgomery County, Ohio, is seeking a driven and energetic staff for the Fire Department. Under the direction of a Fire Lieutenant or Battalion Chief, performs all functions associated with fire suppression, EMS, fire prevention and station and equipment maintenance activities.

QUALIFICATIONS: In addition to the online application, you must attach the following materials in order for it to be considered a complete application: cover letter, resume, job experience questionnaire, certifications, college degree and if applicable, a full copy of any military discharge paperwork.

Required certifications listed below must be attached to your online application by the application deadline. If a certification is currently in progress, it must be supplied by the time of polygraph.

Applicant must possess and attach currently valid copies of the following:

● Ohio Firefighter II ● Ohio Paramedic ● Fire Safety Inspector ● Hazardous Materials Operation ● Advanced Cardiac Life Support ● American Heart CPR or equivalent ● NIMS ICS-100 ● NIMS ICS-700 ● Greater Miami Valley EMS Council protocol testing (within one month of hire date)

● Washington Township Driver/Operator (within six months of hire date) ● Washington Township Squad Leader (within six months of hire date)

● CPAT certificate or passed the Washington Township physical agility test from Kettering Sports Medicine. Valid certificates must be dated one year or newer

at the time of the second interview.

Must possess and maintain a valid driver license and remain insurable under the Township vehicle insurance plan.

Preferred qualifications would include an Associate degree in Fire Science or related field. One year or more of experience in firefighting and/or paramedic work environment. Fire or EMS Instructor certification.

COMPENSATION & BENEFITS:

Salary range is $55,640 to $73,219, plus education and paramedic and is a non-exempt, union position. Entry rate is contingent upon candidate’s experience, qualifications, and related skills, knowledge, and ability. Excellent benefits.

APPOINTMENT PROCEDURE:

The selection process will include a review of all submitted materials. The appointment procedure may include written/video tests, assessment centers, interviews, and polygraphs. Candidate will be required to complete a criminal background check, driver’s license review and personal background investigation. The Fire Chief may waive certain requirements to ensure an adequate candidate pool.

Complete the application online at http://www.washingtontwp.org/jobs and click on any of the red Apply Here buttons.

Make sure to click on the additional information at the bottom of the posting to get additional application information and questionnaire.

For first consideration, requested materials must be received online by 4:00 p.m. Friday, March 16, 2018. Incomplete application submittals will not be called or considered.

March 2018

Questionnaire

Firefighter/EMT-Paramedic (FT)

Name ____________________________________ Day Phone _________________________ Home Phone _______________________

Completed application, questionnaire, resume and cover letter are due back by 4:00 p.m., Friday, March 16, 2018.

Your answers to the following questions are an IMPORTANT source of information that will be used to help select a group of finalists. Answer ALL relevant questions, even if your answers duplicate what you have included in your application, resume or questionnaire. Be specific and thorough. You may continue your answers on another sheet of paper.

1. Ohio Firefighter Level II? _____ No ____ Yes (Attach proof of certification) If no, what is anticipated certification date: ___________________ 2. Ohio Paramedic certification? _____ No ____ Yes (Attach proof of certification) If no, what is anticipated certification date: ___________________

3. Fire Safety Inspector? _____ No ____ Yes (Attach proof of certification) If no, what is anticipated certification date: ___________________ 4. Hazardous Materials Operation level? _____ No ____ Yes (Attach proof of certification)

If no, what is anticipated certification date: ___________________ 5. Advanced Cardiac Life Support Provider? _____ No ____ Yes (Attach proof of certification) If no, what is anticipated certification date: ___________________ 6. American Heart CPR or equivalent? _____ No ____ Yes (Attach proof of certification) 7. ICS-100 National Incident Management System (NIMS)? _____ No ____ Yes (Attach proof of certification)

8. ICS-700 National Incident Management System (NIMS)? _____ No ____ Yes (Attach proof of certification) 9. Greater Miami Valley EMS Council protocol testing? _____ No ____ Yes (Attach proof of certification) 10. Valid driver license and are you insurable? _____ No ____ Yes

