Firefighter Readiness Health Assessment
Use this assessment to report your current health status, symptoms, fatigue, injuries, and any other factors that may affect firefighting readiness before duty.
Responder Information
Full Name
*
First Name
Middle Name
Last Name
Department / Station
*
Role / Rank
*
Please Select
Firefighter
Lieutenant
Captain
Chief
Paramedic
Engineer
Other
Date of Assessment
*
-
Month
-
Day
Year
Date
Health and Readiness Check
Fit for duty today
*
Yes
No
Unsure
Overall energy / fatigue level
*
Very fatigued
1
2
3
4
5
6
7
8
9
Highly energized
10
1 is Very fatigued, 10 is Highly energized
Current symptoms affecting readiness
*
Fever
Cough
Shortness of breath
Chest pain
Dizziness
None of the above
Recent injury or pain affecting duties
*
No
Yes, minor
Yes, significant
Any medications that could affect alertness or performance
*
No
Yes
Operational Health Notes and Acknowledgement
Additional health details or work restrictions
Submit Assessment
Should be Empty: