Fillable FIREFIGHTER MEDICAL EXAMINATION CERTIFICATE (Kilgore College)

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FIREFIGHTER MEDICAL EXAMINATION CERTIFICATE (Kilgore College)

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*Please download this form into Adobe to type in your information. You may then print the pages and give them to your
physician. Your physician will need to fill it out and sign it. This page may be scanned/emailed to kcfa@kilgore.edu or
mailed to: Kilgore College Fire Academy, ATTN: Kristi Simpson, 1100 Broadway, Kilgore, Texas 75662
FIREFIGHTER MEDICAL EXAMINATION CERTIFICATE
Last Name: First: Middle:
Date of Birth: Social Security #:
Address:
(City)
(Province)
(Postal Code)
I certify that I have completed my examination of the examinee and I have concluded that on this date, the
examinee has had:
□ PHYSICAL EXAM
And is to be found physically sound and free from any defect which may adversely affect the performance of duty
appropriate to the type of license sought. (See attached Overall Strengths Demands Required for Firefighters)
Passed
Failed
Physician
Information:
Name
License Number
City
Province
Postal Code
Mailing
Address:
(Street)
Office Phone Number:
Date Signature of Physician
This declaration is not public information and is valid unless withdrawn or invalidated, and is valid only if signed
by a licensed physician.
Fire Academy
Not Applicable
Overall Strength Demands Required for Firefighters
The following criteria are descriptions of the overall strength demand requirements that firefighters are medically
and physically capable to perform.
PHYSICAL DEMAND
DESCRIPTION
Standing/Walking
On concrete, asphalt, burned out buildings to investigate fire sites; to
demonstrate equipment when giving speeches.
Vision
To operate equipment; perform rescue operations.
Hearing/Talking
Communicate during rescue and fire fighter operations; communicate on
the radio and in person with the public; diagnose equipment problems.
Lifting/Carrying
Protective gear (20-26 lbs.) self-contained breathing apparatus (27 lbs.);
ladders up to 24 feet long (64 lbs.); fan (50 lbs.); fire extinguisher (40-45
lbs.); jaws and power unit (60 lbs. each).
Pushing/Pulling
Red line – 20 lbs. of exertion; hose – 45 to over 50 lbs. of exertion; close
valve – 55 lbs. of exertion; for CPR – 35 lbs. of force.
Reaching
For fan, jaws, and power unit in cramped confined space; to lift ladders –
60 inches; for fire extinguishers – 20 inches; for deluge gun – up to 80
inches; for extension ladder – 72 inches; for Hurst tool and power unit – 42
inches; to use ceiling hook to pull ceilings and to wash apparatus.
Handling
To connect hoses; use ladders; use small tools; open and close valves;
handle victims.
Fine Dexterity
To draw pre-fire plans, use chemical monitors; fill out reports; tie ropes and
knots; administer emergency medical treatment.
Foot control
To drive, push gas and brake pedal – 30 lbs. of exertion; to operate
stretcher – 20 lbs. of exertion.
Bending
To fold, couple, and uncouple fire hoses; move equipment and tools;
administer first aid.
Twisting
To operate hose streams; put on self-contained breathing apparatus;
communicate on vehicle; raise and lower scene lights on van and trucks.
Climbing/Balancing
On ladders, stairs, or fire vehicle to obtain equipment; to walk on rafters,
and in attics; to use hose stream.
Machines, Tools, Equipment and Work Aids
Chain saws, smoke ejectors, generators, self-contained breathing apparatus, fire pumps, nozzles, axes, pike
poles, ladders, ropes, Hurst tool and power unit, hoses, deluge gun, halligan tool, stretcher, oxygen, electrical
cords, spanner wrench, emergency medical equipment, and hydrant wrench and computer.
Environmental Factors
Exposed to extreme heat in burning structures; work outside in all types of weather and high humidity.
Exposed to chemicals, exhaust fumes, smoke, burning buildings, noise from truck engines, jaws and power
units, saws, sirens and air horns. Operate power saws, jaws, and power unit tool.
*Information Page
Fire Academy
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FIREFIGHTER MEDICAL EXAMINATION CERTIFICATE (Kilgore College)

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Completed 6 October 2020

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