Form- 04 - Mississippi Fire Personnel Minimum Standards And Certification Board Physical Examination Release Form-04 2009 Page 2
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1
2Mississippi Fire Personnel Minimum Standards and Certification Board
Physical Examination Release Form- 04
(Rev 12/2009)
Page 2 of 2
Student Name: _____________________________ Exam Date: ___________________
Last 4 Digits of SS# ________________
9)
Operating fire apparatus or other vehicles in an emergency mode with emergency
lights and sirens.
10)
Critical, time-sensitive, complex problem solving during physical exertion in
stressful, hazardous environments, including hot, dark, tightly enclosed spaces that
are further aggravated by fatigue, flashing light, sirens, and other distractions.
11)
Ability to communicate (give and comprehend verbal orders) while wearing personal
protective ensembles and SCBA under conditions of high background noise, poor
visibility, and drenching from hoselines and/or fixed protection systems (sprinklers).
12)
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 civilians or other
team members.
*(Elements taken from NFPA 1582 5.1.1)
Other activities may include, but are not limited to the following:
Driving Emergency Vehicles
Rescue Operations
Walking-lateral mobility
Bending
Crouching
Standing
Kneeling
Pushing
Running
Gripping, hands, and fingers
Sense of Touch
Climbing Ladders
Comprehending voice communications
Close vision
Side vision depth perception
Giving verbal communication
Finger Dexterity
Administering emergency care
Lifting, carrying, dragging 0-200 pounds
Walking, rough terrain
Stooping
Sitting
Standing long periods
Twisting body
Pulling
Crawling
Reaching
Climbing Stairs
Hearing alarms
Color ID
Far Vision
Night Vision
Operating passenger vehicles
Elevated temperatures above 250 degrees
I hereby certify that I completed a physical examination of the above named student on the
date identified above.
After reviewing all the information on these two pages, to include the list of firefighting
duties and conditions, it is my medical opinion that this person (check one)
IS
IS NOT
physically able to perform the duties of a fire fighter and participate in the Minimum
Standards Training Course.
Physician's Name (typed or printed clearly): _______________________________________________
This document must be signed by either a Medical Doctor or Doctor of Osteopathy per NFPA 1582 4.4.1
.
Physician's Signature: ________________________________________________________________
(Signature of M. D. or D. O.)
(Date)
Mississippi Fire Personnel Minimum Standards and Certification Board
#1 Fire Academy USA
Jackson MS 39208-9600
Phone: 601-932-2444
Fax: 601-932-2819
MSCB-04
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