Town of Brookfield Fire Department

645 Janacek Road Brookfield, WI 53045 (262) 796-3792 Fax: (262) 796-0410

AUTHORIZATION FOR RELEASE OF INFORMATION (FOR OFFICIAL USE ONLY; NOT TO BE RELEASE TO UNAUTHORIZED PERSONS)

Candidates shall be able to safely perform the physical functional requirements of a Firefighter/EMT for the Town of Brookfield Fire Department without increased risk to personnel and public health and safety. Such determinations shall be made by the examining physician who must become aware of the rigorous physical demands, mental, and emotional responsibilities of protective services. In the interest of public safety, the examining physician is to state to the Commission that the applicant is medically able to perform the physical functional requirements of a firefighter (as presented in the attached job description) without limitations, or of limitations in job placement are indicated, to state the specific restrictions on full job placement. It will then be the responsibility of the Commission and the Chief to judge if the restrictions can be made with reasonable accommodation pursuant to the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA), and State Law counterparts. No Person will be assigned the duties of a Firefighter/EMT in the Town of Brookfield if he/she cannot adequately undertake the job-related responsibilities of being a firefighter/EMT. The present and future safety of the applicant, of co-workers, and the general public, and the special duty of care required by a firefighter/EMT, will be considered in evaluating whether and individual can undertake the job-related responsibilities of being a firefighter/EMT.

AUTHORIZATION FOR RELEASE OF INFORMATION PHYSICAL MEDICAL CERTIFICATION

The following certification must be completed by a physician: I have reviewed the job description for the position of part-time Firefighter/EMT for the Town of Brookfield. "This is to certify that _______________________________________has recently been examined and to a reasonable degree of medical certainty, I believe he/she is physically able to perform the required duties of Firefighter/EMT." PRINT OR TYPE ____________________________________________________________________ (Physician's Name) (Date) Signed: __________________________________________________________________, M.D. (Physician's signature)

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