When a wildland firefighter's screening or OF-178 exam notes a psychiatric diagnosis or medication, the Forest Service asks the treating provider to complete this template. It documents diagnosis, stability, medication history, recent dose changes, supply planning for assignments and any safety concerns, and a Forest Service Medical Officer uses it to decide medical clearance or a waiver.
The employee completes Part A, including fitness level, and authorizes release to the program's Medical Officers. The treating provider (MD, DO, NP, PA or other) completes Part B as applicable, then 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 - Psychiatric
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It asks whether the provider has concerns about the employee's ability to function in a wildland fire environment and respond appropriately to protect their own life or another person's. A separate item asks whether the condition or medications are likely to affect safe operation of a motor vehicle, heavy equipment or powered equipment such as chainsaws.
Fire assignments can last up to 21 days in a row plus travel, often far from pharmacies. The template asks whether the employee has a plan to keep a sufficient supply of medication for the whole assignment, a minimum of 30 days, and, if not, asks the provider to document the plan.