FD-731 Hazardous Devices School Form.pdf

FBI BOMB DATA CENTER

HAZARDOUS DEVICES SCHOOL

COURSE APPLICATION

Privacy Act Statement - Solicitation of inf ormation on this f orm is authorized by Title 42, United States Code (USC), Section 3771(a), which authorizes the Director of the FBI to establish and conduct training programs for state and local criminal justice personnel, and, in the case of your Social Security Number (SSAN), by Executive Order 9397. The primary purpose of soliciting the requested inf ormation is to determine your eligibility f or enrollment in the FBI Hazardous Devices School.

Although provision of the information on this form is voluntary, failure to provide the requested information (with the exception of your SSAN) shall result in the denial of this application. Information provided on this form may be disseminated according to the provisions of Title 5, USC, Section 552a, more commonly known as the Privacy Act of 1974.

This information form is required for all Hazardous Devices School applicants. 1. Date of Application

2. Type of class desired: G Basic Course G Recertif ication Course G Other ______________________ Basic Course Applicants Only: Do you understand that all travel, lodging and subsistence expenditures incurred during the Hazardous Devices School Basic Course are to be borne by your agency? G Yes G No

3. Last Name First Name Middle Name

4. Residence Address (Street, City, State, Zip Code)

5. Birth Date 6. Place of Birth 7. Social Security Number

8. a. Name of relative to be contacted in case of emergency 8. b. Relationship to applicant

9. G Male G Female 10. Height 11. Weight

12. Do you have any physical def ects which would preclude unrestricted, regular participation in the handling of live explosives or wearing of bomb suits, chemical protective suits, respirators and other protective equipment during the Hazardous Devices School training? G Yes G No (If “ yes”, explain)

13. Name, address, and phone number of present f amily physician

14. E-mail Address: a. Business _____________________________________________________

b. Personal _____________________________________________________

15. Business Telephone Number 16. Facsimile Telephone Number

17. Home Telephone Number 18. Cellular Telephone Number

FD-731 (Rev. 9-20-07) U.S. Department of Justice Federal Bureau of Investigation

19. a. Name of public saf ety agency where candidate employed :

b. Length of employment: c. Full Time G Yes G No

20. Employment Address (Street, City, State, Zip Code) 21. Rank or Title

22. Signature of Nominating Official (f rom the applicant’s agency)

Name and Title (Print or Type)

Bomb Squad Information

23. a. Name of Accredited Bomb Squad to which assigned b. Bomb Squad Identif ier Number

c. Name of Bomb Squad Commander (Def ined as the certif ied bomb technician point of contact who will speak for the squad)

d. Mailing Address of Bomb Squad (Street, City, State, Zip Code)

e. Telephone Number of Bomb Squad f. Fax Number of Bomb Squad

g. E-mail of Bomb Squad

h. Signature of Bomb Squad Commander (Required if the Bomb Squad Commander is employed by a dif f erent agency)

24. Waiver: I am about to take a course of instruction at the Hazardous Devices School and am aware that this course may necessitate my personal handling of live explosives, incendiary materials, hazardous chemicals, as well as the wearing of bomb suits, respiratory protective equipment and other personal protective equipment. I acknowledge that I am taking this course on my own initiative. I am f ully aware of the dangers and risks involved in this course of instruction and realize that neither the United States Government nor the Federal Bureau of Investigation is agreeing to act as insurers of my safety. Theref ore, in consideration of the permission extended to me by the United States, through its of f icers and Agents, to take this course of instruction, I do hereby, f orever discharge the Government of the United States and all its of f icers, Agents, and employees, acting of f icially or otherwise, f rom any and all claims or causes of action on account of any injury to me or my property which results through no f ault or wrongdoing on behalf of the Government or its employees during the course of instruction or the handling of any hazardous device. I f urther acknowledge and agree that any claims or causes of actions against the Federal Government I may have f or injuries to myself or to my property during my instruction will be those provided for by the Federal Tort Claims Act or other applicable f ederal statutes.

25. All Applicants: Return this f orm and other designated f orms, including medical f orms, to the Training Coordinator in the FBI Field Of f ice in your region.

