# Interagency Stinging Insect Allergy Waiver/Accommodation Process 

### Introduction

Upwards of five percent of the general population are subject to
anaphylaxis resulting from insect stings every year^1^. Previous
stinging events which produced a systemic reaction
(hives/itching/generalized swelling) or physician prescription of
epinephrine pens are typically the reasons for medical disqualification
in the Interagency medical standards program. For the wildland
firefighter, most of these stings are from wasps, yellow jackets,
hornets, bees, or fire ants. With local level (1^st^ level) support,
this stinging insect allergy waiver/accommodation process is intended to
assist the wildland firefighter in obtaining a waiver with
restriction(s) as quickly as possible.

**[Directions]{.underline}**

This is a seven part process:

1)  FMO/SHRO downloads the Stinging Insect Allergy Packet
    ([www.nifc.gov/medical_standards/resources/stinging_insect.doc](http://www.nifc.gov/medical_standards/resources/stinging_insect.doc))
    and provides to the applicant/incumbent if it is known the
    individual has a stinging insect allergy.

2)  The applicant/incumbent completes the *Wildland Firefighter Stinging
    Insect Allergy* (Attachment #1). The firefighter has their personal
    physician complete the [Personal Physician Section]{.underline}.
    (Note: Any expense incurred is the responsibility of the
    firefighter.) The firefighter should retain a copy for their file
    and use later in this process.

3)  If Attachment #1 is completed **BEFORE** the wildland firefighter's
    exam, the firefighter takes the completed *Wildland Firefighter
    Stinging Insect Allergy* (Attachment #1) form to the scheduled
    medical examination with instruction to the examining clinic's
    health care provider to include this attachment with the completed
    examination form.

4)  If Attachment #1 is completed **AFTER** the wildland firefighter's
    exam, probably after the non-clearance notification is sent to the
    local FMO and SHRO, the firefighter must complete the firefighter
    section and the firefighter's personal physician must complete the
    physician section, then forward to the local FMO/SHRO for use in
    step 5) next.

5)  When a non-clearance determination is sent from the Interagency
    medical standards program to the FMO and SHRO; the FMO, SHRO, and
    wildland firefighter collaboratively review and complete the
    *Stinging Insect Allergy Waiver with Restrictions* forms
    (Attachments #1, #2, and #3).

    a.  If the FMO, SHRO, and wildland firefighter agree that the
        firefighter can safely perform arduous duty given the stinging
        insect allergy concern, then the waiver with restrictions form
        is completed and signed. All three attachments are retained at
        the local SHRO office as an official personnel action with
        supporting documentation.

    b.  If the FMO, SHRO, or wildland firefighter do not agree that the
        firefighter can safely perform arduous duty given the stinging
        insect allergy concern, then management (i.e. FMO or SHRO) will
        notify the Interagency medical standards program. This initiates
        the Interagency Medical Review Board (2^nd^ level) process.

    c.  Attachment #3 is kept in the firefighter's personnel file.

6)  The **completed, signed** *Stinging Insect Allergy Waiver with
    Restrictions* letter (Attachment #2) is faxed to the Interagency
    medical standards office.

7)  The Interagency medical standards office reviews the **signed**
    waiver with restrictions, and if complete, notifies the nationwide
    medical provider to update clearance status to Cleared with
    Restrictions; citing the consensus restrictions.

1\.
<http://www.medem.com/medlb/article_detaillb.cfm?article_ID=ZZZMO0FIA9C&sub_cat=530>

*Attachment #1*

***Wildland Firefighter Stinging Insect Allergy***

**[Firefighter Section]{.underline}** -- (keep a copy for your records)

Your anaphylactic reaction to stinging insects present a safety risk
when working with personnel who do not know you or are unaware of your
stinging insect allergy reactions, especially in hazardous situations.
To reduce this safety risk, you carry at least one EpiPen with you and
have demonstrated that you would be able to self-administer the EpiPen
following a stinging insect envenomation. To mitigate this risk, at a
minimum, the following steps must occur during each fire assignment:

1.  Notify subordinates, supervisors, co-workers, and fire line medic of
    potential for a stinging insect allergic reaction (specify bees,
    wasps, hornets, yellow jacket, and/or fire ants),

2.  Carry prescribed epinephrine kit(s) complying with the manufacture's
    recommendations for temperature exposure ensuring drug efficacy,

3.  Ensure the epinephrine kit expiration date will not exceeded during
    fire assignments,

4.  Confirm with your fire line supervisor that you are trained in the
    correct manner for self-administration,

5.  Notify your fireline supervisors and co-workers of the location and
    use of your epinephrine kit in the event you are unable to
    self-administer, and

6.  Whenever and wherever possible, you must avoid working in the
    immediate vicinity of any known stinging insect nests.

