Chief Or Training Officer
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Chief or Training Officer: In this packet you will find eight (8) forms. The first four (4) forms need to be completed and returned to NIPSTA. The last four (4) forms contain information for you and your candidate. 1. Fire Department Attestation Form 2. Participant Acknowledgment and Release Of Claims Form 3. Candidate information Form 4. Emergency Information Form 5. OSFM Roster Notice 6. Candidate Equipment and Apparel Checklist 7. Required Textbook Notice 8. Physical Fitness Preparation and Expectation All departments must complete the first four (4) forms and return them to NIPSTA no later than one (1) week prior to the start of the program. These forms should be submitted to District Chief and Program Coordinator Orlando Diaz at [email protected]. Please be advised that we maintain an “open campus” philosophy, which means that you and any member of your staff are invited to visit our training grounds at any time to see our operations first-hand. You will also receive weekly progress reports designed to help you track the progress of your personnel, and monitor day-to-day activities. Additionally, you be invited to a Chiefs Luncheon with your Candidate, which will be scheduled mid-way through the nine-week academy program. We thank you for the opportunity and privilege to train your personnel. Please do not hesitate to contact us if you have any Questions, or need more information. Sincerely, Ken Koerber Fire & Technical Rescue Program Director Northeastern Illinois Public Safety Training Academy Cell: 847-567-6976 Email: [email protected] NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Fire Department Attestation Form Candidate Name: Candidates Fire Department: Fire Academy Session Dates: The undersigned individual attests that the above named participant is enrolled in the NIPSTA Fire Academy on the dates listed above, and: . Is an employee of the fire department named above and is authorized to participate in the NIPSTA Fire Academy . Have received medical clearance form a supervising physician to participate in the NIPSTA Fire Academy and engage in the related physical training including use of a self-contained breathing apparatus (SCBA). Has completed an SCBA fit test within the past 12 months and satisfied the fit test requirements. Has been issued NFPA 1852 compliant SCBA equipment that is in good working order, free of defects, has been certified by the employer as serviceable for training, and has met all current hydrostatic, flow testing, and visual inspection requirements as identified by the department and manufacture. Has received training in the proper use, cleaning and maintenance of SCBA, pursuant to the manufacturer . Has been issued NFPA 1851 compliant protective clothing that is not more than 10 years old and is in good condition, free of defects and is suitable for use in the NIPSTA Fire Academy. Furthermore, the undersigned individual confirms that sufficient records of evidence exist to confirm all of the statements above and are available to NIPSTA upon request. Fire Chief Name (print): Department: Fire Chief Signature: Date: NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Candidate Participant Acknowledgment of Conditions and Release of Claims The Northeastern Illinois Public Safety Training Academy (NIPSTA) conducts its training programs in a safe and responsible manner. However, it is not possible to eliminate all potential hazards to participant safety. Before any individual participates in a NIPSTA training program involving live fire instruction, he/she should be familiar with the physical stress and hazards involved. NIPSTA participants are required to read the following explanations of the physical and mental effects of this training. Thereafter, signatures on this form are required as Acknowledgement of Conditions and Release of Claims. Participants who cannot comply with these requirements will not be allowed to participate in any training that involves physical exertion or the use of personal protective equipment. However, these individuals may participate in lecture activities and observe live fire training exercises from a safe distance. This is necessary to provide for the personal well-being and safety of all participants. The undersigned individuals acknowledge: 1. Firefighter training is a physically and mentally stressful activity that involves: physical exertion; exposure to toxic atmospheres, high temperatures and humidity levels; working at heights and in confined spaces; elevated body temperatures; increased pulse rates, respiration and blood pressures; and reactions to emergency situations. 2. Participants who are pregnant or have heart disease, lung disease, hypertension or other medical or mental conditions that may affect their health and safety under live fire conditions are required to consult with a physician before participating in any live fire training activity at NIPSTA. Evidence of the ability to meet the Illinois Department of Labor Respirator Wearers physical evaluation may be required. 3. Participants must utilize protective clothing and self-contained breathing apparatus that satisfy NFPA standards. 4. Participants with facial hair, jewelry or any other impediment to the proper seal of the face- piece on self-contained breathing apparatus will not be allowed to participate in training evolutions where the atmosphere is toxic or may become so. 5. Participant use of alcohol or any other drug that affects mental or physical reactions immediately preceding or during training is prohibited. 6. NIPSTA may use the image or likeness of any participant, as contained in a photograph or digital format, in advertising, promotional or instructional materials without compensation. 7. Participants agree that the work to be performed under this Agreement will be performed entirely at their own risk. Furthermore, participants agree to indemnify and hold harmless NIPSTA and its members, including the Village of Glenview, for any and all injury, liability or loss arising in any way out of the performance of this Agreement. Candidate Signature: Print Candidate Name: Fire Chief Signature: Print Fire Chief Name: NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Candidate Information Form Date this form was CANDIDATE INFORMATION completed Candidate Name Drivers License # State Birth Date: Social Security # (Last 4 Digits Only) XXX-XX- Cell Phone Number ( ) - Email Address HOME ADDRESS (Do not list a P.O. Box) Address Apartment/Unit # City State Zip Home Phone Number ( ) - DEPARTMENT INFORMATION Department Name Department Address City State Zip Department Phone Department Fax FDID# Department Chief Department Chief’s Email OSFM CERTIFICATIONS (Circle all that apply) BASIC FF FIREFIGHTER II ADVANCED HAZMAT OPS TRA OTHER OSFM CERTIFICATIONS CPAT CARD (Circle one) YES NO CURRENT STATUS (Circle one) PAID PT POC VOL What date did you start in the Fire service? ______/______/______ EMT-B? _____ EMT-P?_____ COLLEGE GRADUATE: YES___ NO___ TYPE OF DEGREE_________________ MEMBER OF MILITARY: YES___ NO___ ACTIVE___RESERVE___ NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Emergency Information Form The information provided will be used only in the event you are seriously injured or become ill while attending the NIPSTA Fire Academy. Please take the time to fill the form out accurately, and legibly, as this information may benefit you, your department, or your family in the event of an emergency. EMERGENCY CONTACT INFORMATION Name Cell Phone Work Phone Home Phone Relationship Special circumstances Any health conditions that bad news may affect? Yes No Not that I know of If yes, what is the general condition? Is there a need for an interpreter? If yes, what language? HOME CONTACT INFORMATION Home address City, State, Zip Code Home phone number Pager/Cell Phone Number WORK CONTACT INFORMATION Name of Employer Work address City, State, Zip Code Work phone number NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Office of State Fire Marshal Roster Notice Training Officer, In order for NIPSTA to guarantee your candidate will be scheduled for the OSFM Basic Firefighter, TRA, and Haz-mat Operations exams you must add your candidate to your OSFM department roster no later than Week 1 of the Fire Academy. Directions for adding your candidate to your department’s OSFM roster: 1. Log on to the OSFM website at: www.sfm.illinois.og 2. Select “Fire Service” 3. Select “Fire Equipment Exchange” 4. Select “PSE Web Update System” 5. Enter your departments email address and password to access your department information page, then “log in” 6. Select “Roster”, and add your new employee’s information If you have questions regarding the OSFM roster, please contact the OSFM Division of Personnel Standards and Education. Contact information is on the website. After adding your candidate to the OSFM roster, NIPSTA will register your candidate for the OSFM Basic Firefighter, TRA, and Haz-mat Operations exams. Your candidate will receive information on exam dates after the start of the program. Thank you, NIPSTA Fire Academy NIPSTA FIRE ACADEMY 2300 Patriot Boulevard Glenview Illinois ★ Phone: (847) 998-8090 ★ Fax: (847) 998-8091 Candidate Equipment and Apparel Checklist Each participant will be required to provide the following