Mercer County Fire Protection District

Personnel Questionnaire

First Name	*
Middle Name	*
Last Name	*
Station Assignment	*	Station 3 Station 4 Station 5 Station 6 Station 9 Station 11 Station 12 Station 13
Rank	*	Firefighter Lieutenant Captain Major Battalion Chief Asst. District Chief District Chief Assistant Chief Deputy Chief
Unit Number	*
Date of Birth	*
Start Date (for new firefighters)
Email Address	*
Cell Phone	*
Home Phone	*
Work Phone
Address
Address 2
City	*
State/Province		Kentucky
Zip/Postal	*
Height
Weight
Hair Color
Eye Color
Fire-Related Certifications		Recruit Firefighter (< 150 Hours) KY Certified Firefighter (150 Hours) KY Certified Firefighter (400 Hours)
IFSAC Certifications		Not Certified IFSAC Firefighter Level I IFSAC Firefighter Level II
Instructor Certification		None Fire Service Level I Instructor Fire Service Level II Instructor
EMS Certifications		None EMT - First Responder EMT - Basic EMT - Paramedic
Emergency Management - Weather Spotter		Not Current Current - Attended 2008 Training
Emergency Management Courses (A)		None Fundamentals of Search & Rescue Managing the Search Function Mantracking Search Dog Team
Emergency Management Courses (B)		None Fundamentals of Search & Rescue Managing the Search Function Mantracking Search Dog Team
Hazmat Certification		None Hazmat Awareness Level Hazmat Operations Level Hazmat Technician Level Hazmat Specialist Level
Specialty Certfications		None Large Animal Rescue Rescue Technician
Emergency Contact (Name & Phone)	*
Emergency Contact (Name & Phone)	*
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