Fillable OCCUPATIONAL FIRST AID STATEMENT OF FITNESS (Wellington City Council New Zealand)

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OCCUPATIONAL FIRST AID STATEMENT OF FITNESS (Wellington City Council New Zealand)

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Report continued on reverse side
OCCUPATIONAL FIRST AID
STATEMENT OF FITNESS
Surname of candidate
Given name(s) in full
Date of birth (yyyy-mm-dd)
Mailing address
City
Province
Postal code
Section 3.21(2) of the Occupational Health & Safety Regulation (OHSR) states:
A first aid attendant must be physically and mentally capable of safely
and effectively performing the required duties and the Board may at any
time require the attendant to provide a medical certificate.
Participation in first aid training courses and performing the duties of a first aid attendant
in the field can be physically demanding and may require prolonged kneeling, working in
stooped positions, and rolling patients. Depending on the working conditions, these
physical demands can become rigorous.
Statement of fitness
Answer all the following questions honestly and truthfully regarding any medical conditions.
For more information on the statement of fitness, contact the agency representative.
If the answer to any of the following questions is yes, an Occupational First Aid
Medical Certificate of Fitness, completed by a physician on a form acceptable to
WorkSafeBC, must be provided before certification is issued. The Medical
Certificate of Fitness form can be obtained online at WorkSafeBC.com or from
the agency representative.
Disease conditions — is there medical evidence and/or history of:
Insulin-dependent diabetes Yes No
Seizure disorder Yes
No
Communicable disease Yes
No
Respiratory disease Yes
No
Heart disease Yes
No
Multiple sclerosis Yes
No
Have you experienced any problems in the previous 12 months, related
to the overuse and/or addiction to alcohol, recreational or prescription
drugs, and/or over-the-counter medications?
Yes
No
Have you experienced any psychological or emotional episodes which
could preclude you from performing the duties of an occupational first
aid attendant?
Yes
No
Do you have any visual impairment that would prevent you from
assessing a scene from a distance, performing minor wound care,
removing small slivers, removing small particles from the eye, and/or
assessing a patient for pallor and contusions? Yes
No
RESET
Occupational First Aid
Statement of Fitness
(continued)
Page 2 of 2
Do you have any hearing impairment that would prevent you from
hearing a summons for first aid, hearing and assessing a patient’s
breathing, distinguishing if there is distressed breathing, and/or verbally
communicating with a patient? Yes
No
Do you have any physical condition that would limit you from carrying
22.5 kg (50 lbs), traversing rough terrain such as steep banks, steep
excavations, or high elevations to render first aid? Yes
No
I have answered all the above questions honestly and truthfully. This is
a true reflection of any physical and mental condition that would have a
bearing upon my ability to participate in a first aid training course and/or
function as a first aid attendant.
Name (please print) Signature Date (yyyy-mm-dd)
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OCCUPATIONAL FIRST AID STATEMENT OF FITNESS (Wellington City Council New Zealand)

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Completed 18 January 2022

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