FS 5100-30 Work Capacity Test - Informed Consent

                                                                                                           FS-5100-30 (v. 3/2016)

                                                                                               OMB No. 0596-00164

Work Capacity Test: Informed Consent

Pack Test – Arduous: The 3 mile test in with a 45-pound pack in 45 minutes is strenuous, but no more so than 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 than the field duties assigned.

Walk Test – Light: The 1 mile walk test 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 injuries (blisters, sore legs, sprains) but also heart attack, rhabdomyolysis, compartment syndrome, heat illness, and possibly death.

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. By completing the Health Screening Questionnaire 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,” understood and truthfully answered the Health Screening Questionnaire (if applicable), and understand the purpose, instructions, and risks of the job related to the work capacity test.

Test to be taken (check one):

Pack Test _________ Field Test _________ Walk Test _________

Signature________________________________________ Date _________________________

Printed Name __________________________________________________________________

Unit:______________________________ City:_______________________ State:___________

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 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

OMB 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.