CDC 15212W

Fire Department Health and

Safety Officer
Performance Test Supplement

Extension Course Program (A4L)


Air University
Air Education and Training Command
Acknowledgement
Preparation of this supplement was aided through the cooperation and courtesy of the International Fire
Service Training Association (IFSTA). IFSTA furnished technical materials utilized to develop this
training product. Permission to use the information from IFSTA is gratefully acknowledged. In
accordance with the copyright agreement, distribution of this supplement is limited to U.S. Government
personnel.

ii Health and Safety Officer Performance Test Supplement

 Table of Contents

General Guidance _____________________________________________________________ iv

Evaluator Orientation _________________________________________________________ v
Grading Information __________________________________________________________ vi
Performance Test Summary Sheet _______________________________________________ 1
Skills Test #1 Laws, Codes, and Standards ________________________________________ 3
NFPA Standard 1521, Chapter 5, paragraph 5.2.1, 5.2.2, 5.2, 3 5.3.2 and 5.10.5 ____________________________ 3
Task Specific Instructions and Information _______________________________________________ 3
Skills Test #1 Checklist ______________________________________________________________ 4
Skills Test #2 – Training and Education __________________________________________ 7
NFPA Standard 1521, Chapter 5, paragraphs 5.3.4.1 and 5.3.4.2 ________________________________________ 7
Task Specific Instructions and Information _______________________________________________ 7
Skills Test #2 Checklist ______________________________________________________________ 8
Skills Test #3 - Accident Prevention and Facility Inspection __________________________ 9
NFPA Standard 1521, Chapter 5, paragraphs 5.4.4, 5.4.5, 5.8.1 and 5.8.2. _________________________________ 9
Task Specific Instructions and Information _______________________________________________ 9
Skills Test #3 Checklist _____________________________________________________________ 10
Skills Test #4 – Authority of the Health and Safety Officer __________________________ 13
NFPA Standard 1521, Chapter 4, paragraph 4.3.3; Chapter 5, paragraphs 5.3.3, 5.6.2, 5.6.6 and 5.10.6 ________ 13
Task Specific Instructions and Information ______________________________________________ 13
Skills Test #4 Checklist _____________________________________________________________ 14
Skills Test #5 – Risk Management ______________________________________________ 17
NFPA Standard 1521, Chapter 5, paragraphs 5.1.1.3 and 5.1.3. ________________________________________ 17
Task Specific Instructions and Information ______________________________________________ 17
Skills Test #5 Checklist _____________________________________________________________ 18
Skills Test #6 – Apparatus and Equipment _______________________________________ 19
NFPA Standard 1521, Chapter 5, paragraph 5.7.4.___________________________________________________ 19
Task Specific Instructions and Information ______________________________________________ 19
Skills Test #6 Checklist _____________________________________________________________ 20
Skills Test #7 – Accident Investigation, Procedures and Review ______________________ 21
NFPA Standard 1521, Chapter 5, paragraph 5.5.1 - 5.5.3, 5.5.5, 5.5.6. ___________________________________ 21
Task Specific Instructions and Information ______________________________________________ 21
Skills Test #7 Checklist _____________________________________________________________ 22
Skills Test #8 – Post Incident Analysis ___________________________________________ 23
NFPA Standard 1521, Chapter 5, paragraph 5.14.2, 5.14.2.1, and 5.14.2.2. _______________________________ 23
Task Specific Instructions and Information ______________________________________________ 23
Skills Test #8 Checklist _____________________________________________________________ 24
Health and Safety Officer Performance Test Record _______________________________ 25