26. __________________________________________________ ________________________ Signature of Applicant Date

FD-979a (9-9-04) FBI File Number:

Non-Personnel Consent to Release Information

To Whom It May Concern:

I hereby give consent to any authorized representative of the Federal Bureau of Investigation to obtain any information in your files pertaining to my academic, achievement, athletic, attendance, credit (including credit card and payment device numbers), disciplinary, employment, law enforcement (including, but not limited to, any record of charge, prosecution, or conviction for civil or criminal offenses), military, or professional license records (including any grievance records). I hereby direct each entity to which this form is presented to release such information upon request of the authorized recipient as described above, regardless of any other agreement or direction I may have made.

This consent is executed with full knowledge and understanding that the information is for the official use of the Federal Bureau of Investigation in connection with the determination of suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom I am associated. Consent is granted for the Federal Bureau of Investigation to furnish such information as is described above to third parties in the course of fulfilling its official responsibilities.

Copies of this consent that show my signature are as valid as the original signed by me. This consent is valid for one (1) year from the date signed.

Signature (sign in ink)

Full Name (type or print clearly) Date Signed

Other Names Used Social Security Account No.

Signature of Parent or Guardian (if required)

Place of Birth Date of Birth

Signature of Witness

Name & Title of Witness

PRIVACY ACT STATEMENT

Authority: The collection of information requested by this form is authorized under Executive Order 10450, Security Requirements for Government Employees; Executive Order 12968, Access to Classified Information; and the Fair Credit Reporting Act, 15 U.S.C. §§1681 et seq. Providing requested information is voluntary; however, failure to furnish the requested information and consent may affect our ability to complete the determination of suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom you are associated.

Principal Purpose: The information will be used principally to obtain such academic, achievement, athletic, attendance, credit, disciplinary, educational, employment, law enforcement, military, and professional license records as may be necessary to determine the suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom you are associated. Your Social Security Account Number (SSAN) identifies you in most of the above-listed transactions. We will use your SSAN to accurately identify your records and to process investigations, inquiries, and/or determinations related to this consent.

Routine Uses: In addition to disclosures within the Department of Justice on a need-to-know basis, information reported on this form may be disclosed in accordance with all applicable routine uses as may be published at any time in the Federal Register, including all routine uses for the FBI Central Records System. These routine uses include the following disclosures: to potential sources in order to locate, seek, and obtain information or records pertaining to you; to any appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence, or security matters to which the information may be relevant; to non-FBI employees performing Federal assignments; to courts or adjudicative bodies when the FBI considers it has an interest in the proceedings;

or as otherwise mandated by law, treaty, or Executive Order.

FBI/DOJ

MEDICAL RECORD REPORT OF MEDICAL EXAMINATION

DATE OF EXAM

1. LAST NAME - FIRST NAME - MIDDLE NAME

2. IDENTIFICATION NUMBER 3. GRADE AND COMPONENT OR POSITION

4. HOME ADDRESS (Number, street or RFD, city or town, state and ZIP Code)

5. EMERGENCY CONTACT (Name and address of contact)

6. DATE OF BIRTH 7. AGE 8. SEX 9. RELATIONSHIP OF CONTACT

FEMALE MALE

11. RACE 10. PLACE OF BIRTH

WHITE BLACK AMERICAN INDIAN/

ALASKA NATIVE HISPANIC

WHITE HISPANIC

BLACK ASIAN/PACIFIC

ISLANDER

12a. AGENCY 12b. ORGANIZATION UNIT 13. TOTAL YEARS GOVERNMENT SERVICE

a. MILITARY b. CIVILIAN

14. NAME OF EXAMINING FACILITY OR EXAMINER AND ADDRESS 15. RATING OR SPECIALTY OF EXAMINER

16. PURPOSE OF EXAMINATION

17. CLINICAL EVALUATION

NOR-

MAL (Check each item in appropriate column, enter “NE” if not evaluated) ABNOR-

MAL NOR-

MAL

(Check each item in appropriate column, enter “NE” if not evaluated.) ABNOR-

MAL

A. HEAD, FACE, NECK AND SCALP O. PROSTATE (Over 40 or clinically indicated)

P. TESTICULAR B. EARS - GENERAL (INTERNAL CANALS)

(Auditory acuity under items 39 and 40) Q. ANUS AND RECTUM (Hemorrhoids, Fistulae) (Hemocult Results) C. DRUMS (Perforation) R. ENDOCRINE SYSTEM

