Appendix 3 13403.pdf

Medical Screening Form
New Career Recruits
INFORMATION FOR CANDIDATES - IMPORTANT PLEASE READ
Please ensure:
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 Section  A  is  filled  in  by  you  and  signed  prior  to  seeing your doctor.
 This  medical  assessment  and  the  invoice  are  sent  to
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Fire  and  Emergency  New  Zealand  by your medical centre
[email address] or fax: (04) 471 1793.
 You can request a copy of your medical for your records.
This medical consists of two main areas:
1. Medical History:
Please  ask  your  regular  GP,  or  medical  centre  who  hold  your  medical  history,  to  complete
this medical form. This will usually take a double appointment so please advise when you book
INFORMATION
your appointment that this is for a pre employment Fire and Emergency New Zealand medical.
2. Hearing Test:
Please  make  an appointment with an audiologist for a full audiogram. Fire and Emergency New
Zealand will pay for your consultation. The audiology form is provided seperately.
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If you have any medical queries please contact the Medical Screening Team on 04 496 3716.
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Medical Screening Form | New Career Recruit | November 2021
Candidate Information

Medical Screening Form
New Career Recruits
INFORMATION FOR DOCTORS AND MEDICAL CENTRES - IMPORTANT PLEASE READ
Medical Form: Once completed, please forward this form with the invoice to:
Email: [email address]  or Fax: +64 4 471 1793
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Invoices: Please use ref: 5320/CFFRECRUT for invoices and fax to +64 4 471 1793.ACT
If you have any medical queries, please phone our Medical Screening Team on 04 496 3716. If you have any
accounts queries, please phone Accounts Payable on (04) 496 3666.

Payment can only be made once Fire and Emergency New Zealand receives a completed copy of this
Medical form. Please retain a copy on the patient’s file.

Fire  and  Emergency  New  Zealand  will  not  pay  additional  costs  for  missing  information,  which
should have been completed as part of the Medical Screening form.

Fire  and  Emergency  New  Zealand  will  not  pay  for  any  additional  tests  unless  these  have  been
requested by Fire and Emergency New Zealand to assist with the recruitment process.
INFORMATION
INFORMATION FOR DOCTORS- IMPORTANT PLEASE READ
This candidate is being considered for entry into Fire and Emergency New Zealand as an
OPERATIONAL FIREFIGHTER.
All of the questions on this form are relevant. We ask that every question is
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answered fully and comprehensively. Please read the form carefully.
Considerations:
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As  an  examining  doctor  you  must  consider  the  tasks,  physical  environment  and  safety-critical  nature
of firefighting while undertaking this medical assessment. Please ensure that the forms are completed in
full and all relevant information is provided to Fire and Emergency New Zealand.
Firefighters perform functions that are  physically and psychologically demanding. These functions are
often performed in emergency situations, under difficult environmental conditions. Firefighters are also
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required  to  wear  personal  protective  equipment,  including  structural  firefighting  ensemble  and
breathing apparatus. Any potential cause of sudden incapacity is clearly not compatible with this type
of work. Firefighters require a level of medical fitness compatible with a class 2-5 licence.
The  Fire  and  Emergency  New  Zealand  National  Medical  Officer  will  ultimately  be  responsible  for
determining whether a new applicant is fit to become an operational career firefighter. Please do not pre-
empt this decision by offering an opinion regarding work fitness, as this can create confusion and delay
the process, especially if this opinion is different from that of the National Medical Officer.
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There are some situations where further medical assessments or tests are required before a decision can be
made on work fitness. Fire and Emergency NZ will request these if required.
If  you  have  any  questions  regarding  the  medical  screening  assessment  process,  please  contact  the
Medical Screening Team on 04 496 3716.
Medical Screening Form | New Career Recruit | November 2021
Doctors Information

Medical Screening Form
New Career Recruits
SECTION A - Personal Information (Candidate to complete)
First Name: ____________________________________  Last Name: _______________________________________
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Date of birth (dd/mm/yy):   _______________________  Gender:  Female

