FIRE FIGHTER II APPLICATION PENNSYLVANIA VOLUNTARY FIRE SERVICE CERTIFICATION PROGRAM NFPA Edition

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1 FIRE FIGHTER II APPLICATION PENNSYLVANIA VOLUNTARY FIRE SERVICE CERTIFICATION PROGRAM NFPA Edition SECTION I Last Name First Name M.I. SSN (last four digits required) Street Address City State Zip Code County Date of Birth Home Phone Work Phone Test Date Requested _ Affiliation (Fire Department/Organization) Candidate Street Address City State Zip Section I (A): Please Read and Check One: A candidate should meet the requirements of NFPA 1582, Standard on Medical Requirements for Firefighters and information for Fire Department Physicians prior to physical testing to ensure his/her ability to safely perform the required tasks. I have read (or have had explained to me) and understand the job performance requirements for the Firefighter II certification test. I have no conditions which would preclude me from safely or effectively performing all the functions (practical skills and written test) and tasks for the level for which I am seeking national certification. I have read and/or have been explained and understand the job performance requirements for the Firefighter II Certification test. I will be submitting a request for accommodation for the written National Certification exam. I understand that I MUST contact the Certification Program Manager no later than two weeks prior to the Scheduled certification exam. If you are not participating as a member of an emergency service organization, are you protected by an insurance carrier providing hospitalization and/or Workmen's Compensation in cause of injury? YES NO If YES, you will be required to show proof of insurance coverage with this application. If NO, you will be required to sign a release Waiver prior to taking any portion of the Certification exam. By signing and dating of this document I certify that the information contained in this application and any attachments is accurate and complete to the best of my knowledge and submitted as true and correct in accordance with the OSFC/PSFA certification testing policy and in accordance with Pennsylvania Crimes Code18 Pa C.S. 4904, realing to unsworn falsifications to authorities. Signature of Applicant Date NOTE: All required signatures on this application MUST be in blue or black ink. Test Site Official Use Only: Test Site: Test Site Number: Date Application Received at Test Site Date Application Approved: Candidate Number: Written Exam Results PASS FAIL Skills Exam Results PASS FAIL

2 SECTION II It is understood that the candidate registered on this form has done so with the full knowledge, consent and approval of the named organization on page one of this application; and is protected by an insurance carrier or the organization. Furthermore, I attest that the candidate meet the requirements as noted in Section I (A) of this application. Participation approved by: Signature of Chief Officer Date Chief Officer s Name (Print or Type) Officer s Title SECTION III Act 168 of 2006 amended Title 18 (Crimes and Offenses) of the Pennsylvania Consolidated Statutes, Section 2, subsection (h) (1) Arson and related offenses reads: A person convicted of violating this section or any similar offense under Federal or State law shall be prohibited from serving as a firefighter in this Commonwealth and shall be prohibited from being certified as a firefighter under Section 4 of the Act of November 13, 1995 (P.L. 604, No.61), known as the State Fire Commissioner Act. All individuals making application for certification testing must provide documentation of a background check. Proof of a non-conviction MUST consist of either of the following: 1. An official criminal history record check obtained pursuant to Chapter 91 (relating to criminal history record information) indicating no arson convictions. OR 2. By dating and signing of the following statement by the person swearing to the following: I have never been convicted of an offense that constitutes the crime of arson and related offenses under 18 Pa.C.S 3301 or any similar offense under any Federal or State law. I herby certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand that if I knowingly make any false statement herein, I am subject to penalties prescribed by law, including, but not limited to, a fine of at least $1, Signature of Certification Candidate Name of Certification Candidate (please print or type) Date

