0 New Application
New Application Date of Application: Information Update Probation Start Date:
Re-admission
Reason:
Kotzebue Fire Department
Application for membership
Name: ____________________D.O.B.: __________________SSN: ________________
P.O. Box: _______House #: _________Phone #: (H)______________(W)____________
E-Mail Address: (home) (work)
Application for (check one): _____Fire _____Ambulance _____Both
What would you like to do? What skills can you provide for the KFD? What do you expect to gain from a membership?
What type of training are you interested in? ____________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What training/certifications do you already have? _______________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When would you be available to volunteer? ____________________________________
________________________________________________________________________
________________________________________________________________________
Do you have a valid driver’s license? _____Yes _____No
DL# : __________________ State : Expiration date: ________________
Have you ever been convicted of a misdemeanor or felony? _____Yes _____No
If yes explain, include the date(s), type of offence and a brief description of the outcome. (Attach a separate sheet if necessary) If you purposefully omit any information about your criminal history, the department reserves the right to deny or revoke your membership at any time.
Have you suffered from any type of injury or illness that may affect your ability to perform your duties in full or limit your activities in the Fire Department?
______Yes No
If yes please explain. (Attach a separate sheet if necessary)
Employment History
Current Employer:
Address:
Phone #: Time with Employer:
Job Duties/Position: (Attach separate sheet if necessary)
Previous Employer (if less than 10 years with current employer)
Address:
Phone #: Time with Employer:
Job Duties/Position: (Attach separate sheet if necessary)
Character References
Please provide at least 3 names of people that know you and that are not family, current/previous co-workers or supervisors.
1. Name: Phone #
2. Name: Phone #
3. Name: Phone #
Kotzebue Fire Department
orientation policy
During probation:
1. Probation will last 90 days or until probation requirements have been met or longer at the discretion of the Fire Chief.
2. The volunteer will be assigned a preceptor who will act as the probationer’s orientation leader and help them through the probation process.
3. The volunteer will become certified in Red Cross Professional Rescuer CPR or American Heart Association BLS prior to becoming a full member in good standing.
4. The volunteer will complete a Department approved Infection Control and Haz-Com training prior to becoming a full member in good standing.
5. The volunteer will read and sign a KFD application and abide by the Department SOP’s and policies during the entirety of their membership.
6. The volunteer will be given and expected to read and understand the Orientation packet which will include: KFD SOP’s, Protocols, 10 Codes, and any other material deemed necessary by the Fire Chief.
7. The volunteer will be required to complete the New Employee Orientation Checklist prior to becoming a full member in good standing.
Prior to first ambulance call:
1. The volunteer driver will provide the KFD with a copy of their valid Alaska Driver’s License.
2. The volunteer driver will complete a driver orientation.
3. All new crewmembers will complete an ambulance orientation.
4. All new crewmembers will complete a radio orientation.
5. All new crewmembers will receive an orientation packet.
6. All new crewmembers will be familiarized with OSHA safety and reporting procedures.
I, __________________________ have read, understand, and agree to abide by the KFD policies/guidelines and the policies of the City of Kotzebue.
Signature of volunteer _________________________________ Date _______________
Preceptor
I, __________________________ agree to act as the above probationary member’s preceptor through their probation period to the best of my ability.
Signature of preceptor _________________________________ Date _______________
I, __________________________ hereby apply for membership in the Kotzebue Fire Department and in so making application agree:
To abide by the rules and regulations of the Kotzebue Fire Department and City of Kotzebue.
To obey the commands and instructions of my superior officers, to the best of my abilities, while on the emergency scene, in the station, and during all Department activities.
To give as freely of my time and my energies to the Department as I am able.
To be supportive of the Department in community affairs, keeping in mind that the health and safety of the citizens of Kotzebue and that the prevention and intervention of fire are the primary tasks of all members of the Department.
To maintain a professional attitude and patient confidentiality with regards to all emergency calls and information that I may be privileged to in my duties.
To abide by all state, federal, local, and OSHA requirements for emergency responders.
To allow the City of Kotzebue and/or Kotzebue Fire Department to do background checks, including but not limited to verification of employment information, contacting work-related references, checking criminal conviction records, checking credit reports, checking driving records, verifying academic credentials and licenses (status, expiration dates and related disciplinary actions) and/or personal background checks.
Agree to give time as a volunteer in return for any free training I may receive as an ETT/EMT or Firefighter.
(A form authorizing such background checks must be signed as part of this application process.)
To the best of my knowledge, the information I have provided herein is true and accurate.
Applicants signature: _______________________________ Date: ________________
Chief’s approval: __________________________________ Date: ________________
Board approval: ___________________________________ Date: ________________
Probation start date: _____________________________________________________
In case of emergency, whom should we notify?
Name: _____________________________________ Relationship: _________________
Phone #: (H)______________________________(W)____________________________
New employee orientation checklist
|X |MM/DD/YY |Init.* |Items to be completed by new volunteer |
| | | |Application Packet Signed and Complete |
| | | |Copy of a valid Alaska Driver’s License |
| | | |Hep-B vaccine series started/completed –or- waiver signed |
| | | |Infection control training |
| | | |Haz-com training |
| | | |BLS or Professional Rescuer CPR certified |
| | | |Safety and exposure reporting orientation completed |
| | | |Driver orientation completed |
| | | |Ambulance orientation completed |
| | | |Radio and pager orientation completed |
| | | |Ambulance SOP orientation completed |
| | | |Ambulance protocol orientation completed |
| | | |10-Code orientation completed |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
* Paid staff or Preceptor must initial
If the applicant refuses vaccination, after attending infection control training, He/She must sign the attached refusal form acknowledging His/Her refusal to be vaccinated and acknowledging that He/She will have no claim against the City, its representatives, employees, and agents as a result of refusing such vaccinations.
