MFRI/Baltimore County Fire Service Training Fitness Questionnaire

This questionnaire is SECURE and CONFIDENTIAL. The results of this survey will be stored on a HIPAA-compliant server, and will be made available only to the Baltimore County Volunteer Firefighter's Association Medical Review Board for the purposes stated below.

This questionnaire is used in determining whether or not you have a medical condition that may affect your ability to safely use a respirator. IT IS NOT USED (BY ITSELF) TO DETERMINE YOUR FITNESS TO ENGAGE IN STRENUOUS EMERGENCY ACTIVITIES. We anticipate being able to approve most people for respirator use based upon this questionnaire alone. In some cases we may ask for more information or additional medical testing/examination. For the purposes of this document, the word “respirator” includes: self-contained breathing apparatus, NIOSH filter masks and HEPA filter and air purifying masks.

LOSAP/Member ID

Station Number
20: White Marsh Volunteer Fire Company21: Bowleys Quarters Volunteer Fire Department26: North Point Edgemere Volunteer Fire Department27: Wise Avenue Volunteer Fire Company28: Rosedale Volunteer Fire Company29: Providence Volunteer Fire Company30: Lutherville Volunteer Fire Company31: Owings Mills Volunteer Fire Company32: Pikesville Volunteer Fire Company33: Woodlawn Volunteer Fire Company35: Arbutus Volunteer Fire Department36: Lansdowne Volunteer Fire Department37: English Consul Volunteer Firemen's Association38: Long Green Volunteer Fire Company39: Cockeysville Volunteer Fire Company40: Glyndon Volunteer Fire Department41: Reisterstown Volunteer Fire Company44: Hereford Volunteer Fire Company45: Maryland Line Volunteer Fire Company46: Liberty Road Volunteer Fire Company47: Jacksonville Volunteer Fire Company48: Kingsville Volunteer Fire Company49: Butler Volunteer Fire Company50: Chestnut Ridge Volunteer Fire Company51: Essex Volunteer Fire Company53: Hereford Volunteer Ambulance Association74: Middle River Volunteer Fire and Rescue Company85: Upperco Volunteer Fire Company156: Box 234 Association

DOB Month
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

DOB Day
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DOB Year
200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925