Post on 18-Apr-2018
New Member Application Packet Checklist:
o New Member Application Packet Checklist (1 page) o Letter to new applicants (1 page) o Information for Probationary Members (3 pages) o Application for Membership (4 pages) o Family Information Form (1 page) o Designation of Beneficiary Form (1 page) o Hepatitis B Vaccine Consent & Information Form (2 pages) o Volunteer Criminal History Request and Authorization Form (background
check form) (1 page) o Authorization to Obtain / Release Juvenile Records (Junior Division
Applicant background check form) (1 page)
Old Saybrook Fire Company No. 1, Inc. 310 Main Street
Old Saybrook, CT 06475 860-395-3149
Dear Applicant: Thank you for your interest in becoming a member of the Old Saybrook Fire Company No. 1. There are a few easy steps you need to follow to get the process moving along:
1. Fill out the membership application as well as all the other forms in the packet.
2. Return the completed packet to the Old Saybrook Fire Department, Attn: Training Division.
3. A training officer will contact you to set up an oral interview.
4. After your oral interview, a training officer will clear you to schedule your entry physical. Contact one of our department physicians: Shoreline Medical Associates: (203) 245-4933, 1353 Boston Post Road, Madison.
If you have any questions, contact Capt. Steve Lesko at (860) 876-0806 or via e-mail at training@oldsaybrookfire.com. Good Luck, OSFD Training Division
Old Saybrook Fire Company No. 1, Inc. 310 Main Street
Old Saybrook, CT 06475 860-395-3149
Information for Probationary Members
Thank you for your interest in the Old Saybrook Fire Department. We especially welcome applicants with previous fire or emergency medical experience. The purpose of this sheet is to explain the Department’s policies for Probationary Members. All Probationary Members, including those with experience in the fire service, emergency medical services, or public safety, are expected to follow all Department policies and standard operating guidelines that relate to Probationary Members. These include, but are not limited to, the following: Tuesday Nights Tuesday nights are the night each week we expect you to set aside for fire department activities. The first Tuesday night of the month is our Company meeting. The second and fourth Tuesday nights are Probationary Member training. This is when you will receive your fire service training by participating with your fellow “probies” under direct supervision of the Department’s Training Officers. The third Tuesday of the month is Company drill. Three unexcused absences during the probationary period will result in termination of membership. Term of Probation The Department by-laws provide for a minimum probationary period of six months. There is no guarantee that your probationary term will not be longer. All Probationary Members must complete their training matrix before being proposed for Regular Membership. Previous completion of state certifications will count towards your training matrix; however, all Department-specific training must be completed as well. Probation in General The probationary term is, in part, a period for new members to prove themselves and to give the current membership an opportunity to introduce themselves and work alongside the new members. Probationary Members with experience are being evaluated and observed in the same manner as inexperienced Probationary Members. The Regular Members will eventually vote on whether to bring you in as a Regular Member. You are urged to make a good impression, take the initiative, and make sure the Regular Membership has ample reason to believe you would be an asset to the Department.
