# Form - Annual Medical and Fitness Completion Tracker
> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-FRM-24.
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> Canonical: https://thehumanfactor.ca/library/fire-service-safety/form-annual-medical-and-fitness-completion-tracker
>
> Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/)
>
> General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca.
**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](https://thehumanfactor.ca/library/fire-service-safety/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)](https://thehumanfactor.ca/library/fire-service-safety/form-annual-medical-and-fitness-completion-tracker#ref-nfpa-1580); (CSA Z94.4-18). One row per member; updated as determinations arrive. (S1)
## Part A: Member roster and tier
| 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) |
|:---|:---|:---|:---|:---|:---|:---|
| | | | | | | |
## Part B: Medical evaluation and determination
| 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) |
|:---|:---|:---|:---|:---|:---|:---|:---|:---|
| | | | | | | | | |
## Part C: Respirator clearance, fit test, hearing and vision
| 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) |
|:---|:---|:---|:---|:---|:---|:---|:---|
| | | | | | | | |
## Part D: Fitness, immunization and wellness
| 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) |
|:---|:---|:---|:---|:---|:---|:---|:---|:---|
| | | | | | | | | |
## Part E: Quarterly summary (aggregate; cell sizes of 10 or more)
| 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 | | | |
## Fields
| 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 |
## Instructions
1. 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”.
2. 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.
3. Run the overdue list monthly; an overdue SCBA clearance restricts the member from SCBA assignment in the roster until cleared.
4. Produce Part E quarterly for the program update and the JOHSC. Report volunteers by tier so a gap cannot hide in the department average.
5. Retain for the duration of service plus 30 years with the exposure records (OSHA, n.d.-a, 29 CFR 1910.1020, as the benchmark).
> **Tip: Volunteer and composite departments**
>
> Schedule clinic nights from the overdue list: the tracker tells you how many Tier 1 and Tier 3 evaluations a station night must cover.
## References
CSA Group. (2018). *CAN/CSA-Z94.4-18 (R2023), Selection, use, and care of respirators* (5th ed.).
National Fire Protection Association. (2025). *NFPA 1580, Standard for emergency responder occupational health and wellness* (consolidates NFPA 1581, 1582, 1583 and 1584).
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.