Health and Safety Officer Performance Test Supplement iii

Performance Test Information
General Guidance
This performance test supplement is based on the 2008 Edition of NFPA 1521; Standard for Fire
Department Safety Officer, and provides the detailed performance test checklist items required for
candidate testing. Performance tests shall not be conducted until the candidate has successfully completed
the academic portion of the course by passing the End of Course final exam at an Air University approved
test control facility (TCF). However, it is strongly encouraged that this supplement and the checklist it
contains be used during the normal course of study. Candidates may practice the performance tests at any
time during study and up until testing is conducted. Practice is highly encouraged.
The prerequisites for obtaining DOD certification to Fire Department Health and Safety Officer are Fire
Officer II, Fire Instructor II and ICS 300/400.
Evaluators must be DOD certified at the Fire Officer III level or higher.
This particular course uses eight (8) skills performance test encompassing 15 separate tasks meeting the
objectives identified in the referenced NFPA line items.
A “Task Summary” precedes each skills test checklist identifying all evaluated task associated with the
test. This sheet lists the NFPA line items evaluated, the setting and tools/equipment needed for the listed
tasks, and any evaluator guidance necessary for the task(s). Evaluators should review the summary paying
specific attention to any “Evaluator Guidance” provided.
Scenarios developed should be as realistic and complete as possible. A minimum of two scenarios must be
developed for each performance test requiring one. This allows for the candidate to retest in case of first
time failure. Additionally, scenarios should be changed periodically to dissuade future candidates from
gaining an unfair advantage or allowing for test compromise.
Remember, official performance test notifications must be made at least ten (10) days prior to the actual
performance test or the candidate’s performance test results will not be accepted by the DOD
Administrative Center. Your performance test notifications must be made using the following web site.
http://www.dodffcert.com/performance/notify.cfm. For specific program guidance see DoD Manual
6055.06, DOD Fire and Emergency Services Certification Program.

iv Health and Safety Officer Performance Test Supplement

 Performance Test Information
Evaluator Orientation
You should read and understand the following orientation information before entering the specific skill
station you will be evaluating. If there is any information within this orientation that you do not
understand, you should contact the examination coordinator for clarification. We would like to thank you
for donating your valuable time to assist with the evaluation of candidates in the practical examination.
Your role as a skill station evaluator is critically important. You are to serve as an observer and recorder
of the candidate's actions based on the criteria listed on the score sheet. There are a number of ways to
successfully perform a skill. You should always remember that the way you were taught to perform a skill
is not the only correct way to perform the skill. The ultimate criterion for successful completion of a skill
is: "Was the final outcome met for the parameters set?"
This is a formal examination and not a teaching situation. We discourage excessive dialogue between the
evaluator and the candidate. Peripheral or "nice to know" areas of should not be discussed. Situations or
questions that require you to demonstrate a procedure should be avoided. You should not ask leading
questions. Do not condemn or condone a candidate's actions by expression, gesture, tone of voice, or
attitude. Often, candidates interpret a word or action delivered in jest as being indicative of pass or fail, a
value judgment, or a non-caring attitude. Pay special attention to verbal and non-verbal language.
The reason you were asked to be an evaluator for this station is that your expertise adds to the credibility of
the examination and gives you the knowledge to ask the candidates related questions to substantiate or
define an action. If qualifying questions are necessary, they should be asked at the end of the station. At
no time should you discuss any phase of the candidate's performance with the candidate.
Candidates are allowed to perform each skill once. If they appear overly nervous when first starting the
exam, you may stop them and allow them to collect themselves before starting again. However, once a
candidate initiates a course of action the candidate must be evaluated on the merits of that singular
performance, as would happen in the field. You must provide qualifying information in the comments
section of the score sheet for any performance that is identified as a mandatory failure item.
Visitors are not allowed in the testing area while testing is being conducted. The examination coordinator
may be in the testing area if they are not obstructive to the testing.
You must document in the comments section the reason you marked a mandatory failure item. Additional
comments are welcome, but remember to be specific. Instead of writing "He did a poor job", write exactly
what the candidate did right or wrong. At no time should you discuss the performance with the candidate.
You should never condemn or condone the candidate's actions by verbal or nonverbal means.
If the candidate reaches the time limit indicated on the score sheet before completing the procedure, you
must stop the candidate and direct him/her to return to the staging area and wait for instructions to report to
the next station. All tasks not completed should be scored a zero in the "points awarded" column.
Be very aware of the importance of consistency in giving instructions, setting up scenarios, and making
and recording observations. Every effort should be made to ensure that all details of the examination
scenario are identical for each candidate. Be aware of your own fatigue and if necessary take a break after
notifying the examination coordinator.
You should have received individual written instructions concerning the specific skill and/or skill station
you will be evaluating. If you do not understand any part of these instructions, do not start the evaluation
process. Contact the examination coordinator for clarification.
It is important also to understand the grading process used during the evaluation. Additional information
on grading the skills test is provided on the next page.

