USDA Forest Service FS-5100-31 (Rev. date 12/20/00) OMB 0596-0164

HEALTH SCREENING QUESTIONNAIRE (HSQ)

Assess your health needs by marking all true statements.

HISTORY SECTION A

You have had: (you're supposed to check each one that applies)

SYMPTOMS (you're supposed to check each one that applies)

OTHER HEALTH ISSUES (you're supposed to check each one that applies)

SECTION B
CARDIOVASCULAR RISK FACTORS (you're supposed to check each one that applies)

Privacy Statement

The information obtained in the completion of this form is used to help determine whether an individual being considered for wildland firefighting can carry out those duties in a manner that will not place the candidate unduly at risk due to inadequate physical fitness and health. Its collection and use are consistent with the provisions of 5 USC 552a (Privacy Act of 1974).

Paperwork Reduction Act Statement

Under the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control for this information collection is 0596-0164. Public Report Burden hour is estimated to average 2.5 minutes per response including the time for reviewing instruction (if any) hearing a description of the project. Send comments regarding burden estimate of any other aspect of this survey, including suggestions for reducing burden to: Information Collection Officer, USDA/Forest Service/ 1621 North Kent Street, Room 800 RPE, Arlington, VA 22209' and to the Office of Management and Budget, Office of Regulatory Affairs, Desk Officer for Forest Service, Washington 20503.

 NAME:__________________________________________________________ DATE:________________