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Firefighter/EMT-Paramedic Questionnaire

March 2018

11. Candidate Physical Ability Test (CPAT) certificate or Kettering Sports Medicine physical test. Must be dated one year or newer at the time of the second interview. (Attach proof of certification) ____ No ____ Yes ____ CPAT ____ Kettering Sports Medicine Date taken: _____________

12. Do you have a college degree? (Attach proof of certification)

____ Associate's degree(s) Major: ______________________________________ ____ Bachelor's degree(s) Major: ______________________________________

13. Do you have a certification or training in any of the following areas? Check each area that applies. (Attach proof of certification) ____ Ohio Fire Instructor ____ Fire Investigation ____ Ohio EMS Instructor ____ Ohio CPR Instructor ____ Washington Township Driver/Operator ____ Washington Township Squad Leader 14. Please name the fire department(s) where you have worked as a firefighter (e.g., Full-Time Firefighter, Part-Time Firefighter, Volunteer Firefighter) Please include start and end dates for each position held at a department.

Name of Department Position/Title Dates of Service Full-Time, Part-Time, Volunteer Start and End Dates - Month(s) and Year(s)

____________________________________ __________________________________ ______________________________ ____________________________________ __________________________________ ______________________________ ____________________________________ __________________________________ ______________________________

____________________________________ __________________________________ ______________________________

2 of 3

Firefighter/EMT-Paramedic Questionnaire

March 2018

15. Have you ever had any disciplinary at any position you have held? If yes, please list the employer, type, and dates of discipline. Please be specific (e.g., Washington Township, Written Warning, 5/25/15 for Tardiness and City of Anywhere, Suspension 5/17/16 for three 24 hour shifts and it was for four tardiness).

Name of Department Type of Discipline Reason for Discipline Oral, Written, Suspension (list # of days) and Terminated Month(s) and Year(s)

____________________________________ __________________________________ ______________________________ ____________________________________ __________________________________ ______________________________ ____________________________________ __________________________________ ______________________________

____________________________________ __________________________________ ______________________________ ____________________________________ __________________________________ ______________________________

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FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 1 of 7

Employment Status: Full-Time Approved: September 1, 2010 FLSA Status: Non-Exempt, Bargaining Unit Revised: February 28, 2018 Reports To: Fire Lieutenant or Battalion Chief Reviewed: February 28, 2018

JOB SUMMARY

Under the direction of Fire Lieutenant or Battalion Chief, performs all functions associated with fire suppression, EMS, fire prevention and station and equipment maintenance activities for Washington Township.

REPRESENTATIVE LIST OF RESPONSIBILITIES

This list of responsibilities is representative and is not all-inclusive. Upon request, a reasonable accommodation will be made to enable a qualified individual with a disability to perform these responsibilities.

Responds to fire, EMS, rescue and public service alarms.

Operates emergency vehicles, including but not limited to rescue trucks, pumpers and aerial ladders in a safe and legal manner under all weather conditions and in response to emergency situations.

Safely and effectively operates equipment such as fire extinguishers, pry bars, hooks, ropes, aerial ladders, power tools, self-contained breathing apparatus and specialty equipment, etc.

Lays and connects hose, hold nozzle and directs water streams, raises and climbs ladders.

Uses equipment such as fire extinguishers, pry bars, hooks, ropes, aerial ladders, power tools, self-contained breathing apparatus during training and fire suppression.

Performs salvage operations such as covering exposed furniture and removing excess water and debris.

Administers emergency first aid to injured persons including techniques to restore cardio-pulmonary functions.

Performs public education presentations on fire safety and emergency care throughout the community.

Inspects various types of buildings to ensure compliance with fire prevention codes.

Determines the need for and performs general maintenance work in the upkeep of fire department property such as maintaining and testing fire hose, cleaning and polishing apparatus, making minor repairs to various pieces of equipment, cleaning, and maintenance of the building.

Maintenance, testing, inspection, and upkeep of fire hydrants.

Participates in formal classroom and on-the-job training in modern firefighting methods and techniques, fire prevention procedures and emergency victim care, etc.

Maintains job-related records, correspondence and prepares reports.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 2 of 7

REPRESENTATIVE LIST OF RESPONSIBILITIES (continued)

Assists in administrative staff activities such as preparation of memos, manuals, and budget requests.

Uses a personal computer and related software programs to create spreadsheets, report, and correspondence.

Works in all weather conditions and in all terrain.

Provide excellent customer service.

Ability to communicate, interact and maintain professional, efficient and effective working relationships.

Prepares assigned reports.

Read, writes, understands and edits reports, manuals, labels, letters, memos, and correspondence.

Handles confidential information appropriately.

Understands and follows oral and written instructions.

Reliability, which includes regular and predictable attendance, punctuality, and timely and efficient completion of assigned duties.

Promote, gets along and works in a harmonious relationship with others.

Attends meetings and training.

Other duties as required.

REQUIRED EDUCATION AND EXPERIENCE

High school diploma or equivalent.

Ohio Firefighter Level II certification.

Ohio EMT-Paramedic certification.

Fire Safety Inspector certification.

Ohio Hazardous Materials Operations certification.

Valid American Heart CPR card

Advanced Cardiac Life Support (ACLS) certification.

Successful completion of the Greater Miami Valley EMS Council protocol testing within one (1) month of hire date.

Driver/Operator and Squad Leader within the first six (6) months of hire date.

Any combination of training and experience which provides the necessary knowledge, skills, and abilities.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 3 of 7

PREFERRED EDUCATION AND EXPERIENCE

Associate’s degree in Fire Science or related field.

One (1) year or more of experience in firefighting and/or paramedic work environment.

Fire or EMS Instructor certification.

PREREQUISITE KNOWLEDGE, SKILLS, AND ABILITIES

An individual must possess the following knowledge, skills, and abilities before beginning employment:

Possess a valid Ohio Firefighter Level II certification.

Possess a valid Ohio EMT-Paramedic certification.

Possess a Fire Safety Inspector certification.

Possess a valid American Heart CPR card.

Possess a valid Ohio Hazardous Materials Operations certification.

Possess a valid Advanced Cardiac Life Support (ACLS) certification.

Possess valid Montgomery County protocol standards within two (2) months of hire.

Become a Driver/Operator and Squad Leader within the first six (6) months of hire.

Possess a Fire Safety Inspector certification within one (1) year of hire.

Passing score on the written test, as designated by Washington Township.

Possess a valid CPAT certification or equivalent as designated by Washington Township.

Must have the ability, under emergency response conditions, to legally and safely drive and operate all fire department vehicles, including EMS vehicles, rescue trucks, pumpers and aerial ladders.

Ability to learn the geography of the Township, location of water mains, fire hydrants and major fire/life safety hazards within the Township.

Considerable knowledge of the principles, practices, methods, and equipment employed in modern firefighting and the emergency medical services.

Considerable knowledge of fire hazards and fire prevention techniques.

Considerable knowledge of the hazards and corresponding safety precautions necessary for the safe performance of assigned duties.

Ability to work with peers and officers to enhance career development through education and training opportunities.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 4 of 7

PREREQUISITE KNOWLEDGE, SKILLS AND ABILITIES (continued)

Use a personal computer to create publications, reports and correspondence.

Considerable knowledge of emergency first aid techniques and procedures.

Ability to perform routine maintenance on fire equipment.

Ability to effectively and professionally represent the Township while speaking before groups.

Strong oral communication and presentation skills. Must be able to listen attentively, organize thoughts, speak and write clearly and professionally, and comprehend written documents.

Ability to perform complex mathematical computations related to the Fire Department.

Read, writes, and edits reports and correspondence.

Excellent self-discipline. Ability to work well without immediate supervision.

Excellent judgment. Ability to make prompt and accurate decisions, as directed.

Ability to comply with all Township and job-specific safety requirements.

Ability to work other than normal working hours as necessary.