See, attached refusal form.
Have you had the Hepatitis B vaccination series? Circle one
No / 1 shot / 2 shots / 3 shots / Diagnosed as immune
Have you had the Hepatitis A vaccination series? Circle one
No / 1 shot / 2 shots / Diagnosed as immune
I give permission for the release of medical records, necessary to verify the above vaccination information, to the Kotzebue Fire Department.
Applicant’s signature___________________________________ Date_______________
AUTHORIZATION TO PERFORM
VARIOUS BACKGROUND CHECKS
I, __________________________, am an applicant for membership in the Kotzebue Volunteer Fire Department. As part of the application process, I authorize the City of Kotzebue, the Kotzebue Fire Department and/or the Kotzebue Volunteer Fire Department to do a thorough background check on me. The background check may include, but is not limited to, verification of my employment information; contacting my work-related references; checking my credit reports; checking my driving records; verifying my academic credentials and licenses and/or doing personal background checks on me, including criminal history.
In authorizing any and/or all of these background checks, I specifically release the City of Kotzebue, the Kotzebue Fire Department and the Kotzebue Volunteer Fire Department (and their respective employees, agents and/or representatives) from any liability that may arise from conducting any background checks on me.
_______________________ ______________________
Printed name of applicant Applicants social security #
_______________________ ______________________
Signature of applicant Applicant’s date-of-birth
_______________________
Date of applicant’s signature
_______________________
Printed name of witness
_______________________
Witness’s signature and date
REFUSAL FORM
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease, and I will make no claim against the City of Kotzebue, its representatives, employees and/or agents as a result of refusing such vaccinations. If in the future I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
I have read the preceding statement about Hepatitis B and the Hepatitis B vaccine. I have received infection control training and had an opportunity to ask questions; furthermore, I understand the benefits and risks of the Hepatitis B vaccine and do not wish to receive this vaccination at this time. I request that it not be given to me.
_______________________ _______________________
Printed name of employee Employee’s social security #
_______________________ _______________________
Signature of employee Date of employee signature
_______________________
Printed name of witness
_______________________
Witness’s signature and date
Application Procedures
1. Signed and completed application for membership received by the Kotzebue Fire Department. (all supporting documentation, certifications/license etc. should be included)
2. The KFD Membership Committee will review completed applications and a background investigation will be conducted.
3. After a review of the application and a successful background investigation, the applicant will be scheduled for an interview with the Membership Committee. An applicant may be denied probationary membership and ineligible to continue the application process based on the information provided in the application and or background investigation.
4. Once an applicant has completed the interview, the Membership Committee will make there recommendations to the KFD General Membership on whether they recommend acceptance of the applicant as a probationary member or not.
5. The KFD general membership will make the final decision on whether to accept or reject the applicant.
6. Once an applicant is accepted as a probationary member, they will undergo a series of training and orientation courses as required by OSHA and designed to familiarize them with department operations.
7. After the successful completion of the orientation process and 90 days have passed since the probationary members acceptance, the membership committee will review the probationary members progress and make a decision to grant full Active membership or extend the probation period.
8. In the event that the probation period is extended, the extension will be no longer than an additional 90 days. If a probationary member completes the requirements before the extension time is up, they may ask for a review ahead of time.
9. Failure to complete all required probationary training or orientations would result in the denial of Active Membership with the Kotzebue Fire Department. The probationary member will be required to turn in all department equipment that may have been issued to them and no longer allowed to participate in any department activity or respond to calls.
10. Any person that is denied probationary or full membership may re-apply at another time. The application will remain on file for no more than 6 months after the date of the initial application.
11. At any point during the application process, the Fire Chief retains the right to automatically deny any applicant for membership, with or without cause.
All information obtained during a background investigation will remain confidential and only viewed by the Membership Committee.
|Membership Committee Only |
|Date Reviewed: ___________ |
|Membership Recommended? Yes No |
|Date Presented to General Membership: |
|Membership Committee Signatures: |
| |
| |
Kotzebue Fire Department
Personal Information Record
(All Information pertained herein is confidential and is restricted to authorized personnel only)
The Kotzebue Fire Department is an Equal Opportunity Employer.
This form must be completed after acceptance of a probationary membership.
Basic Information:
|Name: Last First MI. |
|Rank: |Assignment: (Office Use) |
|Status: (Office Use) |Station: |
| |36-100 |
|Call Sign: (Office Use) |Address: Box/Street City: State: Zip: |
|Phone Number: Home: Work: Other: |
|( ) - ( ) - ( ) - |
|SSN: |DOB: M/D/YY |Drivers License & State: |Drivers License Type: |
|/ / |/ / | | |
|EMS Cert. Number: |EMS Cert. Type: |Date of Issue: |Expiration Date: |
|Marital Status: |Spouse’s Name: |
|Single: Married: | |
Next of Kin
|Name: |Relationship: |Address: St./Box City: State: Zip: |
|Phone Number: Home: Work: Other: |
|( ) - ( ) - ( ) - |
Basic Medical Information
|Height: |Weight: |Hair: |Eyes |
|Blood Type: |Race: |Sex: |Allergies: |
| | |Male Female | |
Doctor Information:
|Name: |Address: (If Known) |
|Phone Number: Home: Work: Other: |
|( ) - ( ) - ( ) - |
Equipment Information
|Head Size: |Shirt Size: |Sleeve Length: |Coat Size: |
|Waist Size: |Shoe Size: |Inseam Length: |Boot Size: |
|Print Name: Signature: |Date: |
|For Office Use |
|Reviewed By: Name: Title: |Date: |
|Look-Up I.D. # |I.D. Number Issued: |Issue Date: |Returned Date: |
|Date Entered Into FP: |Active Date: |Inactive Date: |
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