Health and Safety Officer Performance Test Supplement v

Performance Test Information
Grading Information
The following grading criteria will be used to evaluate and determine the pass/fail status of a candidate.
Each of the performance test checklists contains an attainment standard. In this particular course, there
are skills which require successful completion of all the elements, whereas for others the attainment
standards are set at approximately 80% using an “X out of X” format. Both will contain a time limit. For
example, an attainment standard may read, “Successfully complete at least 15 out of 18 steps within 90
minutes” or “Correctly perform all steps outlined above within 60 minutes.” Refer to the task specific
instructions for each skills test for the applicable standard.
If for some reason a particular element/step or standard cannot be completed and the candidate’s
installation cannot simulate or create the item, then the evaluator may mark the item “Not Applicable”
(N/A). The evaluator must then re-adjust the score by multiplying the remaining checklist items by .80 to
determine the number correct required. For example, a performance test requires that 12 out of 15 items
be successfully completed and 2 of the 15 items are marked N/A then the evaluator must multiply the
remaining 13 items by .80 (13 x .80 = 10.4 or 11). The new required minimum passing score is now 11
out 13 items.
There are a total of eight (8) skills performance test encompassing 15 separate tasks. Candidates must
successfully complete and pass 13 of the 15 task with no more than one (1) task failure within any skills
performance test.
--AND--
Where the Standard/Element/Step on the Skills Test checklist is given a rating, the following criteria will
be also be used to determine the pass/fail status of a candidate.
Critical (C) - This rating has been assigned to items, which, if omitted or performed incorrectly, would
result in severe injury to, or death of, an individual. Should a firefighter fail to perform any one item
rated as Critical (C), the firefighter would be unsuccessful in demonstrating the required proficiency level
for that standard.
Major (M) - This rating refers to any item that is very important to the general safety of personnel and
the successful completion of the evolution. Should a firefighter fail to perform any three items rated as
Major (M), the firefighter would be unsuccessful in demonstrating the required proficiency level for that
standard.
General - This rating although there is not symbol, has been given to all remaining items that in
combination are relevant to the successful completion of the evolution. Should a firefighter fail to
perform any four items rated as General, the firefighter would be unsuccessful in demonstrating the
required proficiency level for that standard.
Should a firefighter fail to perform any combination of Major or General rated items resulting in a sum
total of four, the firefighter would be unsuccessful in demonstrating the required proficiency level for that
standard.

vi Health and Safety Officer Performance Test Supplement

 Competency Overview
Performance Test Summary Sheet
Skills Test #1 - Law, Codes and Standards Skills
Task #1. Develop a standard operating procedures (SOPs) or a standard operating guidelines
(SOGs) pertaining to the fire department occupational health and safety program.
Task #2. Prepare a report for the fire chief on the adequacy of, effectiveness of, and compliance
with applicable laws and codes in an occupational health and safety related SOPs/ SOGs.
Task #3. Revise and/or edit an occupational health and safety SOP or SOG.
Skills Test #2 - Training and Education
Task #4. Develop a live fire exercise checklist in accordance with NFPA Standard 1403 and fire
department live fire SOP/SOGs.
Task #5. Perform live fire exercise pre-burn inspection based on NFPA Standard 1403 and fire
department live fire SOP/SOGs.
Skills Test #3 - Accident Prevention and Facility Inspection
Task #6. Develop a fire station safety checklist based on the requirements of NFPA 1500,
Chapter 9.
Task #7. Perform a periodic safety inspection of one fire department facilities based on the health
and safety requirements of Chapter 9 of NFPA 1500, local fire code, and department SOPs/SOGs.
Task #8. Prepare a report the Fire Chief based on safety and health hazards or code violations
encountered during a periodic safety inspection.
Skills Test #4 - Authority of the Health and Safety Officer
Task #9. Develop corrective actions/recommendations for a non-imminent hazard.
Task #10. Prepare a report for the Fire Chief based on all accidents, injuries, deaths, Illnesses and
other health and safety related issues over the past 6 months.
Skills Test #5 – Risk Management
Task #11. Develop a control plan for risk identification, evaluation, prioritization, control
techniques and monitoring in accordance with NFPA 1500, Chapter 4 for use in the Department’s
written risk management plan.
Task #12. Develop an incident risk management plan in accordance with NFPA 1500, Chapter 8
for use in the Department’s written risk management plan.
Skills Test #6 – Apparatus and Equipment
Task #13. Develop a PPE and equipment program to maintain compliance with NFPA 1500,
Chapters 6 & 7.
Skills Test #7 –Accident Investigation, Procedures and Review
Task #14. Prepare a report with corrective recommendations for the fire chief identifying any
incorrect or questionable procedures in the AHJ’s accident and injury reporting procedures.
Skills Test #8 – Post-incident Analysis
Task #15. Prepare a written report as part of the post-incident analysis that addresses pertinent
health and safety issues.

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 1
 Health and Safety Officer Competencies
Skills Test #1 Laws, Codes, and Standards
NFPA Standard 1521, Chapter 5, paragraph 5.2.1, 5.2.2, 5.2, 3 5.3.2 and 5.10.5

Task Specific Instructions and Information

Tasks: Task #1. Develop a standard operating procedure (SOPs) or standard operating
guideline (SOGs) pertaining to the fire department occupational health and safety
program.

Task #2. Prepare a report for the fire chief on the adequacy of, effectiveness of, and
compliance with applicable laws and codes in an occupational health and safety related
SOPs/ SOGs.

Task #3. Revise and/or edit an occupational health and safety SOP or SOG.

Setting: Fire Department Classroom or equivalent.

Tools/ A current copy of the department’s record keeping policy and health and safety laws,
Equipment: codes and standards that pertain to the operation of an occupational health and safety
program.

Attainment Task # 1. Successfully complete 8 of 10 steps within 2 workdays.

Standard:
Task #2. Successfully complete 4 of 5 steps within 2 workdays.

Task #3. Successfully complete all steps within 8 hours.

Evaluator’s Task #1 - Provide the candidate one of the following topics to develop an SOP/SOG:
Guidance:
- Medical screening/health assessment
- Health & wellness promotion
- Performance evaluation
- Employee/member assistance
- Facility safety
- Fire ground safety
- Hazard communication
- Risk management
- Emergency operations planning

Task #3 - If no deficiencies can be identified for revising an existing SOP/SOG in task

#2, provide a safety related SOP/SOG for the candidate to revise based on OSHA
standards and other regulations.

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 3
Health and Safety Officer Competencies
Skills Test #1 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
1. Develop a standard operating 1. In accordance with NFPA Standard 1521,
procedure (SOP) or standard the candidate :
operating guideline (SOG)
pertaining to the fire department A. Conducted needs assessment on
occupational health and safety health and safety topic selected
program.
(1) Gathered necessary information _____ _____
(2) Identified alternatives _____ _____
(3) Analyzed alternatives with _____ _____
Department Staff
(4) Selected alternatives _____ _____

B. Wrote SOP/SOG using correct _____ _____

grammar and proper syntax

C. Included sections in identifying:

(1) Purpose/Scope _____ _____

(2) Responsibilities _____ _____
(3) Periodic Evaluations _____ _____
(4) Records Disposition _____ _____
(5) Log of Coordination _____ _____

D. Report presented to the Fire Chief _____ _____

E. Completed 8 of 10 steps within 2 _____ _____

workdays

2. Prepare a report for the fire chief 2. In accordance with NFPA Standard 1521,
on the adequacy of, effectiveness the candidate:
of, and compliance with
applicable laws and codes in an A. Reviewed all safety related _____ _____
occupational health and safety SOPs/SOGs
related SOPs/ SOGs.
B. Analyzed SOPs/SOGs to determine _____ _____
adequacy and/or failure of guidance

C. Prepared report identifying _____ _____

suggested revisions

D. Wrote report using correct grammar _____ _____

and proper syntax

E. Report presented to the Fire Chief _____ _____

F. Completed 4 of 5 steps within 2 _____ _____

workdays

4 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #1 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
3. Revise and/or edit an 3. In accordance with NFPA Standard 1521,
occupational health and safety the candidate:
SOP or SOG.
A. Selected at least one of the _____ _____
SOPs/SOGs identified in task #2
requiring updates

B. Ensured revision updated the :

(1) Purpose _____ _____

(2) Scope _____ _____
(3) Responsibilities _____ _____
(4) Periodic Evaluations _____ _____
(5) Records Disposition _____ _____
(6) Log of Coordination _____ _____

C. Disseminated/Distributed the health _____ _____

and safety information to
organization members per local
policy and guideline

D. Completed all steps within 8 hours _____ _____

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 5
 Health and Safety Officer Competencies
Skills Test #2 – Training and Education
NFPA Standard 1521, Chapter 5, paragraphs 5.3.4.1 and 5.3.4.2

Task Specific Instructions and Information

Tasks: Task #4. Develop a live fire exercise checklist in accordance with NFPA Standard
1403 and fire department live fire SOP/SOGs.

