Form FS-5100-31 Health Screening Questionnaire

USDA Forest Service FS-5100-31 (v 03/2016) OMB 0596-0164 (Expires 06/2019)

WCT Level

Arduous

Moderate

Light

HEALTH SCREENING QUESTIONNAIRE (HSQ)

Assess your health needs by marking all true statements.

The purpose of the HSQ is to identify individuals who may be at risk while taking the Work Capacity Test (WCT) and
recommend an exercise program and/or medical examination prior to taking the WCT.

Employees are required to answer the following questions which were designed to identify those individuals who may be at medical risk when taking a WCT. The HSQ is not a medical examination. Any medical concerns you have that may place you or your health at risk should be reviewed with your personal physician prior to participating in the WCT.

SECTION A

You have/had:

a heart attack

heart surgery

coronary (heart) angioplasty or stent placement

a pacemaker/implantable cardiac defibrillator/ rhythm disturbance (abnormal heartbeat)

heart valve disease or a heart murmur

heart failure

heart transplantation

congenital (born with) heart disease

personal experience or a doctor’s advice of any other physical reason that would prohibit you from carrying out or participating in strenuous activity

blood pressure greater than 139/89, or you

take blood pressure medication

diabetes: diet controlled or you take medicine to control your blood sugar

You experienced in the last 12 months:

chest discomfort/pain with exertion

breathlessness more than others with exertion

dizziness, fainting, blackouts

muscle or bone/joint problems: spine, knees, back, hips, shoulders, etc. (swelling, moderate pain)

Other Health Issues:

you have a hernia

you take heart or asthma medications

you have epilepsy or a seizure disorder

you have a history of past heat exhaustion/stroke that required medical care

your blood cholesterol level is greater than 200 mg/dL, or your HDL is less than 40 mg/dL, or you take cholesterol medication

I have a waiver for

SECTION B

Cardiovascular risks:

you are physically inactive (i.e., you get less than 30 minutes of physical activity less than 3 days per week)

you have a body mass index (BMI) ≥ 30 *

you don’t know your cholesterol level

you don’t know your blood pressure

you smoke currently or in the past 6 months

*(to determine BMI, go to: National Heart, Lung and Blood Institute: Calculate Your Body Mass Index )

I understand that if I need to be evaluated by a physician, it will be based on the fitness requirements of the position(s) for which I am qualified.

Privacy Statement

The information obtained in the completion of this form is used to help determine whether an individual being considered for wildland firefighting can carry out those duties in a manner that will not place the candidate unduly at risk due to inadequate physical fitness and health. Its collection and use are covered under Privacy Act System of Records OPM/Govt-10 and are consistent with the provisions of 5 USC 552a (Privacy Act of 1974). WARNING: The information you have given constitutes an official statement. Incomplete, misleading, or untruthful information provided on the form may result in delays in processing the form for employment, termination of employment, or criminal sanction. Federal law provides severe penalties (up to 5 years confinement or a $10,000 fine or both), to anyone making a false statement.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0164. The time required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions (if any) or hearing a description of the project, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 975-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

I have read and understand the above, and answered truthfully.

Signature: Printed Name Date

Unit: City State

HSQ Coordinator: