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USFS Fire Medical Form: Seizure, Syncope, Stroke

A Forest Service fire employee whose medical review flags a central nervous system condition brings this four-page template to their treating provider. It covers seizure disorders, syncope of unknown cause, stroke, TIA, anoxic brain injury, Chiari malformation, narcolepsy, shift work disorder, migraine and cluster headache, BPPV, Meniere's disease and restless legs. Forest Service Medical Officers use the answers to decide qualification or a waiver.

Who completes it

The employee completes Part A (name, date of birth, home unit and light, moderate or arduous fitness level), which also authorizes release to Forest Service Medical Officers. The treating provider (MD, DO, NP, PA or other) completes Part B as applicable and signs it with an office stamp.

Submitting and payment

How to submit it
Fax the completed form to the Fire Medical Qualifications Program office as printed on the form; the program also receives documents through the employee's eMedical account.
Who pays
When a Medical Officer requests more medical information, the employee must obtain, pay for and supply it under 5 CFR 339.304(c).

Good to know

  • Part B asks about restrictions on driving, including narrow roads with sudden drop-offs, operating heavy equipment such as a bulldozer, working around a chainsaw, or working on steep ground or ledges.
  • Give the date of the last seizure, syncopal episode, stroke, TIA or anoxic injury, and list related surgeries with dates of return to full duty.
  • For seizure disorders, rate the likelihood of another seizure as low, moderate or high and give recent EEG or other test results, or attach the report.
  • The form records the type of driver's license the employee holds (commercial, regular or none), and for Chiari malformation the required frequency of MRI surveillance.

Get the official form

Download the current version from the source each time; forms change without notice.

USDA Forest Service: Fire Medical Qualifications Program - Central Nervous System/Seizures/ Syncope/Stroke/Headache

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What does the Forest Service seizure medical form ask the provider?

Part B asks the diagnosis, stability and treatment compliance, medications, license type, driving and equipment restrictions, the date of the last event and related surgeries. For seizures it also asks about triggers, the likelihood of another seizure and recent test results such as an EEG.

Can a wildland firefighter with migraines be medically qualified?

The template lets the treating provider document migraine or cluster headache triggers, how often headaches occur and how often they are debilitating. A Forest Service Medical Officer then decides qualification, and waivers are only considered for conditions that are static and stable.

Who submits the CNS medical template to the Forest Service?

The employee brings it to the provider and completes Part A, which authorizes release to Forest Service Medical Officers. The provider completes Part B, signs it and faxes it to the Fire Medical Qualifications Program office as printed on the form.