Medical Assessment Form
For Firefighters
Using Breathing Apparatus
IMPORTANT PLEASE READ: INFORMATION FOR DOCTORS & MEDICAL CENTRES
Once completed, please send this form with the invoice addressed to Fire and Emergency NZ to
Volunteer Recruitment,
Email: [email address] Fax: 04 471 1793
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All of the questions in this form for new volunteer recruits are relevant. We ask that every question on this
form is answered fully and comprehensively. Please read the form carefully. ACT
As an examining doctor, you must consider the tasks, physical environment and safety-critical nature of
firefighting while undertaking this medical assessment, and ensure that the forms are completed in full and all
relevant information is provided to Fire and Emergency New Zealand (NZ).
Firefighters perform functions that are physically and psychologically demanding. These functions are often
performed in emergency situations, under difficult environmental conditions. Firefighters are also 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 NZ National Medical Officer will ultimately be responsible for determining
INFORMATION whether a
new applicant is fit to become a volunteer 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.
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.
OFFICIAL
If you have any questions regarding the medical screening assessment process, please contact Volunteer
Recruitment, who are based at Fire and Emergency NZ National Headquarters in Wellington on 04 496 3716.
THE
INVOICING INFORMATION
•
It is expected that this medical assessment can be completed within a double appointment. If this is not
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possible we would appreciate an itemised account.
Fire and Emergency NZ are predominantly a volunteer organisation with 85% of our workforce serving as
volunteers to respond to emergencies in your community. This applicant is joining as a volunteer.
• Please attach the invoice to the medical assessment and send them together [email address]
• Payment can only be made once Fire and Emergency NZ receives a completed copy of this medical form.
Please retain a copy on the patient’s file.
•RELEASED
Additional tests will not be paid for unless they have been requested by Fire and Emergency NZ.
• Fire and Emergency NZ will not pay for incomplete medical assessments. Please ensure you answer every
question and call us if you have any queries.
Version 19 | January 2023 | Volunteer Recruitment
Medical Assessment Form
For Firefighters
Using Breathing Apparatus
SECTION A - applicant to read and complete
IMPORTANT PLEASE READ: INFORMATION FOR APPLICANTS
Please get this form completed and sent to Fire and Emergency New Zealand quickly – this will
ensure your application to become a volunteer progresses. Ensure you read and sign page 2. 1982
• Fire and Emergency New Zealand pays for the information we request on this form and any other information
we request. If the Medical centre asks you to pay, request they send the invoice with your medical to:
ACT
Email [email address] or fax 04 471 1793
• NHQ will notify you and your brigade leader of the outcome of your application, or if there are any issues
which will cause delays
• Any updates from NHQ will be emailed to the personal email you provided when you first submitted your
application online. Check your spam/junk folder in case our emails end up there.
• If you wear contact lenses, please bring them to the appointment with you.
• If you have any questions phone your volunteer recruitment team 04 496 3716
• If you have to travel from your hometown, for example, if you require a saline test, please ask your
INFORMATION
brigade leader for an Expense Claim Form for mileage reimbursement.
First Name
Last Name
Date of Birth (dd/mm/yyyy)
Gender
OFFICIAL
Postal Address
THE
Post Code
Contact Phone Numbers
Is this your usual Medical Centre/GP?
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If you are not completing this medical assessment with your regular GP, what is the reason?
Occupation
Brigade Applying to
Applicant NHI
RELEASED
Version 19 | January 2023 | Volunteer Recruitment
Page 1 of 8
SECTION A - applicant to read and complete
I declare that:
•
The answers to all questions are true and correct.
•
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.
•
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.
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•
I hereby authorise the National Medical Officer or other Fire and Emergency New Zealand
authorised administrative staff to contact my General Practitioner if any information is required
to process my application to join Fire and Emergency New Zealand.
ACT
I understand that:
•
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.
INFORMATION
Recipients of my health information may include the brigade leader of any brigade of which I
become a member.
•
My health information will be treated in accordance with the Privacy Act 2020 and the Health
Information Privacy Code 2020. I have the right to access, and to correct, my health information
that is held by Fire and Emergency New Zealand.
•
My health information will be retained for a period of 40 years after I exit from Fire and
OFFICIAL
Emergency New Zealand.
Applicant’s Signature
Date
THE
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RELEASED
Version 19 | January 2023 | Volunteer Recruitment
Page 2 of 8
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.
PLEASE ANSWER ALL QUESTIONS.
Any health or medical issue that may affect the ability to carry out the tasks
1 required for the position being applied for?
