The Following Material Is Enclosed and Must Be Reviewed by a Licensed Physician

U n i t e d S t a t e s F o r e s t D e p a r t m e n t o f S e r v i c e A g r i c u l t u r e

File Code: 5100/6180 Date:

Dear Enter Employee’s Name

Your responses on the Health Screening Questionnaire (HSQ) form (FS-5100-31, March 2016) indicate the need for a medical examination. If you are a current Forest Service employee, please share this letter with your supervisor so that he/she can arrange for you to be released on official time, if necessary, to undergo this required physical exam.

The following material is enclosed and must be reviewed by a licensed physician:

1. Important Process Change – Employee will give Medical Provider copy of eMedical email with their OF-178 Physician Access Code. This email sent to employees who need an exam contains a unique access code that allows your medical provider to complete the OF-178 within eMedical.

2. Billing for completed OF-178: Please make sure that the address for billing is completed and the bill will be mailed to your forest or district budget point of contact for payment.

3. Additional testing beyond what is on the OF-178 form will NOT be approved and not be covered by the Forest Service. If additional specialized medical tests are requested by the physician, the cost will be the responsibility of the employee.

4. Letter to Medical Provider for Current/Prospective Employees 5. Work Capacity Test” Brochure 6. Essential Functions and Work Conditions of a Wildland Firefighter (arduous duty only) 7. eOF-178 Medical Exam GUIDANCE SHEET for the Medical Provider

Your OF-178 Medical Exam completed in eMedical will be reviewed by the Fire and Aviation Management Reviewing Medical Officer who will issue appropriate medical clearance via eMedical with a notification to the employee by email.

You have the choice of having this material completed by your own physician or appropriate licensed medical practitioner or by ______, an Agency-designated physician. For either choice, the Forest Service will pay for the reasonable and customary costs of this medical examination. Important Note - Additional Specialized Medical Tests Requested by the Physician: Please refer to item #3 above.

Caring for the Land and Serving People Printed on Recycled Paper Please contact: Enter HSQ Coordinator Name:______at Enter Phone #______if you have questions or concerns about any of the above information.

Sincerely,

Enter HSQ Name, NAME & Title (HSQ Coordinator)

Enclosures