D. NOSE S. G-U SYSTEM

E. SINUSES T. UPPER EXTREMITIES (Strength, range of motion)

F. MOUTH AND THROAT U. FEET

G. EYES - GENERAL (Visual acuity and refraction under items 28, 29, and

36) V. LOWER EXTREMITIES (Except feet) (Strength, range of motion)

H. OPTHALMOSCOPIC W. SPINE, OTHER MUSCULOSKELETAL

I. PUPILS (Equality and reaction) X. IDENTIFYING BODY MARKS, SCARS, TATTOOS J. OCULAR MOTILITY (Associated parallel movements nystagmus) Y. SKIN, LYMPHATICS K. LUNGS AND CHEST Z. NEUROLOGIC (Equilibrium tests under item 41) L. HEART (Thrust, size, rhythm, sounds) AA. PSYCHIATRIC (Specify any personality deviation) M. VASCULAR SYSTEM (Varicosities, etc.) BB. BREASTS N. ABDOMEN AND VISCERA (Include hernia) CC. PELVIS (Females only) NOTES: (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 42 and use additional sheets if necessary.)

18. DENTAL (Place appropriate symbols, shown in examples, above or below number of upper and lower teeth.) REMARKS AND ADDITIONAL DENTAL 0 / Non- X X X X ( X ) 1 2 3 Restorable 1 2 3 restorable 1 2 3 Missing 1 2 3 Replaced 1 2 3 Fixed 32 31 30 Teeth 32 31 30 Teeth 32 31 30 Teeth 32 31 30 by 32 31 30 Partial 0 / X X X X Dentures ( X )

DEFECTS AND DISEASES

R L I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 E G 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 F H T T

19. TEST RESULTS (Copies of results are preferred as attachments) A. URINALYSIS: (1) SPECIFIC GRAVITY B. CHEST X-RAY OR PPD (Place, date, film number and result) TB Tyne Test

(2) URINE ALBUMIN (4) MICROSCOPIC

(3) URINE SUGER

C. SYPHILIS SEROLOGY (Specify test used and results)

D. EKG E. BLOOD TYPE AND

RH

FACTOR

F. OTHER TESTS

NSN 7540-00-634-4038 STANDARD FORM 88 (Rev. 10-94) (EG) 88-126 Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1

NAME

IDENTIFICATION NUMBER NO. OF SHEETS ATTACHED

MEASUREMENTS AND OTHER FINDINGS

24. BUILD 20. HEIGHT 21. WEIGHT 22. COLOR HAIR 23. COLOR EYES

SLENDER MEDIUM HEAVY OBESE

25. TEMPERATURE

26. BLOOD PRESSURE (Arm at heart level) 27.PULSE (Arm at heart level)

SYS. SYS. SYS. A.

SITTING DIAS.

B.

RECUM-

BENT DIAS.

C.

STANDING

(5 mins.) DIAS.

A. SITTING B. RECUMBENT C. STANDING

(3 mins)

D. AFTER EXERCISE E. 2 MINS. AFTER

28. DISTANT VISION 29. REFRACTION 30. NEAR VISION

RIGHT 20/ CORR. TO 20/ BY S. CX CORR. TO BY

LEFT 20/ CORR. TO 20/ BY S. CX CORR. TO BY

31. HETEROPHORIA (Specify distance)

ESO EXO R.H. L.H. PRISM DIV. PRISM CONV. PC PD

CT

32. ACCOMMODATION UNCORRECTED

RIGHT LEFT

33. COLOR VISION (Test used and result)* 34. DEPTH PERCEPTION (Test used and score) CORRECTED

35. FIELD OF VISION 38. INTRAOCULAR TENSION

RIGHT LEFT

36. NIGHT VISION (Test used and score) 37. RED LENS TEST

RIGHT LEFT

39. HEARING 40. AUDIOMETER

RIGHT W/V /15 SV /15 250

RIGHT

LEFT W/V /15 SV /15 LEFT

41. PSYCHOLOGICAL AND PSYCHOMOTOR (Tests used and score)

42. NOTES (Continued) AND SIGNIFICANT OR INTERVAL HISTORY

(Use additional sheets if necessary)

43. SUMMARY OF DEFECTS AND DIAGNOSES (List diagnoses with item numbers)

45A. PHYSICAL PROFILE

P U L H E S

44. RECOMMENDATIONS - FURTHER SPECIALIST EXAMINATIONS INDICATED (Specify)

46. EXAMINEE (Check) A. � IS QUALIFIED FOR Bomb Technician Training at Hazardous Devices School B. � IS NOT QUALIFIED FOR Bomb Technician Training at Hazardous Devices School

45B. PHYSICAL CATEGORY

47. IF NOT QUALIFIED, LIST DISQUALIFYING DEFECTS BY ITEM NUMBER A B C E

48. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

49. TYPED OR PRINTED NAME OF PHYSICIAN SIGNATURE

50. TYPED OR PRINTED NAME OF DENTIST OR PHYSICIAN (Indicate which) SIGNATURE

51. TYPED OR PRINTED NAME OF REVIEWING OFFICER OR APPROVING AUTHORITY SIGNATURE

*Basic applicants only STANDARD FORM 88 (Rev. 10-94) BACK

NO. OF ATTACHED SHEETS

MEDICAL RECORD REPORT OF MEDICAL HISTORY DATE OF EXAM

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. NAME OF PATIENT (Last, first, middle) 2. IDENTIFICATION NUMBER 3. GRADE

4a. HOME ADDRESS (Street or RFD; City or Town; State; and ZIP Code)

5. EXAMINING FACILITY

4b. CITY 4c. STATE 4d. ZIP CODE

6. PURPOSE OF EXAMINATION

7. STATEMENT OF PATIENT’S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)

b. CURRENT MEDICATION REGULAR OR INTERIM

a. PRESENT HEALTH

c. ALLERGIES (Include insect bites/stings and common foods)

d. HEIGHT e. WEIGHT

9. ARE YOU (Check one) 8. PATIENT’S OCCUPATION

RIGHT HANDED LEFT HANDED

10. PAST/CURRENT MEDICAL HISTORY

CHECK EACH ITEM YES NO DON’T

KNOW

CHECK EACH ITEM YES NO DON’T

KNOW

CHECK EACH ITEM YES NO DON’T

KNOW

Household contact with anyone with tuberculosis

Shortness of breath Bone, joint or other deformity

Pain or pressure in chest Loss of finger or toe Tuberculosis or positive TB test Chronic cough Painful or “trick” shoulder or elbow

Blood in sputum or when coughing Palpitation or pounding heart Heart trouble Recurrent back pain or any back injury

Excessive bleeding after injury or dental work

High or low blood pressure

Cramps in your legs “Trick” or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach, liver, or intestinal trouble Nerve injury Wear corrective lenses Gall bladder trouble or gallstones Paralysis (include infantile)

Eye surgery to correct vision Epilepsy or seizure Lack vision in either eye Jaundice or hepatitis Car, train, sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor, growth, cyst, cancer Nervous trouble of any sort Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Parent/sibling with diabetes, cancer, stroke or heart disease

Frequent or severe headaches Frequent or painful urination Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Asbestos or toxic chemical exposure

Recurrent ear infections Sexually transmitted disease Chronic or frequent colds Recent gain or loss of weight Plate, pin or rod in any bone Severe tooth or gum trouble Eating disorder (anorexia, bulmia, etc.)

Easy fatigability

Sinusitis Been told to cut down or criticized for alcohol use

Hay Fever or allergic rhinitis Arthritis, Rheumatism or Bursitis

Head injury Used illegal substances Asthma Thyroid trouble or goiter Used tobacco

NSN 7540-00-181-8638 STANDARD FORM 93 (REV. 6/96) (EG)

Previous edition not usable Prescribed by ICMR/GSA

FIRMR (41 CFR) 201-9.202-1

Designed using Perform Pro, WHS/DIOR, Apr 97

11. FEMALES ONLY

CHECK EACH ITEM YES NO DON’T

KNOW

DATE OF LAST MENSTRUAL

PERIOD

DATE OF LAST PAP SMEAR DATE OF LAST MAMMO-

GRAM

Treated for a female disorder Change in menstrual pattern

CHECK EACH ITEM. IF “YES” EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER

ITEM YES NO

12. Have you been refused employment or been unable to hold a job or stay in school because of:

a. Sensitivity to chemicals, dust sunlight, etc.

b. Inability to perform certain motions.

c. Inability to assume certain positions.

d. Other medical reasons (If yes, give reasons.)

13. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.)

14. Have you ever been denied life insurance? (If yes, state reason and give details.)

15. Have you had, or have you been advised to have, any operation?

(If yes, describe and give age at which occurred.)

16. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

17. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.)

18. Have you ever been rejected for military service because of physical, mental, or other reasons? (If yes, give date and reason for rejection.)

19. Have you ever been discharged from military service because of physical, mental, or other reasons? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, for unfitness or unsuitability.)

20. Have you ever received, is there pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.)

21. Have you ever been arrested or convicted of a crime, other than minor traffic violations? (If yes, provide details.)

22. Have you ever been diagnosed with a learning disability? (If yes, give type, where, and how diagnosed.)

23. LIST ALL IMMUNIZATIONS RECEIVED

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.

24a. TYPED OR PRINTED NAME OF EXAMINEE

24b. SIGNATURE 24c. DATE

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE “TO BE OPENED BY MEDICAL OFFICER ONLY.”

25. PHYSICIAN’S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in items 7 through 11. Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)

26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINEE

26b. SIGNATURE 26c. DATE

STANDARD FORM 93 (Rev. 6-96) BACK

Hazardous Devices School Physical Capacities Form

Applicant’s Name:______________________________________________________________

Dear Doctor:

The above named individual is applying to attend a course at the Hazardous Devices School, which will certify him/her as a bomb technician. This training is physically demanding in that it requires students to wear protective suits while performing tasks. The bomb suit with helmet weighs up to 70 pounds and is quite restrictive. The combination chemical suit (level B) and WMD bomb suit (40-pound suit) also requires the wearing of a self-contained breathing apparatus (SCBA) with respirator. The microenvironment within this equipment can expose the wearer to temperatures in excess of 100 degrees Fahrenheit, and humidity of 100% for periods of up to 30 minutes. Tasks to be performed include carrying a portable x-ray (25 pounds) and disrupter (40 pounds) a distance of at least 600 feet. During these tasks the student must kneel, position the tools and get back up on their own. If they fall, they must be able to get back up without assistance. In order to be accepted to this HDS course, the applicant must not have any of the restrictions listed below.

Please check any of the following medical restrictions that may apply to the applicant:

_____ Restricted from lifting more than 50 pounds.

_____ Restricted from kneeling, bending or twisting.

_____ Restricted from working in a respirator (including negative pressure or SCBA types) .

_____ Overweight to the degree that wearing a 70-pound bomb suit while carrying equipment would present health risks.

_____ Restricted from wearing protective chemical and/or bomb suits.

Comments: ___________________________________________________________________

I have discussed the OSHA Respirator Medical Evaluation Questionnaire with the patient. (Questionnaire may be maintained by health care provider and need not be returned to the patient or the FBI.)

Physician’s Printed Name Physician’s Signature

Date

Maximum Weight by Height From the National Guidelines for Bomb Technicians

Male Female Age Group Age Group Height

(inches) 21-29 30-39 40-49 50+ 21-29 30-39 40-49 50+

58 100 103 106 109

59 105 108 111 114

60 166 169 172 175 110 113 116 119

61 170 173 176 179 115 118 121 124

62 173 176 179 182 120 123 126 129

63 176 179 182 185 125 128 131 134

64 180 183 186 189 130 133 136 139

65 183 186 189 192 135 138 141 144

66 186 189 192 195 140 143 146 149

67 190 193 196 199 145 148 151 154

68 193 196 199 202 150 153 156 159

69 196 199 202 205 155 158 161 164

70 200 203 206 209 160 163 166 169

71 203 206 209 212 165 168 171 174

72 206 209 212 215 170 173 176 179

73 210 213 216 219 175 178 181 184

74 213 216 219 222 180 183 186 189

75 216 219 222 225 185 188 191 194

76 220 223 226 229 190 193 196 199

77 223 226 229 232 195 198 201 204

78 226 229 232 235 200 203 206 209

79 230 233 236 239 205 208 211 214

80 233 236 239 242 210 213 216 219

Age Group Alternative Body Fat Test

21-27 28-39 40-49 50+ Maximum Body Fat (Male) 22% 24% 26% 28% Maximum Body Fat (Female) 30% 32% 34% 36%

OSHA 29CFR, Appendix C to Sec. 1910.134:

OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

To the employer: Answers to questions in Section 1, and to question 9 in Section 2 of Part A, do not require a medical examination.

To the employee:

Can you read (circle one): Yes/No

Your employer must allow you to answer this questionnaire during normal working hours, or at a time and place that is convenient to you. To maintain your confidentiality, your employer or supervisor must not look at or review your answers. Additionally, your employer must tell you how to deliver or send this questionnaire to the health care professional, who will review it.

Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to use any type of respirator (please print).

1. Today's date:_______________________________________________________

2. Your name:__________________________________________________________

3. Your age (to nearest year):_________________________________________

4. Sex (circle one): Male/Female

5. Your height: __________ ft. __________ in.

6. Your weight: ____________ lbs.

7. Your job title:_____________________________________________________

8. A phone number where you can be reached by the health care professional who reviews this questionnaire (include the Area Code): ____________________

9. The best time to phone you at this number: ________________

10. Has your employer told you how to contact the health care professional who will review this questionnaire (circle one): Yes/No

11. Check the type of respirator you will use (you can check more than one category):

a. ______ N, R, or P disposable respirator (filter-mask, non-cartridge type only).

b. ______ Other type (for example, half- or full-face piece type, powered-air purifying, supplied-air, self-contained breathing apparatus).

12. Have you worn a respirator (circle one): Yes/No If "yes," what type(s):________________________________________________

Part A. Section 2. (Mandatory) Questions 1 through 9 below must be answered by every employee who has been selected to use any type of respirator (please circle "yes" or "no").

1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No

2. Have you ever had any of the following conditions?

a. Seizures (fits): Yes/No

b. Diabetes (sugar disease): Yes/No

c. Allergic reactions that interfere with your breathing: Yes/No

d. Claustrophobia (fear of closed-in places): Yes/No

e. Trouble smelling odors: Yes/No

3. Have you ever had any of the following pulmonary or lung problems?

a. Asbestosis: Yes/No

b. Asthma: Yes/No

c. Chronic bronchitis: Yes/No

d. Emphysema: Yes/No

e. Pneumonia: Yes/No

f. Tuberculosis: Yes/No

g. Silicosis: Yes/No

h. Pneumothorax (collapsed lung): Yes/No

i. Lung cancer: Yes/No

j. Broken ribs: Yes/No

k. Any chest injuries or surgeries: Yes/No

l. Any other lung problem that you've been told about: Yes/No

4. Do you currently have any of the following symptoms of pulmonary or lung illness?

a. Shortness of breath: Yes/No

b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline: Yes/No

c. Shortness of breath when walking with other people at an ordinary pace on level ground: Yes/No

d. Have to stop for breath when walking at your own pace on level ground: Yes/No

e. Shortness of breath when washing or dressing yourself: Yes/No

f. Shortness of breath that interferes with your job: Yes/No

g. Coughing that produces phlegm (thick sputum): Yes/No

h. Coughing that wakes you early in the morning: Yes/No

i. Coughing that occurs mostly when you are lying down: Yes/No

j. Coughing up blood in the last month: Yes/No

k. Wheezing: Yes/No

l. Wheezing that interferes with your job: Yes/No

m. Chest pain when you breathe deeply: Yes/No

n. Any other symptoms that you think may be related to lung problems: Yes/No

5. Have you ever had any of the following cardiovascular or heart problems?

a. Heart attack: Yes/No

b. Stroke: Yes/No

c. Angina: Yes/No

d. Heart failure: Yes/No

e. Swelling in your legs or feet (not caused by walking): Yes/No

f. Heart arrhythmia (heart beating irregularly): Yes/No

g. High blood pressure: Yes/No

h. Any other heart problem that you've been told about: Yes/No

6. Have you ever had any of the following cardiovascular or heart symptoms?

a. Frequent pain or tightness in your chest: Yes/No

b. Pain or tightness in your chest during physical activity: Yes/No

c. Pain or tightness in your chest that interferes with your job: Yes/No

d. In the past two years, have you noticed your heart skipping or missing a beat: Yes/No

e. Heartburn or indigestion that is not related to eating: Yes/ No

f. Any other symptoms that you think may be related to heart or circulation problems: Yes/No

7. Do you currently take medication for any of the following problems?

a. Breathing or lung problems: Yes/No

b. Heart trouble: Yes/No

c. Blood pressure: Yes/No

d. Seizures (fits): Yes/No

8. If you've used a respirator, have you ever had any of the following problems? (If you've never used a respirator, check here ” and go to question 9.)

a. Eye irritation: Yes/No

b. Skin allergies or rashes: Yes/No

c. Anxiety: Yes/No

d. General weakness or fatigue: Yes/No

e. Any other problem that interferes with your use of a respirator: Yes/No

9. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire: Yes/No

Questions 10 to 15 below must be answered by every employee who has been selected to use either a full-facepiece respirator or a self-contained breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary.

10. Have you ever lost vision in either eye (temporarily or permanently): Yes/No

11. Do you currently have any of the following vision problems?

a. Wear contact lenses: Yes/No

b. Wear glasses: Yes/No

c. Color blind: Yes/No

d. Any other eye or vision problem: Yes/No

12. Have you ever had an injury to your ears, including a broken ear drum: Yes/No

13. Do you currently have any of the following hearing problems?

a. Difficulty hearing: Yes/No

b. Wear a hearing aid: Yes/No

c. Any other hearing or ear problem: Yes/No

14. Have you ever had a back injury: Yes/No

15. Do you currently have any of the following musculoskeletal problems?

a. Weakness in any of your arms, hands, legs, or feet: Yes/No

b. Back pain: Yes/No

c. Difficulty fully moving your arms and legs: Yes/No

d. Pain or stiffness when you lean forward or backward at the waist: Yes/No

e. Difficulty fully moving your head up or down: Yes/No

f. Difficulty fully moving your head side to side: Yes/No

g. Difficulty bending at your knees: Yes/No

h. Difficulty squatting to the ground: Yes/No

i. Climbing a flight of stairs or a ladder carrying more than 25 lbs: Yes/No

j. Any other muscle or skeletal problem that interferes with using a respirator: Yes/No

Part B. Any of the following questions, and other questions not listed, may be added to the questionnaire at the discretion of the health care professional who will review the questionnaire.

1. In your present job, are you working at high altitudes (over 5,000 feet) or in a place that has lower than normal amounts of oxygen: Yes/No If "yes," do you have feelings of dizziness, shortness of breath, pounding in your chest, or other symptoms when you're working under these conditions: Yes/No

2. At work or at home, have you ever been exposed to hazardous solvents, hazardous airborne chemicals (e.g., gases, fumes, or dust), or have you come into skin contact with hazardous chemicals: Yes/No If "yes," name the chemicals if you know them:______________________________

3. Have you ever worked with any of the materials, or under any of the conditions, listed below:

a. Asbestos: Yes/No

b. Silica (e.g., in sandblasting): Yes/No

c. Tungsten/cobalt (e.g., grinding or welding this material): Yes/No

d. Beryllium: Yes/No

e. Aluminum: Yes/No

f. Coal (for example, mining): Yes/No

g. Iron: Yes/No

h. Tin: Yes/No

i. Dusty environments: Yes/No

j. Any other hazardous exposures: Yes/No If "yes," describe these exposures:________________________________________

4. List any second jobs or side businesses you have:______________________________

5. List your previous occupations:____________________________________________

6. List your current and previous hobbies:______________________________________

7. Have you been in the military services? Yes/No If "yes," were you exposed to biological or chemical agents (either in training or combat):

Yes/No

8. Have you ever worked on a HAZMAT team? Yes/No

9. Other than medications for breathing and lung problems, heart trouble, blood pressure, and seizures mentioned earlier in this questionnaire, are you taking any other medications for any reason (including over-the-counter medications): Yes/No If "yes," name the medications if you know them:_______________________

10. Will you be using any of the following items with your respirator(s)?

a. HEPA Filters: Yes/No

b. Canisters (for example, gas masks): Yes/No

c. Cartridges: Yes/No

11. How often are you expected to use the respirator(s) (circle "yes" or "no" for all answers that apply to you)?:

a. Escape only (no rescue): Yes/No

b. Emergency rescue only: Yes/No

c. Less than 5 hours per week: Yes/No

d. Less than 2 hours per day: Yes/No

e. 2 to 4 hours per day: Yes/No

f. Over 4 hours per day: Yes/No

12. During the period you are using the respirator(s), is your work effort:

a. Light (less than 200 kcal per hour): Yes/No If "yes," how long does this period last during the average shift: ______hrs.______mins.

Examples of a light work effort are sitting while writing, typing, drafting, or performing light assembly work; or standing while operating a drill press (1-3 lbs.) or controlling machines.

b. Moderate (200 to 350 kcal per hour): Yes/No If "yes," how long does this period last during the average shift :______hrs.______mins.

Examples of moderate work effort are sitting while nailing or filing; driving a truck or bus in urban traffic; standing while drilling, nailing, performing assembly work, or transferring a moderate load (about 35 lbs.) at trunk level; walking on a level surface about 2 mph or down a 5-degree grade about 3 mph; or pushing a wheelbarrow with a heavy load (about 100 lbs.) on a level surface.

c. Heavy (above 350 kcal per hour): Yes/No If "yes," how long does this period last during the average shift: ______hrs.______mins.

Examples of heavy work are lifting a heavy load (about 50 lbs.) from the floor to your waist or shoulder; working on a loading dock; shoveling; standing while bricklaying or chipping castings; walking up an 8-degree grade about 2 mph; climbing stairs with a heavy load (about 50 lbs.).

13. Will you be wearing protective clothing and/or equipment (other than the respirator) when you're using your respirator: Yes/No If "yes," describe this protective clothing and/or equipment:________________________

14. Will you be working under hot conditions (temperature exceeding 77E F): Yes/No

15. Will you be working under humid conditions: Yes/No

16. Describe the work you'll be doing while you're using your respirator(s):

17. Describe any special or hazardous conditions you might encounter when you're using your respirator(s) (for example, confined spaces, life-threatening gases):

18. Provide the following information, if you know it, for each toxic substance that you'll be exposed to when you're using your respirator(s):

Name of the first toxic substance:_____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift_________________________________________ Name of the second toxic substance:____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift:________________________________________ Name of the third toxic substance:_____________________________________ Estimated maximum exposure level per shift:____________________________ Duration of exposure per shift:________________________________________ The name of any other toxic substances that you'll be exposed to while using your respirator:

19. Describe any special responsibilities you'll have while using your respirator(s) that may affect the safety and well-being of others (for example, rescue, security):

U.S. Department of Justice Federal Bureau of Investigation Critical Incident Response Group Bomb Data Center 2501 Investigation Parkway Quantico, VA 22135

FBI Hazardous Devices Recertification Course Performance Standard Test Form (Optional for Recertification candidates who exceed height/weight guidelines)

Bomb Squad Commanders are to personally complete and certify this form. Should a candidate fail to demonstrate an ability to complete similar tasks once at the Hazardous Devices School, the candidate will be dismissed from training.

Candidate’s Name

Rank or Title

Agency

Agency Address

(Street, City, State, ZIP)

Business Telephone

I, _______________________________, certify that the above-captioned candidate can perform a series of task-oriented functions while wearing a Full Coverage Bomb Suit in normally encountered environmental conditions.

A recommended series of task-oriented functions is: 1) Have candidate put on Full Coverage Bomb Suit; 2) While wearing Full Coverage Bomb Suit, walk 300 feet, carrying a portable X-ray/film cassette OR disrupter to a simulated IED; 3) Set-up X-ray OR disrupter; 4) Walk back to safe distance and simulate activation of portable X-ray OR disrupter; 5) Return to simulated IED and recover equipment.

Signature of Bomb Squad Commander Date

Name and Title (Print of Type)

Agency

Address (Street, City, State, Zip)

Business Telephone