Task #5. Perform live fire exercise pre-burn inspection based on NFPA Standard 1403
and fire department live fire SOP/SOGs.

Setting: Fire Department live fire training grounds, live burn prop or acquired structure.

Tools/ Given a current copy of NFPA Standard 1403, Standard on Live Fire Training
Equipment: Evolutions and the fire department’s SOP/SOGs on live fire training.

Attainment Task # 4. Successfully complete all steps within 2 workdays.

Standard:
Task #5. Successfully complete 4 of 5 steps within 3 hours.

Evaluator’s Pre-stage a facility for the candidate to conduct a live fire pre-burn inspection.
Guidance:

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 7
Health and Safety Officer Competencies
Skills Test #2 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
4. Develop a live fire exercise 4. In accordance with NFPA Standard 1403,
checklist. the candidate:

A. Developed a checklist that

identified:

(1) Required permits, documents, _____ _____

and insurance
(2) Pre-notification requirements _____ _____
(3) Pre-burn inspection criteria _____ _____
(4) Procedures for using live fire _____ _____
training aids
(5) Safety officers responsibilities _____ _____
(6) General safety requirements _____ _____
(7) Specific safety considerations _____ _____
for the different type evolutions
being conducted
(8) Post Burn procedures to include _____ _____
records and report

B. Trained supervisors on conducting _____ _____

live fire training using the checklist
in developed in step A

C. Completed all steps within 2 _____ _____

workdays

5. Perform live fire exercise pre- 5. In accordance with NFPA Standard 1403,
burn inspection using the the candidate:
checklist created in Task #4.
A. Performed a pre-burn inspection that
included:

(1) Integrity and condition of _____ _____

interior
(2) Integrity and condition of _____ _____
exterior
(3) Status of all utilities _____ _____
(4) Exposure protection _____ _____
(5) Status of water supply _____ _____

B. Completed 4 of 5 steps within 3 _____ _____

hours

8 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #3 - Accident Prevention and Facility Inspection
NFPA Standard 1521, Chapter 5, paragraphs 5.4.4, 5.4.5, 5.8.1 and 5.8.2.

Task Specific Instructions and Information

Tasks: Task #6. Develop a fire station safety checklist based on the requirements of NFPA
Standard 1500, Chapter 9.

Task #7. Perform a periodic safety inspection of one fire department facility based on
the health and safety requirements of NFPA Standard 1500, local fire code, and
departmental SOP/SOG.

Task #8. Prepare a report the Fire Chief based on safety and health hazards or code
violations encountered during a periodic safety inspection.

Setting: Fire Department classroom or equivalent, training facilities, equipment, and other
facilities.

Tools/ Given a current copy of NFPA Standard 1500, the fire department’s SOP/SOG on
Equipment: facility inspections and local fire codes.

Attainment Task #6. Successfully complete 10 of 12 steps within 8 hours.

Standard:
Task #7. Successfully complete 5 of 6 steps within 3 hours.

Task #8. Successfully complete 8 of 9 steps within 8 hours.

Evaluator’s Pre-stage deficiencies in the facility that is being inspected by the candidate for
Guidance: identification.

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 9
Health and Safety Officer Competencies
Skills Test #3 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
6. Develop a fire station safety 6. IAW NFPA Standard 1500, the candidate:
checklist.
A. Developed a facility safety
inspection checklist that covered:

(1) Housekeeping
(2) Exits _____ _____
(3) Walking and working surfaces _____ _____
(4) Apparatus floor _____ _____
(5) Maintenance areas _____ _____
(6) Laundry, cleaning & _____ _____
disinfecting areas _____ _____
(7) Facility exterior/grounds
(8) Fire prevention/protection _____ _____
(9) Hazardous materials _____ _____
(10) Electrical wiring/fixtures/ _____ _____
controls _____ _____
(11) Ventilation Systems
(12) Other _____ _____
_____ _____
B. Complete 10 of 12 steps within 8
hours _____ _____

7. Perform a safety inspection of a 7. In accordance with NFPA Standard 1521,

fire department facility. The candidate:

A. Referenced prior fire station _____ _____

inspection reports

B. Utilized safety inspection checklist _____ _____

developed in Task #6

C. Performed inspection of a fire station

facility that:

