Fire Fighter Intake Form

Your Name

Address (City, State, Zip)

Email

Home Phone

Work Phone

Social Security Number

Date of Birth

Have You Had a Trucking, Construction or Factory Job?

YesNo

Do You Or Have You Shot Guns?

YesNo

If So, Did You Or Do You Use Hearing Protection?

YesNo

Do You Have Any Significant Medical Condition Affecting Your Hearing?

YesNo

Have you been injured or involved in an accident within the last 2 years?

YesNo

Have you had your breathing checked within the last 2 years?

YesNo

Have you ever smoked cigarettes?

YesNo

If yes, age at which you started smoking:

Amount smoked daily:

Age at which you stopped smoking:

Name of Fire Department?

Date First Employed As a Fire Fighter:

Current Rank:

Date of Retirement (If Applicable):

Vehicles Assigned To (Include Years):

Positions Held:

TillerDriver/Passenger JumpseatEngineerOfficermanufacturers Of SirensModelsMechanicalElectronic

Open Cabs?

YesNo

Date Of First Hearing Loss Medical Examination:

Date Of Any Workers' Compensation Or Disability Claim Filed For Hearing Loss:

Treating Doctors (For Hearing)

Name:

Address (City, State, Zip):

Phone Number:

Specialty: