Department of
Agriculture / Forest
Service
File Code: / 5100/6180
Date:
Dear Medical Provider (M.D., D.O., N.P./A.P.N., P.A.):
Enter Employee’s Full Name: ______is a Forest Service employee or prospective employee with theEnter National Forest Name: ______National Forest; Enter Name:Ranger District.
This employee may be involved in wildland firefighting and fire management activities and is required to pass a monitored Work Capacity Test (WCT). The Forest Service requires a medical exam from a licensed physician or other qualified medical provider (noted above) before this individual takes the test. Once that has been completed, and the Agency Reviewing Medical Officer clears them, the individual will be required to pass the WCT at the level noted below. Upon successfully passing the WCT, this employee must be physically capable of performing the requirements of this level of activity required in his/her fire position in wildland fire environmental conditions.
____ Arduous level - requires the individual to complete a 3-mile walk/hike within
45 minutes while carrying a 45-pound pack.
____ Moderate level - requires the individual to complete a 2-mile walk/hike within
30 minutes while carrying a 25-pound pack.
____ Light level - requires the individual to complete a 1 mile walk within 16 minutes.
Important Notes to Medical Provider: Please review the following prior to completing the Certificate of Medical Examination (Optional Form178) within the USFS eMedical system. (All documents are also available under “Physician Documents” on the MQP eMedical website:
- “WCT Brochure”
- “Essential Functions and Work Conditions of a Wildland Firefighter”(for Arduous levels only)
- Employee will provide a copy of their OF-178 email that contains a unique access codefor the medical provider to access and complete the OF-178 exam form within eMedical.
Use the “eOF-178 Medical Exam GUIDANCE SHEET for the Medical Provider” to make sure the exam form is completed correctly within the online eMedical system.
Please evaluate this individual’s medical condition and status in regards to the duties and physical requirements of the conditioning for and taking the WCT at the level indicated above. Please complete and submit Part C of the Optional Form 178. In the “Conclusions” block, please note any limiting factors for the individual in meeting the physical requirements of the job if arduous level and/or the WCT, and any medical conditions corresponding to the information in Part A box 5, giving any medical opinion in regards to their status being static and stable. Your submission of the form will include an electronic signature and date.
The Forest Service authorizes you to bill for the customary and reasonable costs incurred for a standard employment physical examination.
Additional specialized tests beyond what is on the exam form are not authorized and will not be paid for by the USFS.
Payment of Certificate of Medical Examination (Optional Form 178): Please forward the bill to:
Enter Local Forest Address & name of your Budget person who is responsible for paying for OF-178 medical exam within your local Forest.
Thank you for your assistance.
Sincerely,
Enter HSQ Coordinator Name, HSQ Coordinator
Enclosures
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