Male
Postal address: __________________________________________________________________________________
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______________________________________________________________________________________________
Telephone numbers: Hm (       ) ____________________________ Mob (          ) ______________________________
Is this your first medical screening assessment for the New Zealand Fire Service or Fire and Emergency New Zealand?
Yes
No
Is this your usual medical centre?
Yes
No
If you are not completing this medical assessment with your regular GP what is the reason?  __________________
INFORMATION ___________
Present occupation:_____________________________________________________________________________
I declare that:
 The answers to all questions are true and correct.
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 I have read all the questions and answers and the information which I have provided is full and complete.
 I have not withheld any information which might cause Fire and Emergency New Zealand to incorrectly assess
my ability to complete the role for which I have applied.
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 I understand that I could be discharged if I am engaged by Fire and Emergency New Zealand and it is later
discovered that I withheld information and/or provided false information.
 I hereby authorise the National Medical Officer and medical screener's to contact my General Practitioner if
any information is required to process my application to join Fire and Emergency New Zealand.
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 I am providing health information to Fire and Emergency New Zealand and authorising Fire and Emergency
New Zealand to obtain health information from my representatives (such as my General Practitioner).
 My health information will be used for the purpose of determining my recruitment application.
 If my recruitment application is successful, Fire and Emergency New Zealand may use my health information in
databases  for  health  and  safety  risk  management  (including  identification  of  significant  hazards),  baseline
monitoring, and comparison against my future state of health.
 My health information will be treated in accordance with the Privacy Act 2020 and the Health Information
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Privacy Code 2020.  I have the right to access, and to correct, my health information that is held by Fire and
Emergency New Zealand.
 This information will be retained for a period of 40 years after I exit from Fire and Emergency New Zealand.
Candidate’s signature  ___________________________________
Date _______________________________
Medical Screening Form | New Career Recruit | November 2021
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SECTION B – GP to complete
Applicant NHI:
If the answer is Yes to any question below, please give all details of each instance in the panel provided
on the next page, and attach relevant specialist letters and extra pages if needed
Please answer al  questions.
Answer yes or no to al  the questions below:
Yes
No
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Any health or medical issue that may affect the ability to carry out the tasks required for the
1
position being applied for?
(Tasks include but are not limited to: Running, climbing, bending, crawling, heavy lifting, carrying,
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gripping, reaching, and the ability to work independently.)
2
Been diagnosed as having a serious illness, such as cancer or leukaemia?
(Please provide specialist reports)
3
Had the need for any medication relating to physical, neurological or psychological impairment
(e.g. respiratory medication)?
4
Asthma, including childhood or chronic cough?
(If ‘Yes’ complete the asthma questionnaire on page 7
5
Pneumothorax?
6
Active infections such as TB?
INFORMATION
7
Sleep apnoea? (If ‘Yes’ comment below on hypersomnolence)
8
Any heart or vascular condition which restricts fitness for work?
(Please provide any reviews or tests)
9
Chest pain due to proven or suspected angina?
10  Heart attack or heart failure?
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11  Heart valve defect?
12  High or low blood pressure?
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13  Irregular heart rate?  *(If yes, please provide recent ECG if available)
*
14  Peripheral vascular disease?
15  Stroke or TIA (Transient Ischemic Attack)?
16  Any problem affecting general strength or fitness?
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17  Any amputation of a hand, foot or limb?
18  Arthritis or joint replacement?
19  Limb, back or neck condition?
20  Skull or jaw condition affecting ability to wear breathing apparatus?
21  Recurrent joint dislocation?
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22  Epilepsy, fainting attacks, fits or seizures?
23  Intellectual impairment?
24  Brain or head injury/disease, concussion or migraines?
25  Significant bowel disorder?
Medical Screening Form | New Career Recruit | November 2021
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Answer yes or no to al  the questions below:
Yes
No
26  Hernia? (If ‘Yes’ note date and if repaired)
27  Disease of urinary tract?
28  Anaemia or condition causing increased bleeding?
29  Diabetes (type 1    or type 2  ), thyroid or another gland problem?
Hypoglycaemic episodes
Yes               No
HbA1c -
30  Mental illness, clinical depression, anxiety state or psychotic episodes? (see page 5)
31  Substance abuse, or alcohol dependence or abuse?
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32  Any medications being taken?
33  Allergies?
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If you answered YES to any questions above, provide al  details in the table below.
Use extra pages or attach any documents as required. Please include specialists' reports.
Question
Number
Cause
Treatment
Medications
On-going concerns issues
or limitations
INFORMATION
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COVID-19 Vaccination
Is the applicant vaccinated against COVID-19?
Yes * ☐
No ☐
*
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If yes, please provide the following details:
Dose 1 ☐ Date: __________
Dose 2 ☐ Date: __________
Booster ☐  Date: __________
Type (please circle):
Pfizer
Janssen
Moderna
AstraZeneca
Hepatitis Vaccination
GP please note: DO NOT VACCINATE or PROCESS SEROLOGY
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Is the candidate vaccinated against Hepatitis B?           Yes
* No
* Uncertain
If: Yes, attach copy of proof of vaccination if available
* No/Uncertain, Fire and Emergency New Zealand has a formal hepatitis B vaccination programme. A candidate has
access to this programme upon request once they are accepted into Fire and Emergency New Zealand.
Medical Screening Form | New Career Recruit | November 2021
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SECTION C - GP to Complete
Every question must be answered. Please write you answer in the column to the right of the question.
1
Age
2  Height
cm  3  Weight
kg
BMI
BMI =
4
If  BMI  is  above  30,  venous  blood  glucose  is  required  BG /
(mmol/L).
HbA1c =
5
Pulse rate
reg/irre
6
Any heart murmur or abnormal sounds?

