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Forest Service Provider Medication Statement (Fire)

Rather than describing a diagnosis, this Forest Service template asks the prescriber to list a wildland firefighter's medications and attest that none has side effects that would affect safe, efficient performance of fire duties. It is requested during medical qualification review and is read by a Forest Service Medical Officer alongside the OF-178 exam and any condition-specific templates.

Who completes it

The employee completes Part A (name, date of birth, home unit and Light, Moderate or Arduous level). The prescribing provider completes Part B: the medication list, date, signature, printed name, credential (DO, MD, NP, PA or other) and office stamp.

Submitting and payment

How to submit it
The provider faxes the signed statement to the Fire Medical Qualifications Program office at the fax number printed on Part B. The employee's eMedical request explains any response deadline.
Who pays
No fee schedule applies; the Forest Service tells employees that obtaining, paying for and supplying requested medical documentation is their responsibility.

Good to know

  • By signing, the provider confirms reviewing page 3 and understanding the employee may work 16-hour days with limited sleep and irregular meals for an unknown period.
  • The attestation covers duties such as operating vehicles or machinery, driving narrow roads with drop-offs and working on steep, uneven or slick ground or ledges.
  • For transdermal patches, the provider also acknowledges that fire work can raise body temperature above 100°F, which can increase patch absorption.
  • Version v11/2025 is three pages; page 3 describes the Light, Moderate and Arduous work capacity tests from NWCG PMS 310-1.

Get the official form

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

USDA Forest Service: Fire Medical Qualifications Program - Provider Medication Statement

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 if a medication does have side effects relevant to fire duties?

The statement is worded as an attestation that the listed medications cause no side effects that would adversely affect safe performance of fire duties, and it has no box for describing side effects. When that wording does not fit, the Medical Officer relies on the condition-specific template or other records, which have space for restrictions and explanations.

Who should sign the Provider Medication Statement?

The provider who prescribes the medications. The signature block lists DO, MD, NP and PA, with an Other option, and asks for printed name, address, office phone and an office stamp. The attestation refers to medications 'that I prescribe', so it covers the signer's own prescriptions.

Why does the form mention transdermal patches?

Wildland fire work may be done in extreme heat and is likely to push body temperature above 100°F for long periods. The form asks the prescriber of any patch medication to acknowledge that elevated body temperature can increase the absorption rate of transdermal patches before signing the attestation.