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.

Station Number
DOB Month
DOB Year