Old Saybrook Fire Company No. 1, Inc. 310 Main Street
Old Saybrook, CT 06475 860-395-3149
All Probationary Members receive the same level of instruction and are treated equally. If you are coming to us from another Department, please do not take any repetitive instruction that you receive personally. Our goal is to make sure that each new member starts with the same basic knowledge and skills. While we know some new members have experience, it is difficult for us to judge each individual’s level. This is why refreshing the basics with everyone is our preferred method of instruction. Equipment All Probationary Members will be issued personal protective equipment by the Department, and are to use this equipment. This includes helmets: all probationary firefighters are to wear orange probationary shields and orange tetrahedrons on their helmets during their term of probation. There are two reasons for this policy. (1) It enables officers to quickly identify probationary firefighters on the fireground, and (2) as a department, we feel the “black shield” is a symbol of being promoted to regular status and must be earned. If you own your own helmet and wish to use it during your probationary period, it must be outfitted with the probationary shield and tetrahedrons. Fireground Duties As a Probationary Member you will be expected to help out in any capacity necessary on the fireground. Probationary Members are typically responsible for basic tasks such as rolling hose, retrieving equipment, washing trucks after calls and drills, etc. All Probationary Members are expected to complete these tasks. All Probationary Members are expected to seek out things to do during and after calls and drills until all necessary work is completed. SCBA Qualification All Probationary Members must receive the approval of the Training Division before being cleared as an SCBA qualified firefighter in the department. This will typically require satisfactory completion of multiple department SCBA drills. Department Policies and Procedures The Department has its own polices and procedures, which may or may not be similar to those of other area departments. All Department members are expected to follow the policies, procedures, and standard operating guidelines of the Old Saybrook Fire Department. If you have any questions as to these policies, please see a training officer for clarification. Points and Participation As part of your interview and orientation process, the department’s point system will be explained to you. In summary, members receive three points for attending a call, three points for a drill or training class, and one point for a company or committee meeting. Probationary Members are expected to regularly attend drills and meetings and to make as many calls as possible. Your point total will be used to gauge your level of participation in the department. Regular Members are expected to accrue a minimum of 150 points per year, and Probationary Members are held to the same standard. Any
Probationary Member who does not accrue 150 points within a year of joining the Department, or who at any time shows a lack of participation as evidenced by their point total, will be required to meet with the training officers and show cause why they should not be dropped from the Department. Physical Exam ALL applicants must have a full physical examination. This exam must certify the applicant is capable of performing the duties of a firefighter. The physical exam must be given by one of the Department-appointed physicians. The physical exam will be paid for by the Department. The physical exam should NOT be scheduled until the applicant has had his interview with the Training Division. I have read and understand the above. ______________________________________________________________________ Applicant Signature Date
APPLICATION FOR MEMBERSHIP I am applying to become a member in the following division (circle one):
PROBATIONARY (REGULAR FIREFIGHTER)
JUNIOR DIVISION SUPPORT DIVISION
NAME: ________________________________________ DATE OF BIRTH: ____________
ADDRESS: ___________________________________________________________________
OWN / RENT / LIVE WITH PARENTS (Circle One)
HOME TELEPHONE # ______________ WORK # ____________ CELL # _____________
EMAIL ADDRESS: ____________________________________________________________
EMPLOYER’S NAME: ________________________________________________________
EMPLOYER’S ADDRESS: _____________________________________________________
EMERGENCY CONTACT NAME: ______________________________________________
ADDRESS FOR EMERGENCY CONTACT: ______________________________________
EMERGENCY CONTACT TELEPHONE # _______________________________________
RELATIONSHIP TO EMERGENCY CONTACT: _________________________________
OSFD SPONSOR: (PRINT) ___________________ (SIGN) ___________________________
OSFD SPONSOR: (PRINT) ___________________ (SIGN) ___________________________
PLEASE ANSWER THE FOLLOWING QUESTIONS
Do you have any previous firefighting or emergency medical training?
YES _____ NO _____
Old Saybrook Fire Company No. 1, Inc. 310 Main Street
Old Saybrook, CT 06475 860-395-3149
If “YES”, please explain:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any fears or phobias which may affect your ability to be a firefighter?
YES _____ NO _____
If “YES”, please explain:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have a valid CT driver’s license? YES _____ NO _____
What hours do you work? _______________________________________________________
Can you leave work for an emergency response? YES ____ NO ____
PROBATIONARY MEMBERS TRAIN EVERY TUESDAY NIGHT. THREE UNEXCUSED ABSENCES DURING THE PROBATIONARY PERIOD WILL RESULT IN TERMINATION OF MEMBERSHIP.
I hearby make application for membership to the Old Saybrook Fire Company No. 1, Inc. I agree to abide by the Company By-Laws and Constitution, Standard Operating Guidelines and Standing Orders.
I hearby certify that the information contained in this application is true to the best of my belief and knowledge.
Permission is given to the Old Saybrook Fire Company No. 1, Inc. to verify any and all information contained in this application.
SIGNATURE: ________________________________________________________________
DATE: _______________________________________________________________________
FOR APPLICANTS TO THE JUNIOR DIVISION
Scholastic achievement is held in the highest regard by the Old Saybrook Fire Company No. 1 membership. School work, school activities and family commitments are expected to be prioritized over Junior Division activities.
Junior Division training is scheduled for the second Tuesday of the month; monthly meetings are held the first Tuesday of the month.
Three unexcused absences from scheduled activities will result in disciplinary action, up to and including termination from membership. Excused absences can be arranged by contacting a Junior Division advisor or Department Chief.
To be completed by the applicant’s parent / guardian:
Do you understand that the applicant will be asked to assist the fire department in limited risk activities? Do you have any reservations in this regard? _________________________ ____________________________________________________________________________________________________________________________________________________________
In your opinion, how well does the applicant handle stressful situations? ________________ ____________________________________________________________________________________________________________________________________________________________
Do you agree to the curfew conditions as explained in the Old Saybrook Fire Company No. 1, Inc. By-Laws and Constitution? ________________________________________________ ____________________________________________________________________________________________________________________________________________________________
I give permission for _____________________ to be a member of the Junior Division of the Old Saybrook Fire Company #1, Inc. I understand that before this application can be accepted I must meet with the advisor(s) to learn exactly what being a Junior Division member entails.
Parent or guardian signature ____________________________________________________
To be completed by the school:
I understand what being a member of the Junior Division of the Old Saybrook Fire Company No. 1, Inc. requires. As a representative of the school, we feel that ____________ is of good moral character and can handle this responsibility along with his or her academic workload and will be an asset to the fire department.
Dean of students signature ______________________________________________________
Name___________________________ Home Phone_____________Blood Type_______ Home Address_______________________________________________________________ Employer Name, Dept, Supervisor, Address & Phone_________________________________________________ ____________________________________________________________________________________________ Your Physicians Name & Phone Numbers__________________________________________________________ Name & Phone number of the religious organization you may be affiliated with_____________________________ ___________________________________________________________________________________________ Spouse/Significant Other_______________________Home Phone_____________Cell Phone__________ Spouse/SO Home Address________________________________________________________ Spouse/SO Employer Name, Dept, Supervisor, Address & Phone_______________________________ ___________________________________________________________________________________________ Closest Relatives other than Spouses Contact Phone Numbers___________________________________________ ____________________________________________________________________________________________ Children Names, Yr’s of Birth, School they attend____________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Children’s Babysitters Phone Number______________________________________________________________ Please list any special needs that you feel your family may require________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Family Information Form The information contained on this form will be kept confidential and private. It
should be reviewed annually or anytime your aware that a change should be made. Please place in an envelope and drop in the Chiefs Mail Slot. Or Mail it to
Old Saybrook Fire Dept, Training Chief, 310 Main Street, Old Saybrook CT 06475
Date form Filled Out_________________________
Old Saybrook Fire Dept 310 Main Street
Old Saybrook CT 06475 860-395-3149
Designation of Beneficiary Form
Department Name: Old Saybrook Fire Department Member Name:___________________________________________________ Date Joined______________________ Date of Birth_____________________ I hereby designate the following beneficiary (ies) to receive all death benefit proceeds payable under the policy (ies). Primary Beneficiary (ies) Relationship Date of Birth Percent (If under age 18)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________ Contingent Beneficiary (ies) Relationship Date of Birth Percent (If under age 18)
_____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________ This beneficiary form is for: (If department has policy in force) ( X ) Volunteer Firemen’s Accident Policy ( X ) Group Life Policy ( X ) Accident and Sickness Policy ( X ) 24 Hour Accident Policy _________________________________ Member Signature _________________________________ Date
Important: To be retained by the department for it’s records.
Old Saybrook Fire Dept 310 Main Street
Old Saybrook CT 06475 860-395-3149
Hepatitis B Vaccine Consent & Information form.