(1) Identified deficiencies _____ _____

(2) Resolved conflicts _____ _____
(3) Identified corrective actions _____ _____
(4) Established follow up _____ _____
inspection date

D. Complete 5 of 6 steps within 3 hours _____ _____

10 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #3 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
8. Prepare a report the Fire Chief 8. In accordance with NFPA Standard 1521,
based on safety and health The candidate:
hazards or code violations
encountered during a periodic A. Prepared report listing the health and
safety inspection. safety violations encountered during
Task # 8 which contained:

(1) Facility Name _____ _____

(2) Facility Location _____ _____
(3) Date of Inspection _____ _____
(4) Discrepancies Identified _____ _____
(5) Recommended corrective _____ _____
actions
(6) Inspector’s signature _____ _____

B. Wrote report using correct grammar _____ _____

and proper syntax

C. Included a copy of the checklists _____ _____

used to perform the inspection

D. Submitted report to the Fire Chief _____ _____

E. Completed 8 of 9 steps within 8 _____ _____

hours

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 11
 Health and Safety Officer Competencies
Skills Test #4 – Authority of the Health and Safety Officer
NFPA Standard 1521, Chapter 4, paragraph 4.3.3; Chapter 5, paragraphs 5.3.3, 5.6.2, 5.6.6 and 5.10.6

Task Specific Instructions and Information

Tasks: Task #9. Develop corrective actions/recommendations for a non-imminent hazard.

Task #10. Prepare a report for the Fire Chief based on all accidents, injuries, deaths,
Illnesses and other health and safety related issues over the past 6 months.

Setting: Fire Department facility or equivalent.

Tools/ Given a current copy of the department’s standard operating procedures and
Equipment: administrative processes.

Attainment Task # 9. Successfully complete 9 of 11 steps within 2 workdays.

Standard:
Task #10. Successfully complete 10 of 13 steps within 2 workdays.

Evaluator’s If there have not been any incidents related to non-imminent safety hazards, pre-stage
Guidance: safety issues from non-imminent hazards in the fire station which could lead to safety
related mishaps from accidents/unsafe conditions at training scenarios for identification
by the candidate.

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 13
Health and Safety Officer Competencies
Skills Test #4 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
9. Develop corrective actions/ 9. In accordance with NFPA Standard 1521,
recommendations for non- the candidate:
imminent hazards.
A. Reviewed related data for the _____ _____
previous 6 months

B. Analyzed data to determine root _____ _____

causes

C. Analyzed current SOPs/SOGs to _____ _____

determine adequacy or failure in
guidance

D. Prepared report identifying

corrective actions as related to:

(1) Office Areas _____ _____

(2) Station Maintenance _____ _____
(3) Physical Fitness _____ _____
(4) Inspections _____ _____
(5) Apparatus Stall/Parking _____ _____
(6) Training scenarios/venues _____ _____

E. Wrote report using correct grammar _____ _____

and proper syntax

F. Submitted report to the Fire Chief _____ _____

G. Completed 9 of 11 steps within 2 _____ _____

workdays

10. Prepare a report for the Fire 10. In accordance with NFPA 1521, the
Chief based on all accidents, Candidate:
injuries, deaths, Illnesses and
other health and safety related A. Reviewed related data for the _____ _____
issues over the past 6 months. previous 6 months

B. Analyzed data to determine root _____ _____

causes

C. Analyzed current SOPs/SOGs to _____ _____

determine adequacy or failure in
guidance

14 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #4 Checklist (continued)
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
10. (Continued).
D. Prepared report identifying
corrective actions as related to:

(1) Accidents _____ _____

(2) Injuries _____ _____
(3) Deaths _____ _____
(4) Illnesses _____ _____
(5) Exposures _____ _____
(6) Incident Activities _____ _____
(7) Training Scenarios _____ _____
(8) Policy and Guidance Revisions _____ _____
(9) Medical Treatment Guidance _____ _____
and Points of Contacts

E. Wrote the report using complete _____ _____

sentences, correct grammar and
proper syntax

F. Submitted report to the Fire Chief _____ _____

G. Completed 10 of 13 steps within 2 _____ _____

workdays

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 15
 Health and Safety Officer Competencies
Skills Test #5 – Risk Management
NFPA Standard 1521, Chapter 5, paragraphs 5.1.1.3 and 5.1.3.

