Any costs for this medical evaluation shall be borne by the individual.

I authorize Dr.___________________________ to release medical information to my employer,
but only that of which is related to the performance of duties as a firefighter as agreed to by me.

Signature: _____________________________         Date:

SURNAME:                                                       GIVEN NAMES:                                              

Date of Birth:               /               /                    Care Card #:                                                  

                                            “FIREFIGHTER” – VOLUNTEER

The medical examination to be performed by a Physician is to determine if the person above has an acceptable level of health and
 does not present with any disabling medical, cognitive or physical condition which may prevent their effective functioning in the
position of a firefighter. 

The regular duties of a firefighter may include prolonged anaerobic exertion, heavy lifting, working in confined or awkward positions,
ability to immediately function upon waking from deep sleep, exposure to extremes in environment, and exposure to high mental stress.

The Physician shall determine, using any testing procedure he/she feels necessary, if the above person is fit for active firefighting
duties so that the firefighter will NOT jeopardize himself/herself and other personnel or public that he/she may come in contact with
while performing his/her duties. 

 
                   The following is to be completed by a Licensed Physician

                                                         is   /   is not      (please circle appropriate)                                      

physically, medically and cognitively fit for firefighting duties as per the above
requirements.

COMMENTS:                                                                                                                         

 
Physician Name:                                           Physician Signature:                                  

Date:                                                Please provide office address stamp below.

Note to health care provider:  The purpose of this form is to identity the individuals work related abilities and/or restrictions. 
In completing this form, please focus on determining the appropriateness of this individuals health in undertaking the vigorous
requirements of a firefighter. The City is not seeking medical information unrelated to work abilities/restrictions.  This
information will be administered under the requirements of the FOIPP Act.