A Forest Service fire employee with a blood disorder brings this three-page hemopoietic template to their treating provider when the medical review flags it. Part B asks for the diagnosis, medications and indications, whether the condition is static and stable or in remission, related surgeries with return-to-duty dates, and concerns about dehydration, exertional heat injury or rhabdomyolysis in a wilderness fire environment.
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 - Hemopoietic
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Part B asks the diagnosis, a complete medication list with indications, whether the condition is static and stable or in remission with good treatment compliance, surgeries and return-to-duty dates, concerns about dehydration, heat injury and rhabdomyolysis, and any restrictions on fire duties.
It asks whether you have concerns about the employee's ability to function in a wilderness fire environment with an elevated risk of dehydration, exertional heat injury or illness, and exertional rhabdomyolysis, and to specify them. This is separate from the closing question on overall restrictions for fire duties.
The Fire Medical Qualifications Program says that when a Medical Officer requests more medical information, the employee must obtain, pay for and supply it, citing 5 CFR 339.304(c). Separate reimbursement rules apply to the OF-178 exam itself.