Task Specific Instructions and Information

Tasks: Task #11. Develop a control plan for risk identification, evaluation, prioritization,
control techniques and monitoring in accordance with NFPA 1500, Chapter 4 for use
in the Department’s written risk management plan.

Task #12. Develop an incident risk management plan in accordance with NFPA 1500,
Chapter 8 for use in the Department’s written risk management plan.

Setting: Fire Department Classroom or equivalent.

Tools/ Provided with a copy of NFPA Standard 1500 and the department’s standard operating
Equipment: procedures and administrative processes.

Attainment Task #11. Successfully complete 8 of 10 steps within 2 workdays.

Standard:
Task #12. Successfully complete 10 of 13 steps within 2 workdays.

Evaluator’s Provide the candidate with one of the following scenarios for completion of a risk
Guidance: management plan:

- Flammable liquid spill in aircraft hangar

- Medical response to multiple car accident
- Dormitory fire with trapped occupants
- Confined space response with injuries

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 17
Health and Safety Officer Competencies
Skills Test #5 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
11. Develop a control plan for risk 11. In accordance with NFPA Standard 1500,
identification, evaluation, Chapter 4 the candidate:
prioritization, control techniques
and monitoring for use in the A. Developed control plan which:
Department’s written risk
management plan. (1) Identifies the Risk _____ _____
(2) Evaluates the Risk _____ _____
(3) Establishes priorities for action _____ _____
(4) Identifies risk controls _____ _____
(5) Identifies management of _____ _____
monitoring
(6) Identifies follow up actions _____ _____

B. Wrote the plan using correct _____ _____

grammar and proper syntax

C. Submitted plan to the Fire Chief _____ _____

D. Completed 4 of 5 steps in 8 hours _____ _____

12. Develop an incident risk 12. In accordance with the NFPA Standard
management plan for use in the 1500, Chapter 8; the candidate:
Department’s written risk
management plan. A. Developed plan that addresses:

(1) Incident management _____ _____

(2) Communications _____ _____
(3) Emergency Operations _____ _____
(4) Accountability/Members
Operating _____ _____
(5) Control Zones _____ _____
(6) Traffic Incidents _____ _____
(7) RIC _____ _____
(8) Rehabilitation _____ _____
(9) Scenes of Violence, Civil _____ _____
Unrest, or Terrorism
(10) Post-Incident Analysis _____ _____

B. Submitted plan to the Fire Chief _____ _____

C. Completed all steps in 2 workdays _____ _____

18 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #6 – Apparatus and Equipment
NFPA Standard 1521, Chapter 5, paragraph 5.7.4.

Task Specific Instructions and Information

Tasks: Task #13. Develop a PPE and equipment program to maintain compliance with NFPA
1500, Chapters 6 & 7.

Setting: Fire Department Classroom or equivalent.

Tools/ Provided with a copy of NFPA Standard 1500, department’s standard operating
Equipment: procedures and administrative processes.

Attainment Successfully complete all steps within 2 workdays.

Standard:

Evaluator’s None.
Guidance:

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 19
Health and Safety Officer Competencies
Skills Test #6 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
13. Develop PPE and equipment 13. In accordance with NFPA Standard 1500,
program. Chapters 6 & 7 the candidate:

A. Developed a PPE and equipment

program which included criteria for:

(1) Specification _____ _____

(2) Design _____ _____
(3) Selection Process _____ _____
(4) Use and Operations _____ _____
(5) Training _____ _____
(6) Care and Maintenance _____ _____
(7) Periodical inspections _____ _____
(8) Determination of serviceability _____ _____
(9) Records Management _____ _____
(10) Disposal _____ _____

B. Submitted the program overview to _____ _____

the Fire Chief for implementation

C. Completed all steps in 2 workdays _____ _____

20 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #7 – Accident Investigation, Procedures and Review
NFPA Standard 1521, Chapter 5, paragraph 5.5.1 - 5.5.3, 5.5.5, 5.5.6.

Task Specific Instructions and Information

Tasks: Task #14. Prepare a report with corrective recommendations for the fire chief
identifying any incorrect or questionable procedures in the AHJ’s accident and injury
reporting procedures.

Setting: Fire Department Classroom or equivalent.

Tools/ Provided with a copy of NFPA Standard 1500, department’s standard operating
Equipment: procedures and administrative processes.

Attainment Successfully complete all steps within 2 workdays.

Standard:

Evaluator’s None.
Guidance:

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 21
Health and Safety Officer Competencies
Skills Test #7 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
14. Prepare a report with corrective 14. In accordance with NFPA Standard 1521,
recommendations for the fire the candidate:
chief identifying any incorrect or
questionable procedures in the A. Reviewed current accident and _____ _____
AHJ’s accident and injury injury reporting procedures
reporting procedures.
B. Identified any incorrect or _____ _____
questionable procedure

C. Researched proper procedures _____ _____

according to AHJ’s governing
regulations or national consensus
standards

D. Prepared report identifying corrected

procedures for reporting incidents
involving:

(1) Accidents _____ _____

(2) Injuries _____ _____
(3) Deaths _____ _____
(4) Illnesses _____ _____
(5) Exposures _____ _____
(6) Incident Activities _____ _____
(7) Training Scenarios _____ _____
(8) Emergency Medical Care for _____ _____
Life-threatening conditions

E. Wrote report using correct grammar _____ _____

and proper syntax

F. Submitted plan to the Fire Chief _____ _____

G. Completed all steps in 2 workdays _____ _____

22 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Skills Test #8 – Post Incident Analysis
NFPA Standard 1521, Chapter 5, paragraph 5.14.2, 5.14.2.1, and 5.14.2.2.

Task Specific Instructions and Information

Tasks: Task #15. Prepare a written report as part of the post-incident analysis that addresses
pertinent health and safety issues.

Setting: Fire Department Classroom or equivalent.

Tools/ Given and incident where an accident or injury occurred, copy of NFPA Standard
Equipment: 1500, department’s standard operating procedures and administrative processes.

Attainment Successfully complete all steps within 2 workdays.

Standard:

Evaluator’s None.
Guidance:

_____________________________________________________________________________________
Health and Safety Officer Performance Test Supplement 23
Health and Safety Officer Competencies
Skills Test #8 Checklist
PERFORMANCE TASK STANDARDS / ELEMENTS / STEPS YES NO
15. Prepare a written report for the 15. In accordance with NFPA 1521, the
post-incident analysis that candidate:
includes pertinent information
about the incident relating to A. Reviewed analyzed an incident ____ ____
health and safety issues. where an accident or injury occurred

B. Identified Strengths and weaknesses

related to:

(1) Incident operations ____ ____

(2) Personnel assignments ____ ____
(3) Incident action plan ____ ____
(4) Incident safety plan ____ ____
(5) PPE ____ ____
(6) Personnel accountability ____ ____
(7) Rehabilitation operations ____ ____
(8) Rapid invention posture ____ ____
(9) Training issues ____ ____
(10) Safety issues ____ ____

C. Included information and input ____ ____

from Incident Safety Officer

D. Wrote report using correct grammar _____ _____

and proper syntax

E. Submitted report to Incident _____ _____

Commander

F. Completed all steps in 2 workdays _____ _____

24 Health and Safety Officer Performance Test Supplement

 Health and Safety Officer Competencies
Health and Safety Officer Performance Test Record

INSTRUCTIONS: This form must be completed and kept on file. A copy of this form is also required to
be submitted with the candidate’s certification package.

Performance Test Ref # ______________ Date of Evaluation __________________

Candidate’s Name __________________________________ SSN ______________________

Evaluator’s Name __________________________________ SSN ______________________

The candidate has PASSED/FAILED the Health and Safety Officer Performance Tests as marked below:

SKILLS TEST PASSED FAILED

1 - Laws, Codes and Standards ________ ________

2 - Training and Education ________ ________

3 - Accident Prevention/Facility Inspection ________ ________

4 - Authority of the HSO ________ ________

5 - Risk Management ________ ________

6 - Apparatus and Equipment ________ ________

7 - Accident Investigation Procedures and Review ________ ________

8 - Post Incident Analysis ________ ________

If candidate has failed the performance evaluation, provide the following information:
(Use additional sheets, if necessary)

Objective(s):

Reason(s) for failure:

Candidate’s Signature _________________________________________________

Evaluator’s Signature _________________________________________________

____________________________________________________________________________________
"FOUO. This document contains information exempt from mandatory disclosure under the FOIA.
Exemption 5 U.S.C. 552(b)(6) applies. This information is also protected by the Privacy Act of 1974
and must be safeguarded from unauthorized disclosure."