3 SECTION IV PLEASE ATTACH A COPY OF CERTIFICATE FOR ALL BELOW REQUIREMENTS REQUIREMENT: Successful completion of Incident Command System Course: Please check one NFA Incident Command System Course NFA NIMS ICS for the Fire Service NFA NIMS ICS for EMS NFA IS-100 AND IS-200 REQUIREMENT: FIRE FIGHTER I CERTIFICATION NFPA edition, Chapter 6, JPR You must be certified at the Fire Fighter I level. Provide your number and attach a copy of your Fire Fighter I certificate. FIRE FIGHTER I CERTIFICATE NUMBER: REQUIREMENT: HAZARDOUS MATERIALS RESPONSE NFPA edition, Chapter 5, JPR 5.1 General: A candidate MUST be trained or certified (as a minimum requirement) at the First Responder Operations Level in accordance with NFPA 472 "Standard for Professional Competency of Responders to Hazardous Materials/Weapons of Mass Destruction Incidents, Chapter 5 (Core Competencies for Operations Level Responders) and Chapter 6, section 6.6 (Mission Specific Competencies: Product Control). Attach a copy of one of the following recognized certificates. HAZARDOUS MATERIALS OPERATIONS LEVEL, OR HAZARDOUS MATERIALS OPERATIONS LEVEL ANNUAL REFRESHER, OR HAZARDOUS MATERIALS TECHNICIAN LEVEL NOTE: The certificate (training, refresher training or certification) must be current (i.e., within one (1) year of the firefighter certification test date and must meet the requirements of NFPA edition). REQUIREMENT: RESCUE OPERATIONS - NFPA edition, Chapter 6.4.: JPRs and 6.4.2: Attach a copy of a course completion certificate for any one of the following courses. SFA Vehicle Rescue I or its predecessor, Vehicle Rescue, OR SFA Vehicle Rescue II or its predecessor, Advanced Vehicle Rescue, OR Pennsylvania Dept of Health - Basic Vehicle Rescue, OR Pennsylvania Vehicle Rescue Operational Level, OR Pennsylvania Vehicle Rescue Technician Level

4 REQUIREMENT: FIRE DEPARTMENT COMMUNICATIONS NFPA # Edition, Chapter 6.2; JPR Candidate must attach a copy of his/her fire department's incident ("run") report, properly completed for an actual incident by the candidate him/her self. _ Incident Report Form complete and attached _ Incident Report shall include proof of completion by the candidate REQUIREMENT: FIRE PREVENTION, PREPAREDNESS, AND MAINTENANCE - NFPA edition, Chapter 6.5: JPR RESIDENTIAL Perform a fire safety survey of a Private Dwelling. Draw a line diagram of your home detailing each floor level, all doors and windows, the layout of each room on every floor, etc. Indicate escape routes in case of fire, the placement of smoke detectors, established meeting place outside the resident and the procedure for calling the fire department in your community. Uses the attached grid provided and/or attach separate sheet(s) as necessary. a. Each floor / division shall be included with appropriate details (i.e., doors, windows, room layouts to include large items / obstacle); b. must note primary and secondary escape routes c. note smoke detectors/suppression system d. procedure for calling the fire dept should include information that would be obtained/needed by dispatcher NOTE: Computer generated / CAD Floor Plans will be accepted however the following required details must be drawn in by hand by the candidate: escape routes (primary and secondary) and a meeting place. REQUIREMENT: FIRE PREVENTION, PREPAREDNESS, AND MAINTENANCE - NFPA edition, Chapter 6.5: JPR COMMERCIAL Conduct a pre-incident survey and fire safety inspection of a Commercial Building in your area. Prepare a pre-incident survey report that includes: (1) completed safety inspection form; (2) diagrams/sketches of the building floor plan (each floor of the building must be included); (3) a plot plan of the target building, and (4) response assignments for responding companies (apparatus). Attach all required materials to this application. Complete the pre-incident survey information beginning on the next page that is requested as part of this application. This survey shall include the following: _ 1. Safety Inspection form (attached). _ 2. Floor plan diagram and sketches. [You may use copies of the grid sheet attached, or you may use separate sheet(s) as necessary.] a. Each floor / division shall be included with appropriate details (i.e., doors, windows, room layouts to include large items / obstacle); b. Indicate hazards, utilities, and special features; c. Indicate any detection system(s) and/or suppression system(s).

5 _ 3. Plot Plan complete and attached: a. Includes directional symbol b. Hydrants and water supply indicated (with distances) c. Hazards identified d. Street(s) and exposures are labeled _ 4. Response assignments complete and attached: Each unit shall be identified and shall have an initial response assignment. NOTE: The use of existing maps, architectural floor plans, site plans and/or Graphic Information System (GIS) mapping programs will be accepted, however the following required details MUST be included on these plans and MUST be drawn by hand by the candidate (i.e. utilities, hazards, fire suppression/smoke detectors, hydrants, water supply distances, large obstacles [furniture, office desk/equipment, machinery], orientation directional symbol, fire department connections [FDC], and fire alarm control panels). I hereby attest that the candidate noted on this application for Fire Fighter II has authored the required Residential and Commercial drawings. Fire Chief / Chief Officer Signature Date Fire Chief / Chief Officer s Name (Please Print) Organization Name Daytime Contact Number Address