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*If  yes, please describe murmur and provide any paperwork from
*   Yes
No
investigation
Blood pressure
*BP
  =
7
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I
* f  BP  above  140/90  on  first  reading,  please  complete
another BP recording 10 minutes apart.
2nd BP reading =
8
Is chest examination normal?
Yes
No
If
*
*
no, please provide details
Peak flow
Peak Flow
Expected
9
(Please coach patient in correct technique and repeat if lower than expected)
Peak Flow
If peak flow is >80 below expected for female or >100
below expected for male you must provide spirometry.
  L/min
  L/min
10
Spirometry (please attach full report) ONLY IF PEAK FLOW IS SUBOPTIMAL
INFORMATION
Full  range  of  movement  is  normal  in  upper  and  lower
limbs?
11
Yes
*
No
* If no, please provide details:
12
Eyes - is the following normal? Visual fields (more than 120°)
Yes
*
No
at confrontation
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* If no, please provide details:
13
Reduced vision or night blindness?
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Yes
No
Vision Check
Please note:  Glasses are
UNCORRECTED
GLASSES
CONTACT LENSES
incompatible with
Right
Left
Both  Right
Left
Both  Right
Left
Both
breathing apparatus
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Distance Visual Acuity:

(6m)
14.1 Standard-Uncorrected or
6/
6/
6/
6/
6/
6/
6/
6/
6/
with contacts 6/9 both
eyes
Near Visual Acuity:
(35cm)
Hold this paper 35cm away
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from the applicant (without
14.2
glasses) and have them:
 Read numbers at random
 Identify where the gauge
is
Mark Y if able to identify
numbers and gauge.
Medical Screening Form | New Career Recruit | November 2021
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SECTION D - Psychological History
If there is any history of mental illness, please answer all questions in the table below:
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Psychiatric disorders can lead to sudden onset, which may present  risks to the  safety of the individual and others
during firefighting and rescue work.

The presence of psychological/neurological condition may not necessary preclude a candidate from entering Fire and
Emergency New Zealand.
If there is any history of mental il ness, please answer al  questions below

Condition: please specify history, warning signs
Triggers
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(for initial depression and for
List episodes, duration date and
and triggers. Please attach specialist reports
any subsequent episodes)
treatment eg. medication /counselling
Episodes of psychosis?
Yes
No
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If yes, please provide details:
Anxiety?
Yes
No
If yes, please provide details:
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Depression?
Yes
No
If yes, please provide details:
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Do you feel that the triggers are such that Firefighter work may exacerbate the situation?      Yes
No
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Please add any further comments you feel are necessary for Fire and Emergency New Zealand to know about
this candidate to enable us to assess their entry into the Fire and Emergency New Zealand.
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Medical Screening Form | New Career Recruit | November 2021
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Section E - GP to Complete
Please send this completed Medical Screening Assessment form, with a copy of your invoice, to:
Email: [email address]
Fax: +64 4 471 1793
Invoices: For quick payment please use ref: 5320/CFFRECRUT
If you have any medical queries, please phone   (04) 496 3716
If you have any accounts queries, please phone (04) 496 3666
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Please note:
 Payment can only be made once  Fire and Emergency New Zealand receives a completed copy of this Medical
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form. Please retain a copy on the patient’s file.
 Fire and Emergency New Zealand will not pay additional costs for any missing information, which should have
been completed as part of the Medical Screening form.
 Fire and Emergency New Zealand will not pay for any additional tests unless these have been requested by Fire
and Emergency New Zealand to assist with the recruitment process.
I declare that all tests and information carried out on (candidate's name)  _______________________________________
are true and correct to the best of my knowledge.
INFORMATION
GP’s signature: ________________________   ____________________  Date:  _______________________________
Surgery stamp: _____________________________________________
  Contact number: (     ) ____________
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THE  CHECKLIST:
Copy of medical retained on patient’s file
Send medical form and invoice to Fire and Emergency New Zealand, details above. Please ensure ALL
questions are filled out in their entirety.
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Medical Screening Form | New Career Recruit | November 2021
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Section F  - GP to complete: Asthma Questionnaire if any history of asthma/chronic cough/wheeze
Asthma Questionnaire
Please complete ONLY if the candidate has had any history of asthma, including childhood asthma.
Any history of asthma including cases of resolved childhood asthma will require a Saline Challenge or
Mannitol test  to exclude significant bronchial hyper- responsiveness,  which  is  contra-indicated  in  breathing
apparatus  use. FENZ will refer for saline testing.
Firefighters  are  required  to  use  breathing  apparatus  and  wear  personal  protective  equipment  weighing
approximately  20kgs.  This  can  increase  the  respiratory  effort.  Firefighters  can  also  be  exposed  to  gases  and
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particulate matter generated from burning wood or other organic matter.
1
Age of onset:
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2
When was the candidate’s last asthma attack?
3
Frequency, nature and severity of asthma
symptoms:
4
Frequency of asthma symptoms requiring
steroids:
5
Precipitating features:
INFORMATION
6
Current medication - including dosage and when
last prescribed and used:
7
Number of hospital admissions over the last 10
years for asthma:
Peak flow/Spirometry results pre- and post-
Pre:
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8
bronchodilator (if available in accordance with
standards):
Post:
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9
The date of last use of oral and or parenteral
steroids:
GP comments
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Medical Screening Form | New Career Recruit | November 2021
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