Fire Fighter Intake Form

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?
 Yes No

Do You Or Have You Shot Guns?
 Yes No

If So, Did You Or Do You Use Hearing Protection?
 Yes No

Do You Have Any Significant Medical Condition Affecting Your Hearing?
 Yes No

Have you been injured or involved in an accident within the last 2 years?
 Yes No

Have you had your breathing checked within the last 2 years?
 Yes No

Have you ever smoked cigarettes?
 Yes No

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:
 Tiller Driver/Passenger Jumpseat Engineer Officer manufacturers Of Sirens Models Mechanical Electronic

Open Cabs?
 Yes No

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:

Verification: