Justification
for no material, non-substantive change to OMB 0596-0164:
Fire
& Aviation Management Medical Qualifications Program –
Health Screening Questionnaire
April
2015
We
are requesting approval for a non-substantive change to OMB
0596-0164: Fire
& Aviation Management Medical Qualifications Program –
Health Screening Questionnaire.
The
revised form being submitted with this request is:
FS-5100-30
Work Capacity Test: Informed Consent
FS-5100-30
Work Capacity Test: Informed Consent
The
Work Capacity Test (WCT) Informed Consent form is being changed to
reflect that even the WCT can cause serious injury to those that are
not healthy or physically fit. The wording changes in the “Risks”
box and the testifying statement are to get the employee to
acknowledge that this is not an innocuous physical test. The
unit/city/state information requested helps to determine the
appropriate Fire Manager to give the pass/fail information to.
Work Capacity Test: Informed Consent
Pack
Test- Arduous The
3-mile test with a 45 pound pack in 45 minutes is strenuous, but
no more so than the duties of wildland firefighting.
Field
Test-Moderate The
2-mile test with a 25 pound pack in 30 minutes is fairly
strenuous, but no more so than the field duties.
Walk
Test-Light
The 1-mile walk in 16 minutes is moderately strenuous, but no
more so than the duties assigned.
Risks
There
is a slight risk of complications from participating in this
test, including injuriesy (blisters, sore legs, sprainsed ankles)
but also heart attack, rhabdomyolysis, compartment syndrome, heat
illness, and possibly death.especially for those who have not
practiced the test. If you have been inactive and have not
practiced or trained for the test, you should engage in several
weeks of specific training before you take the test. Be certain
to warm up and stretch before taking the test, and to cool down
after the test. The risk of more serious consequences (such as
respiratory or heart problems) is diminished Bby completing the (Health
ScreeningQ)
physical activity readiness Qquestionnaire and/or a physical
exam, the potential risk of serious consequences is reduced.
I
have read the information on this form and in, the brochure “Work
Capacity Test”, and understooand and truthfully answered the
Health Screening Questionnaire (if applicable), and understand the
purpose,
instructions,
and risks of the job related to work capacity test.
I have read the information, understood, and truthfully answered
the HSQ.
Test
to be Taken (check one) Pack test Field
Test Walk Test
Signature
Date _____
Printed
Name
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).
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 5.5 minutes per
response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed,
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.