6 Candidate Name: Social Security #:_ PREPLAN AND FIRE SAFETY INSPECTION OF TARGET BUILDING, Page 1 of 3 BUILDING NAME_ BUILDING ADDRESS OWNER: OCCUPANT: ADDRESS: TYPE OF OCCUPANCY:_ EMERGENCY NOTIFICATION:_ DIMENSIONS: LENGTH WIDTH NO. STORIES TOTAL SQ. FT. BUILT (YR) CONSTRUCTION: WALLS_ FLOORS ROOF FORCIBLE ENTRY POINTS UTILITIES: SUPPLIER / EMERGENCY TELEPHONE SHUT-OFF LOCATION ELECTRIC: WATER: GAS: HVAC:_ STAIRWAYS, TYPE AND LOCATIONS: ELEVATORS, TYPE AND LOCATIONS:_ OTHER VERTICAL OPENINGS, TYPE AND LOCATIONS: PROCESSES:_ HAZARDS: POPULATION AND TIMES: SPECIAL POPULATION TARGETS AND LOCATIONS: SALVAGE TARGETS AND LOCATIONS:_

7 Candidate Name: Social Security #: PREPLAN AND FIRE SAFETY INSPECTION OF TARGET BUILDING, Page 2 of 3 EXPOSURES: DISTANCE TYPES OF CONSTRUCTION NORTH: EAST: SOUTH: WEST: PROTECTION: SPRINKLERS: WET DRY COMPLETE PARTIAL STATIC PRESSURE_ FD CONNECTION LOCATION_ ROOM LOCATION SPRINKLERS CLEAR OF OBSTRUCTIONS? YES_ NO_ N/A CONTROL ROOM CLEAR OF OBSTRUCTIONS? YES_ NO_ N/A FIRE DEPT. CONNECTION ACCESSIBLE? YES_ NO_ N/A FIRE PUMP? YES_ NO_ N/A FIRE PUMP CAPACITY:GPM STANDPIPE: WET DRY STANDPIPE THREAD SIZE: FIRE PUMP LOCATION: CONDITION OF HOSE: FD CONNECTION LOCATION:_ NOTE: In the above bolded section if it does not apply to the structure you are inspecting please mark N/A in all applicable areas. AREA HOSE CABINETS CLEAR OF OBSTRUCTIONS? YES NO N/A_ FIRE ALARM EQUIPMENT (DESCRIBE): _ IS SYSTEM OPERABLE? YES NO IS SYSTEM TESTED? YES NO WATER SUPPLY: TYPE CAPACITY_GPM LOCATION:_ EMERGENCY EXITS: ADEQUATE? YES NO CLEAR OF OBSTRUCTIONS? YES NO

8 Candidate Name: Social Security #: PREPLAN AND FIRE SAFETY INSPECTION OF TARGET BUILDING, Page 3 of 3 HEATING EQUIPMENT: TYPE INSPECTED? YES NO SAFELY ARRANGED? YES NO ROOM CLEAR? YES NO LOCATION OF SHUT DOWN CONTROLS : CONDITIONS FOUND ON INSPECTION: KNOWN OCCUPANCY HAZARDS: (LIST HAZARDS) INSPECTOR S SIGNATURE DATE Permission to conduct this inspection was granted by: Name (please print) Title Phone NOTE: This information requested for training and validation purposes only. All information is confidential.

9 Floor Plan: Candidate Name Candidate Signature Private Dwelling or Commercial Structure

10 Floor Plan: Candidate Name Candidate Signature Private Dwelling or Commercial Structure

11 Floor Plan: Candidate Name Candidate Signature Private Dwelling or Commercial Structure

12 FIRE FIGHTER II APPLICATION PENNSYLVANIA VOLUNTARY FIRE SERVICE CERTIFICATION PROGRAM NFPA 1001 Pre-Requisite Verification Form Candidate Name: My signature below indicates that I have read and understood the requirements of this program, Fire Fighter II, and furthermore I meet the pre-requisites established by the Standard or the Authority Having Jurisdiction. I am 18 years of age or older; I have signed the Act 168 form or have provided an official criminal history record check obtained pursuant to Chapter 91; I have signed the application; I have had a chief officer sign in the required items in Section II of this application; I have attached a copy of the Fire Fighter I certification; I have attached a copy of an approved current Hazardous Materials Operations Course, Operations Refresher, or Technician Training Certificate; I have attached a copy of an approved Rescue Course Certificate; I have attached a copy of approved NIMS course certificate(s); I have attached a copy of completed Safety Inspection form; I have attached a copy of completed Residential Floor Plan; I have attached a copy of completed Commercial Floor Plan; I have attached a copy of completed Plot Plan and Response Assignments Testing Assistance I am physically capable of completing the practical skill exercises. I am able to read and comprehend the written test and related materials. I will be submitting a request for accommodation for the National Certification exam. I understand that I MUST contact the Certification Program Manager no later than two weeks prior to the certification exam; OR I will not be submitting a request for accommodation for National Certification exam. _ Signature Date

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