Recommended by CDC, Required By OSHA: That all employees with potential exposure to blood and body fluids or tissues are offered the Hepatitis B Vaccine free of charge. Description: Since 1986 Hepatitis B vaccine is synthetically made. It does NOT utilize serum from hepatitis B carriers. Contraindications: It should not be ad-ministered to anyone who is allergic to yeast or Thimerisol. Administration: Requires 3 doses, 1 ml intramuscu-larly. 1st dose: at elected date. 2nd dose 1 month later. 3rd dose 6 months after the first dose. *Note: After com-pleting vaccine series, employees can be tested for the presence of detectable antibodies (immune status). Those who have failed to respond to the vaccine will be given a second series. Not all employers commit to post testing. Side Effects: Soreness at injection site and mild systemic symptoms (fever, fatigue). Protection: Currently, CDC does not recommend a booster. Immunity against the Hepatitis B Virus appears to outlast presence of detectable antibodies. The immunity can persist for greater than 2 years. I have read the information about hepatitis B and it’s vaccine. I have had an opportunity to ask questions and un-derstand the benefits and risks of the Hepatitis B vaccination. I understand that I must have three doses to develop immunity. However, as with all medical treatments, there is no guarantee that I will become immune or that I will not experience any adverse side effects from the vaccine. Name_______________________________________________ Date _________________________ Old Saybrook Fire Department SS#__________________________________________________
Status of Hepatitis B Vaccine
_______ I have already received the Hepatitis B Vaccine Series _______ I request that the Hepatitis B Vaccine be given to me. Employee’s Signature _________________________________________ Date__________________ Employee under 18 Parent/Guardian Printed Name___________________________________________ Employee under 18 Parent/Guardian Signature____________________________ Date______________ I have been offered the Hepatitis B Vaccine and do NOT wish to receive it. I understand that due to my potential occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with the Hepatitis B vac-cine, I can receive the vaccination series at no charge to me. Employee’s Signature _________________________________________ Date__________________ Employee under 18 Parent/Guardian Printed Name___________________________________________ Employee under 18 Parent/Guardian Signature____________________________ Date______________
First Dose
Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________
Second Dose
Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________
Third Dose
Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________
TOWN OF OLD SAYBROOK
DEPARTMENT OF POLICE SERVICES
YOUTH SERVICES DIVISION
6 Custom Drive Old Saybrook Connecticut 06475
Phone 860-395-3142 www.oldsaybrookpolice.com FAX 860-395-3142
AUTHORIZATION
TO OBTAIN/RELEASE JUVENILE RECORDS
I hereby authorize the Old Saybrook Department of Police Services to review my child’s documented police contacts and history for the purpose of providing the Old Saybrook Fire Department with an accurate assessment of my child’s application as they pursue membership with the Old Saybrook Fire Department Junior Division. I understand that this information may include arrest related incidents. I further authorize the Old Saybrook Police Department’s School Resource Officer to obtain information from my child’s school records as part of this process. I understand this information may include confidential records including school history, school progress reports and attendance. I understand this information will be used by the Old Saybrook Police Department to review my child’s application to the Old Saybrook Fire Department Junior Division. I also understand that these confidential materials will not be released to anyone else without my further consent or authorization. This authorization will expire in 90 days. Signature of Juvenile Date Signature of Parent or Legal Guardian Date
Old Saybrook Fire Department
Standing Order 2012‐1
Date Issued: April 17, 2012
Titled: Sexual Harassment Policy
POLICY
The Old Saybrook Fire Co. No. 1 Inc. strives to provide members with an environment that is
free of all forms of illegal discrimination, including but not limited to sexual harassment. Sexual
harassment in connection with Fire Company activities is unacceptable and will not be
tolerated. Violations of this policy will be treated as serious disciplinary matters.
DEFINITION OF SEXUAL HARASSMENT
“Sexual harassment” refers to any unwelcome sexual advance, request for sexual favors, or
other verbal or physical conduct of a sexual nature where:
(1) Submission to such conduct is made either explicitly or implicitly a condition of an
individual’s employment, membership, assignment, or good standing in the Company;
(2) Submission to or rejection of such conduct by an individual is used as the basis of any
personnel decision affecting such individual, including membership, good standing, work
assignments, or promotion;
(3) Such conduct is so severe or pervasive that it has the purpose or effect of unreasonably
interfering with the individual’s work performance or creating an intimidating, hostile,
or offensive working environment.