Must have a valid driver's license and remain insurable, without penalty or surcharge, under the Township's vehicle insurance plan.

DEMONSTRATED KNOWLEDGE, SKILLS, AND ABILITIES

An individual must be able to demonstrate the following knowledge, skills, and abilities after training on the job.

Maintains a Ohio Firefighter Level II certification.

Maintains a Ohio EMT-Paramedic certification.

Maintains a Ohio Hazardous Materials Operations certification.

Maintains a Fire Safety Inspector certification.

Maintains a valid Advanced Cardiac Life Support (ACLS) certification.

Maintains a valid American Heart CPR card.

Must have successfully completed the Greater Miami Valley EMS Council protocol testing each year.

Maintains a Driver/Operator and Squad Leader status for the Washington Township Fire Department.

Maintains all Federal and state certificates as required.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 5 of 7

DEMONSTRATED KNOWLEDGE, SKILLS, AND ABILITIES (continued)

Must successfully demonstrate the ability, under emergency response conditions, to legally and safely drive and operate all fire department vehicles, including EMS vehicles, rescue trucks, pumpers and aerial ladders.

Considerable knowledge of the geography of the Township, location of water mains, fire hydrants and major fire/life safety hazards within the Township.

Considerable knowledge of the principles, practices, methods, and equipment employed in modern firefighting and the emergency medical services.

Demonstrates the ability to differentiate normal conditions from a potentially hazardous environment.

Demonstrates the ability to identify sick and injured patients.

Demonstrates the ability to differentiate between safe and unsafe conditions.

Demonstrates the ability to open and close valves.

Demonstrates the ability to read and inspect gauges.

Wears and effectively uses all protective firefighting gear, including service boots, self-contained breathing apparatus, protective headgear, and fire resistant hood, gloves, coats and pants while performing firefighting activities.

Be knowledgeable of and follow departmental policies.

Any other skills, and abilities and knowledge required as the job changes.

PHYSICAL REQUIREMENTS

Upon request, a reasonable accommodation will be made to enable a qualified individual with a disability to perform these requirements.

Uses fingers/hands/arms frequently.

Lift, carries and pushes up to 100 pounds.

Occasional crawling, kneeling, bending and climbing, including stairs and ladders.

Ability to reach over shoulders.

Must have good eyesight and depth perception.

Ability to work at a rapid pace.

Ability to hear.

Walking and standing on various surfaces including rough terrain, as required.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 6 of 7

PHYSICAL REQUIREMENTS (continued)

Frequent sitting, as required.

Ability to work in inclement weather.

Moves about in close quarters and areas.

Demonstrates the ability to maintain the strength and stamina required to operate pertinent tools and equipment.

Grips, lifts, carries, loads and unloads from Fire Department vehicles all necessary Fire Department authorized equipment.

Ability to climb to the top of an aerial ladder and back down.

Demonstrates the ability to off-load and maneuver 200 feet of 2 inch or 1 ¾ inch fire hose.

Demonstrates the ability to maneuver, with assistance, 2 ½, 3 and 5-inch hose, as necessary.

Raises a 24-foot extension ladder with help of one other person.

Demonstrates the ability to drag 150 pounds while outfitted in full firefighting gear.

Demonstrates the ability to carry, with assistance, a minimum of 150 pounds over a flat surface as wells as up or down an incline.

Walk, run, and jumps as needed to respond to emergency situations.

Dresses in full firefighting gear within a designated time frame.

Demonstrates the flexibility necessary to vertically step into a fire, EMS or rescue vehicle while dressed full firefighting gear.

Possess sufficient dexterity to successfully perform all standard and recognized paramedic functions.

Possess sufficient visual acuity in order to function optimally in dense smoke and darkness.

Hears instructions and commands while wearing protective headgear at the fire and emergency scenes and training.

Follows a fire hose back to its source by relying on the sense of touch.

Detects body movement, temperature and deformity through a sense of touch.

Balances on many surfaces as may be encountered in the course of firefighting/EMS rescue operations and fire safety inspections.

