Work Capacity Test — 2002 brochure
|Circle the appropriate Yes or No response to the following questions:|
|Y||N||1)||During the past 12 months have you at any time (during physical activity or while resting) experienced pain, discomfort or pressure in your chest.|
|Y||N||2)||During the past 12 months have you experienced difficulty breathing or shortness of breath, dizziness, fainting, or blackout?|
|Y||N||3)||Do you have a blood pressure with systolic (top #) greater than 140 or diastolic (bottom #) greater than 90?|
|Y||N||4)||Have you ever been diagnosed or treated for any heart disease, heart murmur, chest pain (angina), palpitations (irregular beat), or heart attack?|
|Y||N||5)||Have you ever had heart surgery, angioplasty, or a pace maker, valve replacement, or heart transplant?|
|Y||N||6)||Do you have a resting pulse greater than 100 beats per minute?|
|Y||N||7)||Do you have any arthritis, back trouble, hip /knee/joint /pain, or any other bone or joint condition that could be aggravated or made worse by the Work Capacity Test?|
|Y||N||8)||Do you have personal experience or doctor’s advice of any other medical or physical reason that would prohibit you from taking the Work Capacity Test?|
|Y||N||9)||Has your personal physician recommended against taking the Work Capacity Test because of asthma, diabetes, epilepsy or elevated cholesterol or a hernia?|
Regardless whether you are taking the Work Capacity test at the Arduous, Moderate or Light duty level, a “Yes” answer requires a determination from your personal physician stating that you are able to participate. For Arduous Duty Employees, if you do not have a personal physician determination allowing you to take the Work Capacity Test, the FMO may request an Annual Form examination through the Interagency Wildland Firefighter Medical Standards Program.
I understand that if I need to be evaluated, it will be based on the fitness requirements of the position(s) for which I am qualified.
Participant:_________________ Administrator:_________________ Date:__________
Release Date: January 2006 APPENDIX W-1
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