Printed Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date
\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Personal Physician Section]{.underline}**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ has a
history of a systemic allergic reaction to insect stings and is

^Printed\ name\ of\ wildland\ firefighter^

required to submit and have on file medical documentation before being
considered for a medical clearance for wildland firefighting. The
medical documentation consists of a signed and dated letter from the
firefighters' personal physician that:

1.  \_\_\_\_\_\_\_\_\_\_\_\_confirms that the individual holds a current
    valid prescription for epinephrine

^Personal\ Physician\ initials^ (minimum one dose) generally in the form
of EpiPen auto injectors.

2.  \_\_\_\_\_\_\_\_\_\_\_\_confirms that the prescription will remain
    valid including approved refills through

> ^Personal\ Physician\ initials^ the period that is to be covered by
> the wildland firefighter medical clearance.

3.  \_\_\_\_\_\_\_\_\_\_\_\_confirms that the physician is aware of the
    nature of the work and the potential types

> ^Personal\ Physician\ initials^ of assignments, temperature extremes,
> environmental conditions, geographic locations in which the
> firefighter may be assigned for duty and of the manner in which the
> epinephrine will be stored to retain efficacy.

4.  \_\_\_\_\_\_\_\_\_\_\_\_confirms that the firefighter understands
    the limitations and consequences of the EpiPen

> ^Personal\ Physician\ initials^ and other forms of epinephrine due to
> the temperature extremes inherent to wildland fire.

5.  \_\_\_\_\_\_\_\_\_\_\_\_confirms that the firefighter understands
    the uses of an antihistamine in conjunction with

> ^Personal\ Physician\ initials^ epinephrine for treating an allergic
> reaction.

6.  \_\_\_\_\_\_\_\_\_\_\_\_confirms, in the opinion of the physician,
    the medication can be used safely and effectively
    ^Personal\ Physician\ initials^ by the individual.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Physician's Printed Name Signature Date

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address License number and State Telephone Number

*Attachment #2*

*Stinging Insect Allergy Waiver with Restrictions*

AGENCY LETTERHEAD HERE

Number range CHAPTER

Employee Name:

The Medical Review Officer determined that you have a medical condition
not meeting the Federal Interagency Wildland Firefighter Medical
Standards, an anaphylactic reaction to stinging insects. Based on a
verbal consultation and agreement with **(Insert FMO name here),** and
your demonstrated experience managing your medical concern through
**(Insert EpiPens, oral antihistamines, etc.),** a waiver with
restrictions is warranted as you demonstrated the ability to perform the
essential functions of arduous duty safely, without risk to yourself or
others.

Your anaphylactic reaction to stinging insects presents a safety risk
when working with personnel who do not know you or are unaware of your
reaction, especially in hazardous situations. While this is a serious
safety condition, your history of managing this concern for the last
**XX** years supports a waiver with restrictions. To mitigate this risk,
the following steps must occur during each fire assignment:

**RESTRICTIONS**

1)  Notify subordinates, supervisors, co-workers, and fire line medic of
    potential for allergic reaction,

2)  Carry prescribed epinephrine kit(s) complying with the
    manufacturer\'s recommendations for temperature exposure ensuring
    drug efficacy,

3)  Ensure the epinephrine kit expiration date will not exceeded during
    fire assignments,

4)  Confirm with your fireline supervisor that you are trained in the
    correct manner for self-administration,

5)  Notify your fireline supervisor and co-workers of the location and
    use of your epinephrine kit in the event you are unable to
    self-administer, and

6)  Whenever and wherever possible, you must avoid working in the
    immediate vicinity of any known stinging insect nests.

As you continue your fire career, your anaphylactic reaction to stinging
insects will continue to be an issue during periodic medical
examinations, and as such, re-evaluation for waiver/accommodation
throughout your career.

Should your medical condition change which would adversely impact your
ability to safely and efficiently perform the tasks required of an
arduous duty wildland firefighter you are required to notify your FMO
and me.