Performs any and all firefighting and/or EMS activities, including standing, in full firefighting gear, in all types of extreme weather conditions.

FIREFIGHTER

Washington Township is an Equal Opportunity Employer. Page 7 of 7

PHYSICAL REQUIREMENTS (continued)

Bends, crouches, stoops, crawls, stretches and otherwise maneuvers as necessary around numerous obstacles and tight spaces, as may be found in burning buildings or accident and emergency scenes, as well as training activities.

Remains physically and mentally alert during prolonged periods of intense, sustained physical activity in difficult environments.

Performs rescue, EMS and/or firefighting activities below ground, at extreme heights, or in close proximity to hazardous materials.

Climbs to the top of an aerial ladder and back down.

Demonstrates the ability to open and close valves.

Demonstrates the ability to read and inspect gauges.

Steps vertically three feet to enter a fire/EMS vehicle.

Wears and effectively uses all protective firefighting gear including service boots, self-contained breathing apparatus, protective headgear and fire resistant hood, gloves, coats and pants.

Any other physical requirements as job changes.

FIREFIGHTER

MARCH 2018

FIREFIGHTER RECRUITMENT OVERVIEW

If you are asked to continue forward in the hiring process, the dates and locations listed below are provided to you as a courtesy. Please note that these are tentative dates/locations and are subject to change without notice. Everyone will be notified of the final outcome.

Event Date and Time Location

Ergometrics Test Friday, March 23 at 8:30 a.m. Washington Township Fire Training Center 8320 McEwen Road, Dayton (back of the building)

First Interview Tuesday, April 3 Washington Township Fire Headquarters

8320 McEwen Road, Dayton

Second Interview Tuesday, April 10 Washington Township Fire Headquarters 8320 McEwen Road, Dayton

Final Interview To Be Determined Washington Township Government Center 8200 McEwen Road, Dayton

FIREFIGHTER MARCH 2018

FIREFIGHTER PHYSICAL TEST INFORMATION Physical Ability Test You must provide a copy of a physical ability test either a Candidate Physical Ability Test (CPAT) or Kettering Sports Medicine and the certificate must be dated one year or newer at the time of the second interview. If you do not have one, you may contact a CPAT provider or Kettering Sports Medicine to obtain this certificate. The cost of the certification is your responsibility. Scheduling If you wish to schedule a test, you may contact one of these two providers:

Candidate Physical Ability Test (CPAT) You may contact the Miami Valley Fire and EMS Alliance for further details at 937-512-5103 or www.mvfea.com to review their test schedule.

Kettering Sports Medicine

Please contact Cindy at 937-395-3910 to schedule an appointment. You will need to have written authorization from your physician that you are medically cleared to take this test. The doctor’s release and the protocols for this test are included.

Kettering Sports Medicine Center Protocol Information Sheet

Washington Township Fire Department Firefighter Physical Abilities Test

1. Measure Candidate’s vertical/overhead reach height to the inch from floor to heel of hand and weigh candidate, weight in

lbs prior to application of weighted vest and air pack.

2. Enter measurements on Lift test form at indicated areas as well as lift requirement for shoulder to overhead lift indicated

per reach height from “Lift Force chart—35 Foot Extension Ladder.

3. Perform Non-material handling and Material handling testing with candidates wearing 29 lb. vest (simulating weight of turn

out gear) with 25 lb. air pack for total added weight of 54 lbs.

4. Perform Frequent Material handling testing (No weighted vest or air pack worn due to specific standardized test

requirements).

5. Test to maximum lift level but do not exceed test requirement settings greater than smallest weight increments allowed by

test equipment used, (This does not include outcomes for resistance related tasks performed with momentum influence).

