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USFS Fire Medical Form: Heart Disease and Devices

A Forest Service fire employee with heart disease, a murmur or valve disease, prior heart surgery or a pacemaker or implanted defibrillator brings this four-page template to their treating provider. Part B covers diagnosis, stability, medications, cardiac rehabilitation, stress test and echocardiogram dates and results, planned testing, procedures with return-to-duty dates, and device checks. 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

  • For CAD or an abnormal rhythm, give the last stress test date and results (or attach the report), the last echocardiogram, future testing frequency and blood pressure at the last visit.
  • For a pacemaker or implanted defibrillator, record the diagnosis that led to it, the last device check or interrogation, and for an ICD the last discharge and average frequency.
  • List each heart surgery or procedure with its date and the date the employee was cleared back to full work duties.
  • Every provider answers whether there are restrictions on 16-hour fire shifts for up to 21 days in heat, smoke and altitude far from definitive care.

Get the official form

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

USDA Forest Service: Fire Medical Qualifications Program - Heart Disease/Heart Murmur/Heart Surgery/Cardiac Implantable Devices

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 heart disease medical form ask?

Part B asks the diagnosis, stability and treatment compliance, medications, cardiac rehabilitation dates, stress test and echocardiogram history, whether future stress tests or ECGs are indicated and how often, blood pressure, surgeries and procedures, and pacemaker or ICD details.

Can I attach reports to the Forest Service cardiac template?

Yes. The form lets you include the stress test report instead of writing out the results, and the imaging report instead of writing echocardiogram results for murmurs or valve disease. Send them with the completed form to the Fire Medical Qualifications Program office.

Can a wildland firefighter with an ICD be cleared?

The template collects what a Medical Officer needs, including when the defibrillator last discharged and how often it does. The treating provider doesn't make the qualification decision; a Forest Service Medical Officer decides, and waivers apply only to conditions that are static and stable.