Employees who use a prosthesis and want a Forest Service fire qualification bring this template to their treating provider. It asks about the prosthesis type and location, power needs, how it holds up to embers and heat, its fit with agency fire clothing, and the employee's mobility on rough ground, so a Medical Officer can decide clearance, a waiver or accommodations.
The employee completes Part A (name, date of birth, home unit and Light, Moderate or Arduous level). The treating provider (MD, DO, NP, PA or other) completes Part B as applicable and signs with credentials and an office stamp.
Download the current version from the source each time; forms change without notice.
USDA Forest Service: Fire Medical Qualifications Program - Prosthetic
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Part A records the employee's fitness level, Light, Moderate or Arduous, and the general questions apply to all. The PPE section applies to anyone who has possession of fire PPE (Nomex), regardless of level, so the provider should complete it whenever the employee is issued fire clothing.
It asks whether the employee, with the prosthesis, can move rapidly on steep terrain and rocky, loose or muddy surfaces, wet leaves and grasses without undue risk of sudden or subtle harm. If the answer is no, the provider specifies the concern for the Medical Officer's review.