WCT and FIREFIGHTER CERTIFICATION DATA SHEET

Use this form to document that an individual has met all required elements to be certified, which include the work capacity test (WCT), annual fireline refresher training and fire shelter training. The WCT date ranges and WCT administrator eligibility are listed in Administrative Procedure 10.18. Email the completed WCT and Firefighter Certification Data Sheet to the Texas Interagency Coordination Center at or verification, recording and forwarding to the Human Resources Department.

TEST ADMINISTRATORS
NAME / LOCATION / DATE / INITIALS
WCT
REFRESHER
SHELTER
PERSONNEL
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training

*Candidate’s initials indicate completion of the Health Screening Questionnaire prior to testing.

WCT and FIREFIGHTER CERTIFICATION DATA SHEET

(Continuation Page)

PERSONNEL
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training
NAME: / LOCATION / TIME / DATE / INITIALS*
WCT: Light / Moderate / Arduous
Annual Fireline Refresher Training
Fire Shelter Training

*Candidate’s initials indicate completion of the health screening questionnaire prior to testing.

WCT and FIREFIGHTER CERTIFICATION DATA SHEET

INSTRUCTIONS

Test Administrators

Name – Print each approved administrator’s name.

Location – Print the location for each test or training.

Date – Enter the date for each test or training.

Initials–Each administrator initials to acknowledge the accuracy of the information for the test or training.

Personnel

If more than five employees are tested or trained, use one or more continuation pages to record information about the additional employees. Enter page numbers on the bottom of the first page and each continuation page.

Name – Print the name of the employee being tested or trained.

WCT – Circle the work capacity test level attempted.

Location -- Print the location for each test or training.

Time – Enter the appropriate time for each test or training.

For WCT, enter the time to complete the test in minutes and seconds.

For Annual Fireline Refresher Training, enter the training contact time in hours.

For Fire Shelter Training, enter the shelter deployment time in seconds.

Date – Enter the date for each test or training.

Initials – The employee being tested or trained initials to acknowledge (1) that the Health Screening Questionnaire was completed and submitted prior to taking the WCT and (2) that the test or training information is accurate.

Completed Data Sheet

One of the test administrators should email the completed data sheet to .

TICC personnel confirm the authority of the test administrators and record the test and training results for the participating employees.

TICC forwards a copy of the verified data sheet to the Human Resources Department. The Human Resources Department prepares a list of employees to receive an incentive payment based on the WCT results and sends the list to the payroll office for processing.

Issued 11/09/2012Page __ of __