Yes
No
(Tasks include but are not limited to: Running, climbing, bending, crawling, heavy
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lifting, carrying, gripping, reaching, and the ability to work independently.)
2 Been diagnosed as having a serious illness, such as cancer or leukaemia? Yes
No
(Please provide specialist’s reports)
ACT
3 Had the need for any medication relating to physical, neurological or
psychological impairment?
(e.g. respiratory medication)
Yes
No
4 Asthma, including childhood or chronic cough?
(If ‘Yes’ please complete the Asthma Questionnaire on page 8)
Yes
No
5 Pneumothorax?
Yes
No
6 Active infections such as TB?
Yes
No
7 Sleep apnoea?
INFORMATION
(If ‘Yes’ comment on hypersomnolence)
Yes
No
8 Any heart or vascular condition which restricts fitness for work?
(Please provide any reviews or tests)
Yes
No
9 Chest pain due to proven or suspected angina?
Yes
No
10 Heart attack or heart failure?
Yes
No
OFFICIAL
11 Heart valve defect?
Yes
No
12 High or low blood pressure?
Yes
No
THE
13 Irregular heart rate?
*(If yes, please provide recent ECG if available)
*Yes
No
14 Peripheral vascular disease?
Yes
No
15 Stroke or Transient Ischemic Attack?
Yes
No
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16 Any problem affecting general strength or fitness?
Yes
No
17 Any amputation of a hand, foot or limb?
Yes
No
18 Arthritis or joint replacement?
Yes
No
19 Limb, back or neck condition?
Yes
No
RELEASED
20 Skull or jaw condition affecting ability to wear breathing apparatus?
Yes
No
21 Recurrent joint dislocation?
Yes
No
22 Epilepsy, fainting attacks, fits or seizures?
Yes
No
Version 19 | January 2023 | Volunteer Recruitment
Page 3 of 8
SECTION B continued - GP to complete
23 Intellectual impairment?
Yes
No
24 Brain or head injury/disease, concussion or migraines?
Yes
No
25 Significant bowel disorder?
Yes
No
26 Hernia?
(If yes, note date and if repaired)
Yes
No
27 Disease of urinary tract?
Yes
No 1982
28 Anaemia or condition causing increased bleeding?
Yes
No
29 Diabetes (type 1 or type 2
), thyroid or another gland problem?
Yes
No
Hypoglycaemic episodes
ACT
Yes
No
HbA1c -
Mental illness, clinical depression, anxiety state or psychotic episodes?
30
(complete details on page 6)
Yes
No
31 Substance abuse, or alcohol dependence or abuse?
(provide full details and reports)
Yes
No
32 Hearing loss, need to wear hearing aids, or any problems with balance? Yes
No
(please circle)
33 Reduced vision or night blindness?
Yes
No
INFORMATION
34 Any medications being taken?
Yes
No
35 Allergies?
Yes
No
If you answered YES to any questions above, provide all details.
Please include specialist reports.
OFFICIAL
Treatment
#
Cause
(Please include specialist
Medications
Ongoing concerns,
THE
reports if available)
issues or limitations
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RELEASED
Version 19 | January 2023 | Volunteer Recruitment
Page 4 of 8
SECTION C - GP to complete
PLEASE ANSWER ALL QUESTIONS. Please write your answer in the column to the right of the question.
1 Age
2 Height
cm
3 Weight
kg
4 BMI
(If
* above 30, complete HbA1c or blood glucose (mmol/L)
BMI=
*BG/HbA1c=
5 Pulse rate
reg/irreg
6 Any heart murmur or abnormal sounds?
1982
*Yes
No
* If yes, please describe murmur and provide any paperwork from investigation
Blood pressure
*BP=
7
If
* BP above 140/90 on first reading, please complete another BP recording 10
ACT
minutes apart.
2nd BP reading =
8 Is chest examination normal?
Yes
*No
(If n
*
o, please provide details)
Peak flow
Expected
Peak Flow
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
Spirometry
10
(please attach full report)
INFORMATION
ONLY IF PEAK FLOW IS SUBOPTIMAL
11 Full range of movement is normal in upper and lower limbs?
Yes
No
*
*
If no, please provide detail s
12 Normal hearing to conversation?
Yes
*No
(If
* no, please provide latest hearing test)
OFFICIAL
PLEASE ANSWER ALL QUESTIONS THE
13 Eyes – is the following normal? Visual Fields (more than 120°) at confrontation
Yes
No
UNCORRECTED
GLASSES
(Mandatory)
Please note: Glasses are incompatible
CONTACT LENSES
Distance Visual Acuity: (6m)
with breathing apparatus
14.1 Standard-Uncorrected or
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Right Left Both Right Left Both Right Left Both
with contacts 6/9 both eyes
6/
6/
6/
6/
6/
6/
6/
6/
6/
Near Visual Acuity: (35cm)
Hold this paper 35cm away
from the applicant (
without
100 150 200
glasses) and have them:
14.2
RELEASED
• Read numbers at random
50
250
• Identify where the gauge is
Mark Y if able to identify
Uncorrected
numbers and gauge.
