1.    Fire Department:

2.    Fire Chief or Fire Administrator:

Name:
Title:
Address:
Address:
Address:
Telephone:
FAX:
E-mail:

Please send the CPAT License to this individual at this address.

3. Is your jurisdiction seeking to implement the CPAT program for recruiting, mentoring, and testing of fire department candidates in full accordance with the terms and conditions set forth in the CPAT Manual, 2nd Edition?

Yes    No

a. If yes, implementation will be within:

      Next 3 months    2002    2009 or beyond

4. Individuals responsible to CPAT Program Recruiting, Mentoring, and Testing:

Recruiting:

Name:
Title:
Address:
Address:
Address:
Telephone:
FAX:
E-mail:

Mentoring:

Name:
Title:
Address:
Address:
Address:
Telephone:
FAX:
E-mail:

Testing:

Name:
Title:
Address:
Address:
Address:
Telephone:
FAX:
E-mail:

5. Has the CPAT equipment been purchased through the CPAT established vendors specified in Appendix D of the CPAT Manual, 2nd edition?

Yes    No

a.    If yes, was the equipment purchased:

  As a package through CPAT Distribution

  Though individual

b.     If other vendors were utilized, please provide their names(s) and address(es):

	Name:
	Equipment Item:
	Address:
	Address:
	Address:

	Name:
	Equipment Item:
	Address:
	Address:
	Address

	Name:
	Equipment Item:
	Address:
	Address:
	Address:

6. Will the CPAT Test be conducted directly by your employer or will an external source (e.g. consultant, other fire department, state/provincial fire academy, University/college) be utilized to conduct the CPAT Test?

Internally, by jurisdiction  Externally, by outside organization

a. If conducted internally or externally, will the CPAT course been arranged in accordance with the guidelines for test equipment and designed as found in Appendix D of the CPAT Manual, 2nd Edition?

Yes    No

b. If completed externally, please provide the name and address of the organization:

7. Was a transportability study completed?

Yes    No

a.    If yes, was the study completed:

Internally, by employer  Externally, by outside vendor/consultant

b.    If completed externally, please provide the name and address of the vendor/consultant:

c.    Were incumbent fire fighters involved in the transportability study?

Yes    No

8. How many weeks will the candidates be given to prepare for the CPAT test from the time of their first orientation session?

Weeks

9. Pursuant to the IAFF/EEOC conciliation agreement , will the candidates be offered the opportunity to handle and practice with the CPAT apparatus a minimum of 2 sessions within the 8-week period prior to the scheduled test?

Yes    No

10. Pursuant to the IAFF/EEOC conciliation agreement, will the candidates be offered to perform 2 timed practice runs using CPAT apparatus within 30 days of the scheduled test?

Yes    No

11. Has a mentoring program been established?

Yes    No

a.    If yes, were incumbent fire fighters involved in the mentoring process?

Yes    No

12. Was a physical fitness training program established for potential recruits?

Yes    No

13. Is your CPAT Test conducted:

Outdoors    Indoors

    a.    If outdoors, are environmental considerations factored in the decision to test?

       Yes    No

14. Were the proctors trained prior to testing in accordance with appendix 4-1 of the CPAT Manual, 2nd Edition?

Yes    No

15.Are you using the pass/fail cutoff time as prescribed in the CPAT Manual?

  Yes    No

16. Pursuant to the IAFF/EEOC conciliation agreement, collecting data on the number of male, female, and minority applicants and the pass/fail rates of each via the IAFF online database Administrator Program is a mandatory licensure requirement. Are you willing to transfer data for each candidate to the IAFF?

Yes    No

The IAFF does NOT grant a license for the creation of derivative works, or works that are based on whole or in portion of the CPAT. This includes works that are written as well as oral. Specific, written permission is necessary from the IAFF in order to create derivative works. The copyright on the CPAT is registered with the United States Copyright Office and the IAFF reserves all rights and remedies for copyright infringement for any illegal use, distribution, copying or creation of derivative works that are not covered by this license.

By completing and submitting this application, the applicant agrees to only use the CPAT in whole in complete accordance with the CPAT Manual, and only for the purpose of candidate recruiting, mentoring and testing. This includes, but is not necessarily limited to, recruiting, mentoring, preparatory programs, orientation programs, and proper program administration including using specified equipment, test parameters, qualified proctors and test personnel. CPAT licenses are subject to termination at the election of the IAFF by written notice for any reason and a license cannot be transferred or sub-licensed to any third parties. Any attempt by the licensee to use the CPAT for testing incumbents is inconsistent with the scope of this license, and is therefore prohibited.

Name of individual who completed form: