firetrax host standard data entry form · foiii fire officer 3 foiv fire officer 4 inst fire...
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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
2fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
3fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
4fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
X Qual Description CertificationNumber Issue Date Expiration
Date
5fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
6fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
X Qual Description CertificationNumber Issue Date Expiration
Date
7fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
X Qual Description CertificationNumber
Issue Date ExpirationDate
8fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
X Qual Description CertificationNumber
Issue Date ExpirationDate
9fireTRAX Host Personnel Application ver. 2.2 Page of 9
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
X Qual Description CertificationNumber
Issue Date ExpirationDate
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