fireTRAX Host Standard Data Entry Form · FOIII Fire Officer 3 FOIV Fire Officer 4 INST Fire...

1fireTRAX Host Personnel Application ver. 2.2 Page of 9

fireTRAX HostStandard Data Entry Form

Personnel Information

*Required Fields: Any field proceeded by an asterisk (*) is a required field.

*Last Name (25 Characters Max)

*First Name (25 Characters Max) Middle Initial (1 Character)

*Department Name (15 Characters Max.) *ID # (DL Number)

Status (Active, Full Time, Part Time, Volunteer) Rank (10 Characters Max.)

Date of Hire (mm/dd/yyyy) *Date of Birth (mm/dd/yyyy)

Driver License State Driver License Number Driver License Expiration

Address One (25 Characters Max.)

Address Two (25 Characters Max.)

City (25 Characters Max.) State Zip Code

Phone Number Mobile Phone

Fax / Radio number Email Address

Application Approval (Office Use Only)

Approved By

Card Issue Date Card Expiration Date


Medical Information

The following medical information is optional and may be used to create aMedical Barcode.

Gender Blood Pressure Heart Rate Blood Type

Physician Name (25 Characters Max.) Physician's Phone Number

Emergency Contact (25 Characters Max.) Contact Phone Number

Emergency Contact 2 (25 Characters Max.) Contact 2 Phone Number

Insurance Carrier (25 Characters Max.) Policy Number

Allergies (25 Characters Max.) Allergies 2 (25 Characters Max.)

Medications (25 Characters Max.) Medications 2 (25 Characters Max.)

Religion (25 Characters Max.) Organ Donor (Yes/No)

Hair Color Eye Color Height Weight

Medical History Short (32 Characters Max.)

Medical History Long


X Qual Description CertificationNumber Issue Date Expiration

Date

ACLS Advanced Cardiac LifeSupport

ACSR Advanced Confined SpaceRescue

ARFF Airport Firefighter

ARESRACE Amateur Radio EmergencyService

ARO Amateur Radio Operator

ANIM Animal Control Specialist

INVEST Arson Investigator

EMT Basic EMT

BOMB Bomb Tech

BUS Bus Driver

CERTINST CERT Instructor

CERT CERT Team Member

CERTTTT CERT Train the Trainer

CNA Certified Nurses Aid

CHAP Chaplain

CDL Commercial Driver License

CS Confined Space Rescue

COR Coroner

Qualifications


CO Corrections Officer

CPR/FA CPR First Aid Certified

CPRINS CPR Instructor

CISM Critical Incident StressManagement Team Member

DAMAT Damage Assessment Team

DARE Dare Officer

DATDisaster Action TeamMember

DRS Dive Rescue Specialist

DT Dive Tender

D/OAE Driver/Operator Aerial

D/OARFF Driver/Operator AirportFirefighting Vehicle

D/OMWS Driver/Operator MobileWater Supply

D/OPU Driver/Operator Pumper

ELECT Electrician

EVOC Emergency VehicleOperations

EVT Emergency Vehicle Tech

TO EMS Training Officer 1

TOII EMS Training Officer 2

EMTI EMT Intermediate

EMTS EMT Specialist


Date


ENG Engineer

ENVS Environmental Specialist

EO Equipment Operator

ET Evidence Tech

FIN Finance Officer

INSPI Fire Inspector 1

INSPII Fire Inspector 2

INSPIII Fire Inspector 3

FOI Fire Officer 1

FOII Fire Officer 2

FOIII Fire Officer 3

FOIV Fire Officer 4

INST Fire Service Instructor

INSTI Fire Service Instructor 1

INSTII Fire Service Instructor 2

INSTIII Fire Service Instructor 3

FF Firefighter

FFI Firefighter 1

FFII Firefighter 2

FFIII Firefighter 3

X Qual Description CertificationNumber

Issue Date ExpirationDate


GO Government Official

HMA Haz-Mat Awareness

HMICHaz-Mat IncidentCommander

HMO Haz-Mat Operations

HMR Haz-Mat Response

HMS Haz-Mat Specialist

HMT Haz-Mat Technician

HAR High Angle Rescue

HN Hostage Negotiator

ICER Ice Rescue Tech

IC Incident CommanderQualified

ISO Incident Safety Officer

K9DRUG K9 Officer – Drug

K9OSRK9 Officer –Search & Rescue

K9WAT K9 Officer - Water Rescue

KCEMKansas Certified EmergencyManager

LEILaw EnforcementInvestigator

LEO Law Enforcement Officer

LPN Licensed Practical Nurse

LINE Lineman


Date


LOG Logistics Officer

MD Medical Doctor

MFR Medical First Responder

MUL Medical Unit Leader

MNTL Mental Health Professional

MLT Meth Lab Tech

MORT Mortician/Funeral HomeStaff

MBOLMotor Boat OperationsLicense

MCTOMultiple Company TacticalOperations

MAFF Mutual Aid Responder

NARC Narcotics Investigator

NRPNeonatal ResuscitationProvider

NIMS NIMS Trained

OPS Operations

EMTP Paramedic

PALSPediatric Advanced LifeSupport

PAOPersonal AccountabilityOfficer

PA Physician's Assistant

PF Pilot - Fixed Wing

PH Pilot – Helicopter




PLN Planning Officer

PLUMB Plumber

PHTLSPre-Hospital Trauma LifeSupport

PIO Public Information Officer

RADQualified RadiologicalMonitor

RIT Rapid Intervention Team

LGI Red Cross Life Guard

LGITRed Cross Life Guard Inst.Trainer

WSIRed Cross Water SafetyInstructor

RN Registered Nurse

RT Rescue Tech

Rope Rope Rescue

SO Safety Officer

SATERNSalvation Army AmateurRadio

SRO School Resource Officer

SCBASelf Contained BreathingApparatus

SS Sharp Shooter

SPX Small Pox Vaccinated

STL Strike Team Leader

SWAT SWAT Team Member




TFL Task Force Leader

TELEI Telecommunicator 1

TELEII Telecommunicator 2

TIC Thermal Imaging Camera

None Unknown Qualifications

VEHX Vehicle Extrication

VET Veterinarian

VFF Volunteer Firefighter

WR Water Rescue

WSO Water Supply Officer

WELD Welder

WFOI Wildfire Officer 1

WFOII Wildfire Officer 2

WFOIII Wildfire Officer 3

WFF Wildland Firefighter



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