6. Complete test form with comments as needed at bottom of form. Sign and date.

7. Fax results to Dawn Barnett at (937) 438-2742, Human Resources for Washington Township for processing.

8. Call Dawn Barnett, at (937) 432-2758 to inform that Candidate passed/did not pass test.

NON-MATERIAL HANDLING TEST REQUIREMENTS INVOLVE THE FOLLOWING AREAS:

Walking, Standing, Crawling (Standard and combat crawl), Climb Stairs / Ladder with Flexibility maneuvers

while on ladder, Balance, Reach Forward, Reach back, Bending, Squatting, Kneeling,

Finger Coordination: dexterity test

MATERIAL HANDLING TEST RQUIREMENTS INVOLVE THE FOLLOWING AREAS

Floor to Waist lift (Requirement 90 lbs)

Waist to Shoulder lift (Requirement 87 lbs)

Shoulder to Overhead lift (Force requirement is determined by reach height / ladder lift force chart)

Horizontal Push (Requirement 103 lbs); Horizontal Pull / (Requirement 109 lbs)

Rope-Pull down for extension ladder raising simulation 30 lbs resistance with time requirement

Shoulder to Overhead: Repetitive chopping with axe.

Frequent lifting: Performance of a repetitive lifting test is performed without turnout gear or weighted vest.

Floor to Waist: Requirement 45 lbs. Waist to Shoulder: Requirement 44 lbs

Biomechanics application: Candidate’s performance of safe body mechanics application is monitored throughout testing

process i.e. and test can be stopped if candidate is unable to perform test activities using safe body mechanics.

Activity tolerance / Endurance level: Rated during test activity performance by monitoring heart rate throughout testing.

There are standardized tests that include criteria for pass/fail for “American Medical Association” standards for age

related ratings of 85 percent heart rate, (max allowance).

Comments: (i.e., problem solving, ability to follow directions, motor skills) are documented on test form which is sent to

the above named (#7 and /or #8) individuals.

Pass/ Fail: Candidate must pay the full $100.00 prior to testing and pass all criteria requirements of test for test to be

considered a “Pass.” If candidate is not able to pass all criteria, then test is considered a “Failed test,” (There is no

reimbursement for failed test). Candidate can opt out of test at any time after any part of criteria is not met, or evaluator

can decide to stop testing if evaluator determines that it is not safe for candidate to continue. If candidate does not “opt

out” and evaluator determines it is safe to continue with test, candidate can choose the option of attempting to complete

testing to determine areas that candidate will need to work on, if decision is made for re-test, per Washington Township

Fire Department criteria (candidate must generally wait three months before attempting to retest).

Fire fighter Applicant Name:__________________________________ PASS /FAIL Test Date:_______

Evaluator Signature:____________________________________________________________________ Form: 5/09, 8/12, 3/13

Please wear pants or bring sweatpants to avoid a rug burn during one of the tests. You may not sit down to remove them.

540 Lincoln Park Blvd. Kettering, OH 45429

Phone: 937-395-3910, Fax: 937-395-3950

MEDICAL CLEARANCE: Firefighter Physical Abilities Test

Applicant’s Name:______________________________________ DOB:______________________

Dear Doctor,

This applicant has been referred for participation in testing for the Heavy physical demand requirements

associated with fire fighting duties. If the applicant is identified as having any of the medical problems or risks

listed below, we must require medical clearances to proceed with the requested services.

General Medical Concerns:

□ Systolic blood pressure ≥ 160 or diastolic blood pressure ≥ 90 mmHg on at least two specific occasions.

□ Pregnancy

□ 65 years or older

□ Other, please specify: _______________________________________________________________

___________________________________________________________________________________

Medical Clearance:

The signature of a physician (MD or DO) below indicates that the applicant is under his/her care for the

concerns checked above or has been examined and is safe to perform the required heavy physical demand level-

duties of a firefighter. (The testing will include strength testing and gradually progressed exercise in an aerobic

target heart range).

(Please Check)

□ No restrictions

Or Precautions:

□ No maximal strength testing

□ Exercise heart rate not to exceed ________ bpm.

□ Gradual progression of endurance and strength exercise as tolerated

□ Other, please specify: __________________________________________________________________

Physician Signature: _______________________________________________ Date: _________________ (Print or Stamp Name and Address) (Rev. 7/01, 6/10, 8/12)