Form- 04 - Mississippi Fire Personnel Minimum Standards And Certification Board Physical Examination Release Form-04 2009
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1
2Mississippi Fire Personnel Minimum Standards and Certification Board
Physical Examination Release Form- 04
(Rev 12/2009)
Page 1 of 2
Student Name: ______________________________ Last 4 Digits of SS#: ___________
Sponsoring Fire Department: _______________________________________________
Physician Examination Date: _________________________
Name of Doctor: ______________________________________________
Office Address: __________________________________________________________
Phone Number: ________________________
Fax Number: _____________________
This document must be signed on page two (2) by either a Medical Doctor or Doctor
of Osteopathy per NFPA 1582 4.4.1. The Medical Doctor or Doctor of Osteopathy shall
consider the physical, physiological, intellectual, and psychological demands of the
occupation when evaluating the student's ability to perform the essential job tasks.
The duties of a fire fighter include, but may not be limited to essential job tasks and
performances of these activities:
1)
Performing firefighting tasks (e.g.hoseline 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 while wearing personal protective ensembles and self-contained
breathing apparatus (SCBA), including working in extremely hot or cold
environments for prolonged time periods.
2)
Wearing an SCBA, which includes a demand valve-type positive-pressure facepiece
or HELPA filter masks, which requires the ability to tolerate increased respiratory
workloads.
3)
Depending on the local jurisdiction, climbing six or more flights of stairs while
wearing fire protective ensemble weighing at least 50 pounds (22.6 kg) or more and
carrying equipment/tools weighing an additional 20 to 40 pounds (9 to 18 kg).
4)
Wearing fire protective ensemble 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 degrees F (39 degrees C).
5)
Searching, finding, and rescue-dragging or carrying victims ranging from newborns
up to adults weighing over 200 pounds (90 kg) to safety despite hazardous
conditions and low visibility.
6)
Advancing water-filled hoselines up to 2-1/2 inches (65 mm) in diameter from fire
apparatus to occupancy {approximately 150 feet (50 m)}, which can involve
negotiating multiple flights of stairs, ladders, and other obstacles.
7)
Climbing ladders, operating from heights, walking or crawling in the dark along
narrow and uneven surfaces, and operating in proximity to electrical power lines
and/or other hazards.
8)
Unpredictable emergency requirements for prolonged periods of extreme physical
exertion without benefit of warm-up, scheduled rest periods, meals, access to
medication(s), or hydration.
MSCB-04
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