Both Eyes:
Y/N
0
300
Version 19 | January 2023 | Volunteer Recruitment
Page 5 of 8
SECTION C continued –
GP to complete
PSYCHOLOGICAL HISTORY
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 an applicant 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,
Triggers
(for initial depression and for
List episodes, duration date and
warning signs and triggers
1982
any subsequent episodes)
treatment eg. medication /counselling
Episodes of psychosis? Yes
No
If yes, please provide details
ACT
and any related paperwork
PLEASE ATTACH SPECIALIST REPORTS
Anxiety?
Yes
No
If yes, please provide details:
triggers, dates and duration
of episode/s treatment
(counselling, medication)
PLEASE ATTACH SPECIALIST REPORTS
INFORMATION
Depression?
Yes
No
If yes, please provide details:
triggers, dates and duration
of episode/s treatment
(counselling, medication)
PLEASE ATTACH SPECIALIST REPORTS
OFFICIAL
COVID-19 VACCINATION
Is the applicant vaccinated against COVID-19?
Yes
* ☐
No ☐
THE
*If yes, please provide the following details:
Dose 1 ☐ Date: ______
____
Dose 2 ☐ Date: ______
____
Booster ☐ Date: ______
____
Type (please circle):
Pfizer
Janssen
Moderna
AstraZeneca
HEPATITIS & TETANUS
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DO NOT VACCINATE OR PROCESS SEROLOGY FOR HEPATITIS OR TETANUS
Is the applicant vaccinated against Hepatitis A?
Yes ☐
No ☐
Uncertain ☐
Is the applicant vaccinated against Hepatitis B?
Yes ☐
No ☐
Uncertain ☐
Is the applicant vaccinated against Tetanus?
Yes ☐
No ☐
Uncertain ☐
RELEASED
Please add any further comments you feel are necessary for Fire and Emergency New Zealand to know
about this applicant for us to assess their entry into Fire and Emergency New Zealand.
Version 19 | January 2023 | Volunteer Recruitment
Page 6 of 8
SECTION D - GP to complete
Please email or fax all pages of this medical form and your invoice to Fire and Emergency New Zealand Volunteer
Recruitment.
Email: [email address] Fax: 04 471 1793
If you have any medical queries, please phone Jane 04 496 3716 or Vanessa 04 498 5685
If you have any account queries, please phone 04 496 3666
Please note:
•
Payment can only be made once Fire and Emergency New Zealand receives a completed copy of this1982
Medical 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.
ACT
•
Fire and Emergency New Zealand will not pay for any additional tests unless these have been
requested by Fire and Emergency to assist with the recruitment process.
I declare that all tests and information carried out on
are
true and correct to the best of my knowledge.
GP’s signature
Date
INFORMATION
GP’s name
Contact Number
Surgery Stamp:
OFFICIAL
THE
UNDER
PLEASE COMPLETE: CHECKLIST BEFORE SENDING
A copy of this medical has been saved to the patient’s file.
The medical assessment and invoice has been sent to Fire and Emergency New Zealand
Volunteer Recruitment via email [email address] or fax 04 471 1793
RELEASED
All questions have been answered
Version 19 | January 2023 | Volunteer Recruitment
Page 7 of 8
GP to complete if any history of asthma, chronic cough or wheeze
ASTHMA QUESTIONNAIRE
Please complete ONLY if the applicant has a history of asthma, including childhood asthma
1 Age of onset
2 When was the applicant’s last asthma attack?
3 Frequency, nature and severity of asthma symptoms
4 Frequency of asthma symptoms requiring steroids
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5 Precipitating features:
ACT
6 Current medication – including dosage and when last prescribed and used:
7 Number of hospital admissions over the last 10 years for asthma
Pre:
8
Peak flow/Spirometry results pre- and post-bronchodilator
(if available in accordance with standards
Post:
INFORMATION
9 Date of last use of oral and or parental steroids
GP COMMENTS
OFFICIAL
THE
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FIRE AND EMERGENCY NZ WILL REFER APPLICANT FOR SALINE TESTING IF NECESSARY
RELEASED
Version 19 | January 2023 | Volunteer Recruitment
Page 8 of 8
Document Outline
