AGENCY LETTERHEAD HERE Number range CHAPTER

Employee Name:

The examining physician\'s report indicated a medical condition not
meeting the Federal Interagency Wildland Firefighter Medical Standards
was noted, **(Insert restricted vision medical concern here; e.g.
decreased visual acuity greater than 20/800, monocular vision, retinal
scar)**. Based on a verbal consultation with **(Insert FMO name here)**
and your experience as a **(Insert arduous duty red card qualifications
here)**, a waiver with restriction**(s)** is warranted as your work
history demonstrates the ability to perform the essential functions of
arduous duty safely and efficiently, without risk to yourself or others.

**Insert Qualifications, Experience, and Training which demonstrates the
ability to safely perform arduous duty given the medical concern here.**

**Insert employee's current methods to mitigate the safety risks
associated with the medical concern here.**

**Insert supporting documentation noting employee's ability to safely
perform arduous duty with the medical concern here.**

During fire assignments, it is crucial that personnel above, below, and
at your arduous position level be made aware of your **(Insert medical
concern here)** and could present a safety risk when working with
personnel who do not know you or are unaware of your medical concern,
especially in hazardous situations. At a minimum, in order to mitigate
this risk, the following steps must occur during each fire assignment:

**POSSIBLE RESTRICTIONS**

1.  Notify subordinates, coworkers, and supervisors who work with you on
    fire assignments about your **(Insert medical concern here)** to
    mitigate a safety risk to yourself or others,

2.  Ensure you and your fire line supervisor assess your duties as an
    arduous level wildland firefighter for potential hazards encountered
    during wildland and prescribed fire operations to include mitigation
    steps for visual hazards,

3.  Wear ANSI approved personal protective eyewear equipment during
    fireline operations,

4.  Carry sufficient pairs of corrective lenses (glasses) in case(s) to
    correct your vision to 20/40 or better in each eye at all times,

5.  Utilize a spotter when backing a vehicle or trailer,

6.  Operate motor vehicles during daylight hours only,

7.  Operate motor vehicles during daylight hours only, unless evaluation
    by the government license examiner determines that night time
    operations can be safely allowed,

8.  Chainsaw operation is not permitted,

9.  Chainsaw operation permitted only after thorough testing and
    evaluation by a certified chainsaw instructor,

10. Utilize and carry a spare high intensity beam headlamp at all times
    for use at night to improve your depth perception.

As you continue your fire career, your **(Insert medical concern here)**
will continue to be an issue during periodic medical examinations, and
as such, re-evaluation for waiver/accommodation throughout your career
may be needed.

Should your medical condition change (e.g. further detriment of vision
in either eye) which would adversely impact your ability to safely and
efficiently perform the tasks required of an arduous duty wildland
firefighter, including prescribed fire operations, 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 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; *OR, if the individual was not provided an
    opportunity to request waiver/accommodation at the local level,
    use*: 1) 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.

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 the qualification standards process, please
contact me. If you have any questions regarding a color vision
deficiency awareness program, please contact your safety officer. If I
can be of further assistance, please feel free to contact me at your
leisure at XXX-XXX-XXXX.

Sincerely,

signed SHRO and title

cc: FMO

Safety Officer

I accept this waiver with restrictions as outlined above.

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