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Resources to Assist You

First Visit Information &Forms

Baseline/ Pre- Employment

Fill these forms out if you have not been to Well America
or are getting hired by a department.

Baseline/ Pre-Hire Questionnaire
Audio
Prescription Drug Questionnaire
Respirator Questionnaire

Annual Physical

Hazmat Team/Tech

Fill these out in addition to annual physical paperwork if you are HAZMAT

Periodic Form
If you have completed an Initial Form,
you only need to fill out the Periodic Form.

Initial Form
If you have never completed an Initial Form,
you only need to fill out the Initial Form.

Additional Forms & Resources

Clinicians Return to Work Form

INJURY FORMS

Firefighting is a dynamic and physically challenging activity and all members must be fully capable to do their job safely and effectively.  To that end, it is imperative that all members be able to perform the necessary job functions without restrictions that may affect the safety of themselves or others on their crew.  The following list of essential job functions is taken from NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, 2013 Edition, to guide the physician in evaluating the ability of a member with specific medical conditions to perform specific job tasks.

This form ensures the Fire Department that it has a clear understanding of the types of restrictions you may have placed on the firefighter.  Please check all boxes appropriately and sign below.  Return this form to the firefighter.  Questions can be directed to your Fire Department Human Resources Manager.
Clinicians Return to Work Form Download


PAT LAB Protocol

(Some departments/districts may vary)
PAT LAB Protocol PDF Download

Mental Health

Infectious Disease or Exposure