Form
Form - Annual Medical and Fitness Completion Tracker
Document FSSMS-FRM-24Stage 1Revision 5Version 0.3.3
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Purpose. The department’s record of who is due for what and whether it was done, holding dates, tiers, status flags and the fitness-for-duty category only. It contains no results, diagnoses, laboratory values, audiogram thresholds or fitness scores; those stay with the custodian (the fire department physician, clinic or peer fitness trainer) under the information-sharing protocol in Medical, Fitness and Wellness Program section 17.9. It is the evidence for the medical, hearing and respiratory programs’ completion indicators and for the audit (NFPA 1580, 2025); (CSA Z94.4-18). One row per member; updated as determinations arrive. (S1)
| Member ID | Station | Career / volunteer | Operational role (interior, SCBA-qualified / exterior / operator / officer / support) | Medical tier (A annual / 1 entry / 2 periodic / 3 annual volunteer) | Age band (under 40 / 40 and over) for the stress-test cohort | Risk-flagged cohort (Y/N, set by the physician; no reason recorded) |
|---|---|---|---|---|---|---|
| Member ID | Last medical (date) | Next due (date) | Fitness-for-duty category (Fit / Fit with restrictions / Temporarily unfit / Unfit) | Restricted essential job task numbers (if any) | Review date (if restricted or temporarily unfit) | Stress test in cohort (done date / not in cohort) | Exposure summary sent to physician (date) | Physician attestation received (date) |
|---|---|---|---|---|---|---|---|---|
| Member ID | Respirator medical clearance (Cleared / Not cleared / Cleared with conditions; date) | Fit test (date; next due) | Baseline audiogram (date) | Last audiogram (date; next due) | Audiometry status (No shift / Shift flagged / Retest due by / Follow-up closed) | Vision standard met (Y/N) | Driver licence class and medical current for operators (Y/N; expiry) |
|---|---|---|---|---|---|---|---|
| Member ID | Annual fitness assessment (done date / declined / not applicable) | Exercise prescription on file with the trainer (Y/N) | Hepatitis B series and titre (Complete / Incomplete / Declined) | Td or Tdap current (Y/N) | MMR and varicella (Immune / Incomplete / Declined) | Influenza this season (Y/N / Declined) | TB screen (date; by risk) | Sleep-disorder screen done in medical (Y/N) |
|---|---|---|---|---|---|---|---|---|
| Measure | Career | Volunteer by tier | Department |
|---|---|---|---|
| Medical current (per cent) | |||
| Stress test complete in cohort (per cent) | |||
| Respirator clearance current for SCBA-qualified members (per cent) | |||
| Fit test current (per cent) | |||
| Baseline audiogram (per cent); annual audiogram current (per cent) | |||
| Fitness assessment complete (per cent) | |||
| Immunization complete (per cent) | |||
| Members overdue (count) and corrective action numbers | |||
| Prepared by (role), date; sent to program manager, JOHSC |
| Field | Type | Required | Who completes |
|---|---|---|---|
| Roster and tier (Part A) | ID, choice | Yes, every member | Program manager from HR and roster |
| Medical dates and category (Part B) | Dates, choice, task numbers | Yes | HSO from the physician’s determination |
| Cohort flags | Y/N | Yes | Physician (flag only) |
| Respirator, fit test, hearing, vision (Part C) | Dates, choice, Y/N | Yes for SCBA-qualified and operators | HSO; Respiratory Protection program administrator |
| Fitness and immunization (Part D) | Dates, choice | Yes | Peer fitness trainer (completion only); clinic (status flags) |
| Quarterly summary (Part E) | Percentages, counts | Quarterly | Program manager |
- Build the tracker in the records system with row-level access limited to the program manager, the HSO and the Respiratory Protection program administrator; station officers see only their members’ due dates and “current / overdue”.
- Enter only what the custodian sends: a category, a flag, a date. If a result arrives, return it to the custodian and log the privacy event.
- Run the overdue list monthly; an overdue SCBA clearance restricts the member from SCBA assignment in the roster until cleared.
- Produce Part E quarterly for the program update and the JOHSC. Report volunteers by tier so a gap cannot hide in the department average.
- Retain for the duration of service plus 30 years with the exposure records (OSHA, n.d.-a, 29 CFR 1910.1020, as the benchmark).
CSA Group. (2018). CAN/CSA-Z94.4-18 (R2023), Selection, use, and care of respirators (5th ed.). https://www.csagroup.org/store/product/2426374/
National Fire Protection Association. (2025). NFPA 1580, Standard for emergency responder occupational health and wellness (consolidates NFPA 1581, 1582, 1583 and 1584). https://www.nfpa.org/codes-and-standards/nfpa-1580-standard-development/1580
Occupational Safety and Health Administration [OSHA]. (n.d.-a). Access to employee exposure and medical records (29 C.F.R. § 1910.1020). U.S. Department of Labor. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1020