This four-page Forest Service template covers musculoskeletal conditions and disorders of the central or peripheral nervous system in wildland firefighters. After a screening or OF-178 exam flags such a condition, the treating provider documents diagnosis, procedures, relapses, deficits, pain and hand function, and a Forest Service Medical Officer uses the answers to decide clearance or a waiver.
The employee completes Part A with identifying details and fitness level, which also authorizes release to the program's Medical Officers. The treating provider or relevant specialist completes Part B as applicable and signs with credentials and an office stamp.
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USDA Forest Service: Fire Medical Qualifications Program - Musculoskeletal/Central Nervous System/Peripheral Nervous System
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It is used for musculoskeletal conditions and central or peripheral nervous system conditions in employees seeking Forest Service fire qualifications. The program has a separate template for seizures, syncope, stroke and headache, so the Medical Officer's request indicates which template applies to the employee's diagnosis.
Yes. Part B asks for surgeries or procedures related to the diagnosis, with the date of each and the date the employee was released back to full work duties. It also asks whether there are complications such as vascular, gastrointestinal or cardiac problems related to the diagnosis.