LAST NAME FIRST NAME M.I. SOCIAL SECURITY NUMBER S TREET ADDRESS CITY STATE ZIP CODE) COUNTY DATE OF BIRTH HOME PHONE WORK PHONE TEST DATE REQUESTED AFFILIATION (FIRE DEPARTMENT/ORGANIZATION) STREET ADDRESS CITY STATE ZIP NOTE: It is understood that the candidate registered on this form has done so with the full knowledge, consent, and approval of the above named organization; and is protected by an insurance carrier or the organization. Participation approved by: SIGNATURE OF CHIEF OFFICER DATE DAYTIME PHONE NUMBER 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. SIGNATURE OF APPLICANT DATE RETURN COMPLETED APPLICATIONS TO THE TEST SITE OF YOUR CHOICE TEST SITE OFFICE USE ONLY: Test Site: Test Site Number: Date Application Received at Test Site: Candidate Number: Application Approved: Written Exam Results: PASS FAIL Skills Exam Results: PASS FAIL Skill Stations To Retest: The Pennsylvania Voluntary Certification Program is accredited by the National Board on Fire Service Professional Qualifications. Successful completion of a certification level permits you to apply to the National Board on Fire Service Professional Qualifications for national certification and registry. -1-
REQUIREMENT: Chapter 4.1(3), 4.3 NFPA # 1001-2002 Ed. EMERGENCY MEDICAL CARE As a minimum capabilities will include infection control, CPR (adult/child/infant), bleeding control and shock management. The following is a listing of FSCAC approved training courses which meet the requirements of this section. Each candidate must show as a minimum an approved CPR card/certificate and an approved First Aid Course card/certificate. Check the EMS certification you possess; indicate issue/expiration dates and attach a copy of your certificate(s) or both side(s) of your certification cards. AHA Heartsaver FACTS Issue Date: Expiration Date: AHA Heartsaver First Aid Issue Date: Expiration Date: ARC - Standard First Aid Issue Date: Expiration Date: ARC - Community First Aid Issue Date: Expiration Date: ARC - Emergency Responder Issue Date: Expiration Date: ASHI - First Aid Issue Date: Expiration Date: NSC - First Aid Issue Date: Expiration Date: PA DOH Emergency First Responder Issue Date: Expiration Date: PA DOH EMT Issue Date: Expiration Date: PA DOH EMT Paramedic Issue Date: Expiration Date: PA DOH Healthcare Professional Issue Date: Expiration Date: AHA Heartsaver CPR (Adult/Child/Infant) Issue Date: Expiration Date: AHA Heartsaver CPR (Adult/Pediatric) Issue Date: Expiration Date: AHA Healthcare Professional (Preferred) Issue Date: Expiration Date: ARC Adult CPR & Infant/Child CPR Issue Date: Expiration Date: ARC Community CPR (Adult/Child/Infant) Issue Date: Expiration Date: ARC CPR Professional Rescuer (Preferred) Issue Date: Expiration Date: ASHI CPR (Adult/Child/Infant) Issue Date: Expiration Date: NSC CPR (Adult/Child/Infant) Issue Date: Expiration Date: NSC Professional Rescuer CPR Issue Date: Expiration Date: --------------------------------------------------------------------------------------------------------------------------- REQUIREMENT: Chapter 5.1.1 NFPA # 1001-2002 Ed. Candidate must meet requirements of NFPA 472 Standard for Professional Competence of Responders to Hazardous Materials Incidents. Candidates must be certified at the First Responder Awareness Level in accordance with NFPA 472 "Standard for Professional Competence of Responders to Hazardous Materials Incidents", Chapter 2. Attach a copy of one of the following recognized certificates. Certificate must be current, i.e., within one (1) year of test date. HAZARDOUS MATERIALS AWARENESS LEVEL, OR AWARENESS LEVEL ANNUAL UPDATE (Refresher) OR HAZARDOUS MATERIALS OPERATIONS LEVEL (IAFF or ISFSI), OR HAZARDOUS MATERIALS OPERATIONS LEVEL ANNUAL REFRESHER, OR The candidate meets the competencies of 29 CFR 1910.120/40 CFR 311 and is certified to the Awareness level or higher. SIGNATURE OFFICIAL S TITLE DATE -2-
REQUIREMENT: Chapter 5-3 NFPA # 1001-2002ed: Job Performance Requirement (JPR) 5-3.10 (Interior Structural Fire Attack) In order to be certified as a Fire Fighter I, a candidate must have demonstrated his/her ability to attack and extinguish an interior structural fire operating as a member of a team. The following courses of instruction have been determined to meet this requirement. Attach a certificate showing successful completion of any one of the following (check which one applies): PA State Fire Academy Local Level Structural Burn Session (SBS) PA State Fire Academy Resident Course Engine Company Operations at Residential Fires (ZSFB) or its predecessor Structural Fire Fighting I. City of Pittsburgh Bureau of Fire Recruit Training City of Philadelphia Fire Department Recruit Training Harrisburg Area Community College (HACC) Fire Academy curriculum Pennsylvania Department of Corrections Fire Emergency Response Team Training You may also use an Essentials of Fire Fighting Module I (EBM) certificate ONLY UNDER THE FOLLOWING CONDITIONS, ALL OF WHICH MUST BE MET: 1. The EBM course you attended was held at a training facility that is also a Certification Field Test Site; AND 2. You are taking your Fire Fighter I practical test at the same facility where you attended your EBM course; AND 3. A live interior structure fire exercise was included as part of the course; AND 4. You personally participated in an interior structure fire attack while attending the course; AND 5. The training facility/test site has records available that confirm your participation in the burn itself. If any ONE or more of these conditions are NOT met, you may NOT use your EBM certificate to meet the live fire requirement, and must furnish one of the six certificates listed previously. My EBM certificate meets all 5 of the qualifications above and I am attaching a copy to meet the live burn requirement of Fire Fighter I. (Test site/training facility must attach a copy of the records referred to in # 5 when processing this application.) -3-
CANDIDATE NAME SOC. SEC. As the Authority Having Jurisdiction, I attest that _ has meet the competencies identified below that relate directly to the rules, regulations, and operations of this organization. NFPA 1001-2002 Ed. FIRE FIGHTER I: Chapter 5-1.1.1 General Knowledge Requirements Describe the organization of the fire department. Explain the role of the Fire Fighter I in the organization. Explain the mission of fire service. Explain the fire department s standard operating procedures and rules and regulations as they apply to the Fire Fighter I. Explain the role of other agencies that may respond to emergencies as they relate to the fire department. Explain aspects of the fire department s Member Assistance Program. The critical aspects of NFPA 1500 Standard on Fire Department Occupational safety and Health Program as they apply to the Fire Fighter I. Specific JPR requirements: Explain the procedures for a citizen to report a fire or other emergency.(jpr 5-2.1) Explain the procedure for receiving an alarm from dispatch or a report of an emergency from the public and demonstrate appropriate action. (JPR 5-2.1) Define the purpose and function of all alarm-receiving instruments and personnel-alerting equipment provided to the department and its members. (JPR 5-2.1) Identify procedures required for receipt and processing of business and personal calls. (JPR 5-2.2) Define and demonstrate prescribed fire department radio procedures, including routine traffic (JPR 5-2.3) emergency traffic (JPR 5-2.3) emergency evacuation signals. (JPR 5-2.3) FIRE CHIEF SIGNATURE DATE FIRE CHIEF'S NAME (Please print) ORGANIZATION NAME -4-
Chapter 5-5 PREVENTION, PREPAREDNESS, AND MAINTENANCE; Job Performance Requirement (JPR) 5-5.1 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, and the procedure for calling the fire department in your community. Use the space provided below, or attach separate sheet(s) as necessary. FIRE CHIEF SIGNATURE DATE FIRE CHIEF'S NAME (Please print) -5-
