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USFS Fire Medical Form: Genitourinary Conditions

A Forest Service fire employee with a genitourinary condition brings this three-page template to their treating provider when the medical review flags it. Part B asks for the diagnosis, medications, stability and compliance, surgeries with return-to-duty dates, any ostomy, and whether the provider has concerns about dehydration, exertional heat illness or exertional rhabdomyolysis on fire assignments. Forest Service Medical Officers use it 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

  • The heat question asks whether the employee can function where dehydration, exertional heat illness and exertional rhabdomyolysis are elevated risks.
  • For an ostomy, give its location, whether it is permanent or temporary, and the date of any reversal.
  • Describe surgeries with the surgery date and the date the employee returned to full, unrestricted work duties.
  • The employee marks the work capacity test level in Part A, and the last page describes the duties and work capacity test for light, moderate and arduous levels.

Get the official form

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

USDA Forest Service: Fire Medical Qualifications Program - Genitourinary

Official pagePDF

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Frequently asked questions

What does the Forest Service genitourinary medical template ask?

Part B asks the diagnosis, medications and indications, whether the condition is static and stable with good treatment compliance, surgeries and return-to-duty dates, concerns about dehydration, heat illness or rhabdomyolysis, ostomy details, and whether there are any restrictions on fire duties.

Do I have to answer every question on the genitourinary form?

Part B is completed as applicable by the medical provider, so the ostomy questions only apply if the employee has one. Every provider should answer the closing question on restrictions for long, hot, remote fire assignments and sign with credentials and an office stamp.

Where do I send the Forest Service genitourinary form?

Fax the completed form to the Fire Medical Qualifications Program office, as printed in Part B, where questions can also be directed. The employee manages the rest of the medical clearance process, including information requests, through the program's eMedical system.