Date:

To: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Security Number: xxx-xx-\_\_\_\_\_

In reviewing your recent employment physical examination for the
Wildland Firefighter Program, I am bringing to your attention the
following findings:

Diabetes Mellitus

Please have your doctor review this letter and any enclosed documents as
soon as possible. Your doctor will need to sign the statement at the
bottom of the second page indicating whether or not you are able to
safely perform the arduous duties of a Wildland Firefighter. I also
request that your doctor include documentation of:

1.  Current treatment plan

2.  Any episodes of hypoglycemia

3.  Any hospitalizations for diabetes within the last year

4.  Evidence of good diabetic control, such as a recent hemoglobin A1c
    level

5.  Lack of target organ damage, specifically to include the presence or
    absence of heart disease, kidney disease, eye disease and neuropathy

A final rating determination cannot be made until this additional
information is received. Please have your doctor send or fax the
completed form and medical reports to:

> Comprehensive Health Services, Inc.
>
> Attention: Interagency WLFF
>
> 8229 Boone Blvd Suite 700
>
> Vienna, VA 22182-2623
>
> Fax: (703) 288-5482

Sincerely,

Interagency Wildland Firefighter

Medical Standards Program

**PHYSICIAN EVALUATION** (*Attach explanation, notes and/or lab
reports)*

**Part A**

Diagnosis:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Prognosis:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Has he/she had any episodes of hypoglycemia within the last two years?
(If yes, please

explain.) □ No □ Yes
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Has he/she been hospitalized for diabetes within the last year? (If yes,
please explain.)

□ No □ Yes
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Recent Hemoglobin A1c level (with date) or other evidence of good
diabetic control: \_\_\_\_\_\_

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

Does this person have any evidence of end organ damage? (Please explain
any "yes"

answers.)

Heart disease □ No □Yes

Kidney disease □ No □ Yes

Eye disease □ No □ Yes

Neuropathy □ No □ Yes

Please include documentation of a current treatment plan:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

**Part B**

I have reviewed this letter and all enclosed documents, including the
[Essential Functions and Work Conditions of a Wildland
Firefighter]{.underline}, and in my opinion:

The individual is able to safely perform the essential functions of a
Wildland Firefighter.

The individual is [not]{.underline} able to safely perform the essential
functions of a Wildland Firefighter at this time (explain below).

The individual is able to safely perform the duties of a Wildland
Firefighter with the following restrictions:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

Signature of Physician:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of Physician:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address of Physician:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Phone: ( \_\_\_\_\_\_\_ )
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Note: The Wildland Firefighter Program does not reimburse any expenses
associated with further evaluation or treatment for the above issues. If
you have any questions, contact your Fire Management Officer, Servicing
Personnel Officer, or Agency representative.

For: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Security Number: xxx-xx-\_\_\_\_\_

08/06