Republic of the Philippines
Department of the Interior and Local Government
BUREAU OF FIRE PROTECTION
REGIONAL OFFICE III
DMGC, Brgy. Maimpis, City of San Fernando, Pampanga
Hotline Number: 0943-700-3136
Email: fcos.region3@[Link]
HEALTH DECLARATION FORM
I, _____________________________________, of legal age, residing at
___________________________________, and applicant for the position of Fire
Officer 1, do hereby solemnly declare and attest to the following:
1. That I am voluntarily participating in the Physical Agility Test (PAT);
2. That I am consenting to the collection and use of my health information for the
purpose of assessing my suitability to participate in the PAT;
3. That to the best of my knowledge, I am in good health and physically fit to
undergo strenuous physical activity;
4. That I have no known illness, injury, or medical condition, communicable or
non-communicable that may endanger myself or others during the physical
activities required;
5. That I have not been recently diagnosed with, nor am I presently exhibiting
symptoms of any condition that would impair my performance or safety during
exertion;
6. That I have not sustained fractures, undergone surgery, or suffered any
serious musculoskeletal injury within the past six (6) months;
7. That I am not under any medication that affect my physical or mental
capabilities, including but not limited sedatives, analgesics, or maintenance
drugs;
(For Female Applicants Only)
a. That I am not currently pregnant;
b. That I have not delivered a child whether normal or caesarean within
the last six (6) months; and
c. That I am not using contraceptive methods that may impair physical
exertion, including oral, injectable, or intradermal contraceptives.
8. That I understand that the Physical Agility Test (PAT) involves strenuous
physical activity which includes pull ups, push ups, sit-ups, flatter kick, 100m
run, and endurance run;
9. That I understand the risks involved in participating in the PAT and my
responsibility to disclose any relevant medical condition and health issues;
10. That I have fully disclosed all medical conditions and health issues that may
affect my performance in the PAT;
11. That I understand that this declaration does not substitute for a
comprehensive medical or diagnostic evaluation, which may be required at
subsequent stages of the recruitment process;
12. That I assume full responsibility for any health risks and consequences that
may arise from my participation in the test, except in cases of proven gross
negligence or willful misconduct on the part of the BFP personnel facilitating
the test, or from any untoward behavior committed by my fellow applicants or
any other person;
13. That I shall not hold liable the officers, staff, and authorized representatives
of the Bureau of Fire Protection (BFP) for any injury, illness, or harm that
may arise as a result of my participation in the Physical Agility Test, except in
cases of proven gross negligence or willful misconduct; and
14. That this declaration is executed truthfully and to the best of my knowledge,
for the recruitment process.
Signed this ______ day of ________________, 2025 at
_________________________________________.
______________________________
Applicant Name and Signature
Contact Number: ________________
SUBSCRIBED AND SWORN TO before me this _______ day of ________________,
2025 at ________________________________, affiant having presented valid
government-issued ID number _____________________, issued on
____________________, at _____________________________.
_____________________________
Administering Officer / Notary Public