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Forest Service Thyroid/Endocrine Fire Medical Form

The Forest Service uses this template when a wildland firefighter's screening or OF-178 exam shows a thyroid or other endocrine disorder. The treating provider checks the diagnosis, states whether it is controlled and stable, lists medications and flags risk of seizures, cardiac abnormality, dehydration or exertional heat illness, so a Medical Officer can decide clearance or a waiver.

Who completes it

The employee completes Part A with identifying details and Light, Moderate or Arduous fitness level, authorizing release to the program's Medical Officers. The treating provider or endocrinologist completes Part B as applicable and signs with credentials and an office stamp.

Submitting and payment

How to submit it
Fax the completed template to the Fire Medical Qualifications Program office using the number printed on Part B; the employee's eMedical request explains timing.
Who pays
No fee schedule applies; the employee is responsible for obtaining and paying for documentation requested by the Medical Officer.

Good to know

  • Diagnosis checkboxes cover hypothyroidism or Hashimoto's, hyperthyroidism or Graves', Addison's disease, diabetes insipidus and panhypopituitarism, with an Other line.
  • The form asks whether the condition is controlled, static and stable with good compliance, which the Medical Officer needs before any waiver can be considered.
  • For diabetes insipidus, record how often hyponatremia episodes occur and the date of the last one.
  • Diabetes mellitus and pre-diabetes have their own Forest Service template, so use this one for thyroid and other endocrine conditions.

Get the official form

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

USDA Forest Service: Fire Medical Qualifications Program - Thyroid/Other Endocrine

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

Why does the thyroid/endocrine form ask about heat illness?

Firefighters may work 16-hour shifts in heat above 100°F with irregular meals and limited water access, far from definitive care. The template asks whether the employee may be at risk for seizures, cardiac abnormality, dehydration or exertional heat illness, and asks the provider to explain any concern.

Does a well-controlled hypothyroid patient still need this form?

If the Medical Officer requests it, yes. The form lets the provider confirm the condition is controlled and stable, list medications and answer the restriction question, which gives the Medical Officer what is needed to decide clearance. The Medical Officer, not the provider, makes the final determination.