FIRE FIGHTER ONE SKILL EVALUATION FORMAT The information listed herein serves as a guide to the practical skills required for Fire Fighter One Certification and lists the source for the practical, hands-on performance skills required for by a candidate. The format used in Pennsylvania s practical examination is based on the Job Performance Requirements (JPRs) listed in Chapter 5 of the 2002 Edition of NFPA 1001, Fire Fighter Professional Qualifications. Excepted are the JPRs (such as the live structure burn requirement) that are tested by the application process itself. Those wishing to further reference the performance standards should refer to Appendix A of the Essentials of Fire Fighting, 4 th Edition published by IFSTA or by referral to a copy of the 2002 Edition of NFPA 1001 Upon being notified by a test site that a Fire Fighter I test is scheduled, The State Fire Academy will select a total of 12 skill stations from the 27 available on the menu. The site will be notified of this selection and will test those stations. Certain stations judged critical to fire fighter survival or baseline skill will be tested each time a test is given at any accredited test site across the state. The remainder will be selected randomly from the menu on a rotating basis. Candidates testing at any particular test site will not know what specific skill stations will be presented until the day of the test, so you must be prepared and capable to test to any or all of the Prerequisite Skills listed for any JPR under Fire Fighter One. While there are generally several safe, effective ways to perform any given skill, candidates should familiarize themselves with the method(s) and procedures illustrated in the IFSTA Essentials of Fire Fighting, 4 th Ed. manual. That source will be used as the final reference to settle any discrepancy. A complete listing of all Skill Stations included as part of the Fire Fighter I practical skills test is provided on the next page. In the event that a candidate should fail a skill station, the following is the policy of the PA Voluntary Fire Fighter Certification Program: 1. If the candidate fails three (3) or fewer skill stations during the Fire Fighter I skill testing session, the candidate will be afforded the opportunity to retest the station, or stations, on the day of the failure. 2. The candidate will be permitted only one (1) retest attempt of any skill on the day of skill station failure. 3. If the candidate fails four (4) or more skill stations, the candidate must retest on another date at either the same testing site or another testing site of the candidate s choice. Candidate must have prior approval of the Test Site Coordinator to retest on a future date. 4. In the event of a skill station failure, the candidate MUST retest the skill station that was failed. A test site may not substitute another skill for the previously failed skill. 5. All retesting must be completed within one (1) year of the date of the failure. -6-
Fire Fighter I Skill Station Menu STATION SKILL TO BE PERFORMED MANDATORY/RANDOM A SCBA OPERATIONAL CHECK MANDATORY STATION B SCBA DONNING MANDATORY STATION C PRIMARY SEARCH & UTILITY CONTROL MANDATORY STATION D SCBA CYLINDER REMOVAL/REFILL/REPLACEMENT RANDOM STATION E ROOF LADDER/ROOF CUT RANDOM STATION F GROUND LADDERS MANDATORY STATION G KNOT TYING/TOOL HOISTING RANDOM STATION H OPERATING NOZZLE FROM LADDER RANDOM STATION I HOSELINE ADVANCEMENT MANDATORY STATION J SPRINKLER SYSTEM OPERATION RANDOM STATION K RESCUE UNCONSCIOUS VICTIM RANDOM STATION L SALVAGE COVERS RANDOM STATION M FIRE STREAM/FOAM LINE RANDOM STATION N FIRE EXTINGUISHER USE RANDOM STATION O INSPECTION/COILING ROPE RANDOM STATION P WATER SUPPLY/PUMP CONNECTIONS MANDATORY STATION Q FIRE CONTROL RANDOM STATION R USING LIGHTING EQUIPMENT RANDOM STATION S RIDING FIRE APPARATUS RANDOM STATION T REPLACING BURST HOSE SECTION RANDOM STATION U FORCIBLE ENTRY THROUGH DOOR RANDOM STATION V OPENING WINDOWS/BREAKING GLASS RANDOM STATION W OVERHAUL/OPENING WALLS RANDOM STATION X ADVANCING LINE FROM STANDPIPE RANDOM STATION Y NATURAL GROUND COVER FIRE ATTACK RANDOM STATION Z INSPECTION OF HOSE & LADDERS RANDOM STATION -7-