If you are dissatisfied with this determination, you have the right to
request a national level review by the Interagency Medical Review Board
(IMRB). You have XXX **(30 for applicant/incumbents permanent positions,
5 for temporary seasonal hires)** calendar days from the date you
receive this letter in which to submit a written request for a review
and to submit additional information to support your request. Failure to
make a written request within

*Attachment #2*

this time frame will result in termination of the IMRB procedures. Your
written request for IMRB review, along with all supporting
documentation, must be submitted to:

Kevin Jensen

Interagency Medical Standards Program Manager

1387 South Vinnell

Boise, ID 83709

In your written request for review by the IMRB, include:

1)  A statement on why you are disputing the local level determination
    and describe how you safely and efficiently perform the essential
    functions of an arduous wildland firefighter, given you medical
    non-clearance issue AND a statement on whether you are requesting a
    waiver, a waiver with restriction(s) or a waiver with
    accommodation(s);

**In addition, include** **any additional information not provided at
the local level for review, in the following areas**:

2\) Any additional medical information regarding your medical
non-clearance issue (if applicable to your request);

3\) A history of your qualifications, experience and training which
demonstrates your ability to safely perform arduous duty;

4\) Any method(s) used to mitigate the safety risks associated with your
medical non-clearance issue;

5\) Documentation of your performance abilities, including Incident
Personnel Performance Rating evaluations (NFES 1576);

6\) Any other documentation submitted by you, your supervisor, or others
on your behalf describing how your work history demonstrates your
ability to safely perform arduous duty wildland firefighting, given your
medical non-clearance issue(s); and,

7\) If you are requesting waiver with accommodation (reasonable
accommodation), state the specific accommodation(s) you are requesting
and provide supporting information/documentation on how you meet the
definition of a qualified individual with a disability.

Any additional information you choose to provide must be received in the
time frame described above if the IMRB is to consider this information
in support of your medical qualifications for arduous level wildland
firefighting. Should you need to request an extension of the time
frames, you must do so in writing and prior to the expiration of the
above time frames. A request for an extension must be submitted to me,
and I will notify the Medical Standards Program Specialist of your
request. The Medical Standards Program Specialist will obtain a decision
on your request for an extension from your Agency FFAST Representative
and notify me of the decision. I will then notify you. (Note: An
extension may result in moving your IMRB request to the next scheduled
IMRB.)

The IMRB will review all the medical and supporting information provided
by you and make a qualifications recommendation to the appropriate
agency management official, who will then make the final
waiver/accommodation determination. You will be notified in writing of
the Agency's determination, which is final.

\[*For Forest Service Bargaining Unit employees include*:\] You may be
entitled to have a Union representative attend the IMRB as an observer.
You should contact your Union representative for additional information
on Union representation.

*Attachment #2*

Please sign below acknowledging receipt of this letter and return the
acknowledgement copy to me. If you have any questions regarding the
medical examination or qualification standards process please contact
me. If I can be of further assistance, please contact me at your
leisure.

signed SHRO and title

cc: FMO

Safety Officer

I accept this waiver with restrictions as outlined above.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Firefighter's signature Date

*Attachment #3*

*FMO/SUPERVISORS STATEMENT*

*Stinging Insect Allergy Waiver with Restrictions*

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Name of firefighter)

requested a waiver with restrictions for the immune standard, stinging
insect allergy, as found in the Federal Interagency Wildland Firefighter
Medical Qualification Standards.

I discussed with the firefighter the medical complications which may
arise from an allergic reaction to stinging insects and reviewed the
listed restrictions with the firefighter to ensure that their safety and
the safety of their co-workers is not compromised at any time performing
arduous duty. I support a waiver with restrictions for this firefighter.

**RESTRICTIONS**

1)  Notify subordinates, supervisors, co-workers, and fire line medic of
    potential for allergic reaction,

2)  Carry prescribed epinephrine kit(s) complying with the
    manufacturer\'s recommendations for temperature exposure ensuring
    drug efficacy,

3)  Ensure the epinephrine kit expiration date will not be exceeded
    during fire assignments,

4)  Confirm with your fireline supervisor that you are trained in the
    correct manner for self-administration,

5)  Notify your fireline supervisor and co-workers of the location and
    use of your epinephrine kit in the event you are unable to
    self-administer, and

6)  Whenever and wherever possible, you must avoid working in the
    immediate vicinity of any known bees nests.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of FMO/supervisor (please print)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of FMO/supervisor

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address of FMO/supervisor

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date signed

> Forward this form to: YOUR SERVICING HUMAN RESOURCES OFFICE for
> inclusion in the firefighter's personnel folder