Form A "Self Assessment Checklist & Fitness Declaration Form" - Singapore

Form A is a Singapore Civil Defence Force - issued form also known as the "Self Assessment Checklist & Fitness Declaration Form".

A PDF of the latest Form A can be downloaded below or found on the Singapore Civil Defence Force Forms and Publications website.

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Download Form A "Self Assessment Checklist & Fitness Declaration Form" - Singapore

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COMPANY EMERGENCY RESPONSE TEAM COURSE
SELF ASSESSMENT CHECKLIST & FITNESS DECLARATION FORM
This form applies to the following courses:
WSQ Respond to Fire & Hazmat Emergency (3 days course)
WSQ Respond to Fire Emergency in Buildings (2 days course)
The purpose of the following self assessment checklist is to find out if you need to go
through medical screening before signing up for a CERT course. Please read the questions
carefully and answer each question honestly with a “YES” or a “NO”.
Has your doctor ever said that you have a heart
1
condition and that you should only do physical activity
YES / NO
recommended by a doctor?
Do you feel pain in your chest when you do physical
2
YES / NO
activity?
In the past month, have you had chest pain when you
3
YES / NO
were not doing physical activity?
Do you lose your balance because of dizziness or do you
4
YES / NO
ever lose consciousness?
Do you have a bone or joint problem (for example, back,
5
knee or hip) that could be made worse by a change in
YES / NO
your physical activity?
Is your doctor currently prescribing drugs (for example,
6
YES / NO
water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do
7
YES / NO
physical activity?
If you answered “Yes” to any of the above questions, or if you are not 100% sure of the
answer to any of the questions, you will need to go through a medical screening before you
can take part in the CERT courses. Please download the information for doctors (Form B)
and the certificate of fitness (Form C) for your doctor to endorse from our website at
http://www.scdf.gov.sg/content/scdf_internet/en/building-professionals/CERT.html.
If you answered “No” to all of the above questions, you may use this form as a declaration
of fitness and sign up for CERT courses without further medical screening. Please complete
the declaration below and submit this form as a declaration of fitness together with your
registration form to the training organisation.
I, ______________________________ (name), IC number ______________, declare that all
information provided is true. I am aware that the CERT courses have physically demanding
activities and I will immediately inform the course instructors if I am feeling unwell.
_______________________________________
____________________
Signature of course applicant
Date
Form A – Self Assessment Checklist & Fitness Declaration Form
Singapore Civil Defence Force
Updated 10/11/2014
COMPANY EMERGENCY RESPONSE TEAM COURSE
SELF ASSESSMENT CHECKLIST & FITNESS DECLARATION FORM
This form applies to the following courses:
WSQ Respond to Fire & Hazmat Emergency (3 days course)
WSQ Respond to Fire Emergency in Buildings (2 days course)
The purpose of the following self assessment checklist is to find out if you need to go
through medical screening before signing up for a CERT course. Please read the questions
carefully and answer each question honestly with a “YES” or a “NO”.
Has your doctor ever said that you have a heart
1
condition and that you should only do physical activity
YES / NO
recommended by a doctor?
Do you feel pain in your chest when you do physical
2
YES / NO
activity?
In the past month, have you had chest pain when you
3
YES / NO
were not doing physical activity?
Do you lose your balance because of dizziness or do you
4
YES / NO
ever lose consciousness?
Do you have a bone or joint problem (for example, back,
5
knee or hip) that could be made worse by a change in
YES / NO
your physical activity?
Is your doctor currently prescribing drugs (for example,
6
YES / NO
water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do
7
YES / NO
physical activity?
If you answered “Yes” to any of the above questions, or if you are not 100% sure of the
answer to any of the questions, you will need to go through a medical screening before you
can take part in the CERT courses. Please download the information for doctors (Form B)
and the certificate of fitness (Form C) for your doctor to endorse from our website at
http://www.scdf.gov.sg/content/scdf_internet/en/building-professionals/CERT.html.
If you answered “No” to all of the above questions, you may use this form as a declaration
of fitness and sign up for CERT courses without further medical screening. Please complete
the declaration below and submit this form as a declaration of fitness together with your
registration form to the training organisation.
I, ______________________________ (name), IC number ______________, declare that all
information provided is true. I am aware that the CERT courses have physically demanding
activities and I will immediately inform the course instructors if I am feeling unwell.
_______________________________________
____________________
Signature of course applicant
Date
Form A – Self Assessment Checklist & Fitness Declaration Form
Singapore Civil Defence Force
Updated 10/11/2014