Medical Certification - Release To Return To Work Form (Page 2 of 2) in pdf

**The following is a list of essential job functions employees in a Firefighter, Lieutenant

or Battalion Chief position may be required to perform during active duty, per NFPA 1582

standards:

1. Performing fire-fighting tasks (e.g., hose line operations, extensive crawling, lifting and carrying

heavy objects, ventilating roofs or walls using power or hand tools, forcible entry), rescue

operations, and other emergency response actions under stressful conditions while wearing

personal protective ensembles (PPE) and self-contained breathing apparatus (SCBA), including

working in extremely hot or cold environments for prolonged time periods.

2. Wearing an SCBA, which includes a demand valve-type positive pressure facepiece or HEPA

filter masks, which requires the ability to tolerate increased respiratory workloads.

3. Exposure to toxic fumes, irritants, particulates, biological (infectious) and non-biological

hazards, and/or heated gases, despite the use of PPE including SCBA.

4. Depending on the local jurisdiction, climbing 6 or more flights of stairs while wearing fire

protective ensemble weighing at least 50lb or more and carrying equipment/tools weighing an

additional 20 to 40lb.

5. Wearing fire protective ensemble that is encapsulating and insulated. Wearing this clothing will

result in significant fluid loss that frequently progresses to clinical dehydration and can elevate

core temperature to levels exceeding 102.2°F (39°C).

6. Searching, finding, and rescue-dragging or carrying victims ranging from newborns up to adults

weighing over 200lb to safety despite hazardous conditions and low visibility.

7. Advancing water-filled hose lines up to 2.5 in. in diameter from fire apparatus to occupancy

(approximately 150 ft.); can involve negotiating multiple flights of stairs, ladders, and other

obstacles.

8. Climbing ladders, operating from heights, walking or crawling in the dark along narrow and

uneven surfaces, and operating in proximity to electrical power lines and/or other hazards.

9. Unpredictable emergency requirements for prolonged periods of extreme physical exertion

without benefit of warm-up, scheduled rest periods, meals, access to medication(s), or

hydration.

10. Operating fire apparatus or other vehicles in an emergency mode with emergency lights and

sirens.

11. Critical, time-sensitive, complex problem solving during physical exertion in stressful, hazardous

environments (including hot, dark, tightly enclosed spaces), further aggravated by fatigue,

flashing lights, sirens, and other distractions.

12. Ability to communicate (give and comprehend verbal orders) while wearing PPE and SCBA

under conditions of high background noise, poor visibility, and drenching from hose lines and/or

fixed protection systems (sprinklers).

13. 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 (e.g., two

in, two out as described in NFPA 1500).

The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or

requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law,

Northshore Fire Department asks that the health care provider not provide any genetic information when responding to requests for medical information.

“Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests,

the fact that an individual or an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried

by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Rev. 9/14

Medical Certification - Release To Return To Work Form Page 2

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