EXAMPLES OF SEXUALLY HARASSING CONDUCT
The following are some examples of conduct that may constitute sexual harassment. This list is
not exhaustive. Other conduct not specifically listed may also constitute sexual harassment.
(1) Engaging in sexual flirtation, touching, making advances, or propositioning another
member, if that person has indicated or it is known such conduct is unwelcome.
(2) Touching or grabbing any part of an employee's body after that person has indicated, or
it is known, that such physical contact was unwelcome.
(3) Verbal abuse of a sexual nature.
(4) Making graphic or suggestive comments about an individual’s dress or physical
appearance.
(5) Using sexually degrading language to describe an individual.
(6) Displaying sexually suggestive materials such as explicit photographs, drawings, or
videos.
(7) Making a comment or spreading a rumor that embarrasses, ridicules, or demeans a
person because of the individual’s gender or sexual orientation.
(8) Threatening or implying, either explicitly or implicitly, that a member’s refusal to submit
to sexual advances may adversely affect the member’s good standing, advancement,
assigned duties, or any other privilege or condition of membership.
(9) Continuing to ask an employee to socialize on or off‐duty when that person has
indicated s/he is not interested.
(10) Inappropriately using electronic communications, including electronic mail, social
media, text messages, or the internet for any of the above purposes.
MEMBER RESPONSIBILITIES
(1) Members shall refrain from engaging in any activity or behavior which may constitute
sexual harassment. As defined above sexual harassment refers to behavior or conduct
of a sexual nature that is “unwelcomed.” Thus, a consensual relationship between two
members would typically not constitute a violation of these sexual harassment
guidelines.
(2) Any member who believes that he or she has been subjected to sexually harassing
conduct by another member, member of the public, or member of another agency is
encouraged to directly inform the offending person or persons that such conduct is
unwelcome and must stop.
(3) If the member does not wish to communicate directly with the alleged harasser or
harassers, or if direct communication has been ineffective, then the person with the
complaint should immediately notify the Chief, Deputy Chief, or an Assistant Chief.
(4) Any member who witnesses sexually harassing conduct, or who becomes aware that
another member has been subjected to sexual harassment, is urged to promptly report
the harassment to the Chief, Deputy Chief, or an Assistant Chief.
(5) Any member who engages in conduct that constitutes sexual harassment shall be
subject to disciplinary action in accordance with Company By‐Laws, Standard Operating
Guidelines, and Standing Orders.
ADDITIONAL RESPONSIBILITIES OF OFFICERS
(1) The line officers and administrative officers are leaders of the Company. As such, they
represent the organization to the membership, the public, and other agencies with
which the Company works.
(2) All line officers and administrative officers shall make all reasonable efforts to ensure
that the Company, its facilities and activities are free from sexual harassment.
(3) Any line officer or administrative officer who witnesses or is made aware of allegations
of sexual harassment by or against a member shall promptly report such information to
the Chief, Deputy Chief, or an Assistant Chief.
(4) Any line officer or administrative officer who engages in conduct that constitutes sexual
harassment, or who upon being made aware of such conduct fails to promptly report it
to the Chief, Deputy Chief, or an Assistant Chief, shall be subject to disciplinary action in
accordance with Company By‐Laws, Standard Operating Guidelines, and Standing
Orders.
INVESTIGATION AND DISCIPLINE
(1) Upon receiving a report or complaint of sexual harassment, the Chief shall thoroughly
investigate the allegations.
(2) Care will be taken to protect the identity of the person with the complaint and of the
accused party or parties, except as may be reasonably necessary to successfully
complete the investigation.
(3) If the investigation reveals the presence or occurrence of sexual harassment, the Chief
shall impose appropriate discipline in accordance with the Company By‐Laws, Standard
Operating Guidelines, and Standing Orders.
(4) If the investigation does not determine the presence or occurrence of sexual
harassment, the person with the complaint and the accused person shall be so
informed, with appropriate instruction provided to each.
RETALIATION
No member or officer shall retaliate against another member for complaining about or
reporting sexually harassing conduct, or for participating in any investigation of such conduct.