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Alaska 07-6177 Firefighter Presumption Exam Form

Alaska firefighters need a baseline lung, heart and cancer screening examination to qualify for the workers' compensation presumption under AS 23.30.121. This form records it: blood pressure, weight and cotinine, chest X-ray, PFT, resting and stress EKG, lipids, a neurological exam, and cancer screening by lymph node palpation, digital rectal exam, PSA, blood counts, blood chemistry and urinalysis.

Who completes it

The firefighter fills in the identification block (name, age, employer, personal physician and occupation) before the exam and hands the form to the examiner, who records the findings and signs.

Submitting and payment

How to submit it
After the examiner signs, the firefighter signs one copy and submits it to the employer, as the form instructs.
Who pays
The form does not say who pays for the examination.

Good to know

  • A stress EKG is called for if the firefighter is 40 or older or the resting EKG is abnormal, and there are no contraindications to the test.
  • Abnormal neurological findings call for referral for a CAT scan to check for a brain tumor; inconclusive cancer screening can lead to further studies the examiner recommends.
  • The form is a Word document (.doc), revised 09/2012, not a PDF. The companion medical history form, 07-6176, is completed by the firefighter.
  • It does not replace fire departments' own medical history and fitness-for-duty evaluations.

Get the official form

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

Firefighter's Presumption Lung & Heart Physical Examination and Cancer Screening Form (AS 23.30.121)

Official pageWord file

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Frequently asked questions

Who needs Alaska Form 07-6177?

Firefighters who want the occupational disease presumption in AS 23.30.121 for lung, heart and certain cancers use it to document a baseline examination. The firefighter brings it, with the companion history form 07-6176, to the medical examiner, who completes the findings and signs.

When is a stress EKG required on the firefighter exam?

The form calls for a stress EKG if the firefighter is 40 or older, or if the resting EKG shows abnormalities, provided there are no contraindications to performing the test. Both resting and stress EKG results are recorded as normal or abnormal with details.

Which cancers does the Alaska firefighter form screen for?

It covers brain (through the neurological exam, with CAT scan referral if abnormal), malignant melanoma by visual screening, non-Hodgkin's lymphoma by lymph node palpation and blood tests, prostate by digital rectal exam and PSA, leukemia by blood count, and kidney, bladder and ureter cancer by blood chemistry and urinalysis.