The Forest Service Fire Medical Qualifications Program uses this hearing template, titled for the years between routine audiograms, when a fire employee has hearing loss or wears hearing aids. Part B asks whether the employee can understand speech with background noise at conversation level, with and without aids, and for arduous duties whether they can do so at 500 to 3000 Hz with aids.
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.
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USDA Forest Service: Fire Medical Qualifications Program - Hearing/hearing Aids (years between routine audiogram)
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For light or moderate duties, whether the employee can understand speech with background noise at conversation level, with or without hearing aids. For arduous duties with hearing aids, whether they understand speech with background noise at 500 to 3000 Hz. A no answer needs a recommended course of action.
The employee fills in Part A with name, date of birth, home unit and fitness level, authorizing release to Forest Service Medical Officers. The treating provider completes Part B and signs with credentials (DO, MD, NP, PA or other), address and office stamp.
The template is built for employees who use hearing aids, asking which ears are aided and how well speech is understood with them. A Forest Service Medical Officer, not the provider, decides qualification and any waiver, and waiver mitigations may include yearly updates.