Diabetes Mellitus Information regarding any hospitalizations for diabetes within the last year she been hospitalized for diabetes within the last year? …
Date:
To: __________________________________
Social Security Number: xxx-xx-_____
In reviewing your recent medical examination for the Interagency Wildland
Firefighter Medical Qualification Standards Program, further information is
required regarding:
Diabetes Mellitus
Please have your physician review this letter and any enclosed documents as
soon as possible Your physician will need to provide the additional
information requested below as well as complete and sign page two of this
letter
I request that your physician provide:
1 Current treatment plan
2 Documentation regarding any episodes of hypoglycemia
3 Information regarding any hospitalizations for diabetes within the
last year
4 Evidence of good diabetic control, such as a recent hemoglobin A1c
level
5 Documentation of 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 Your medical exam status will remain as Pending
Further Evaluation until the requested information is received
Therefore,
please ensure that your physician faxes or mails the requested information
as soon as possible to:
Comprehensive Health Services, Inc
Attention: Interagency WLFF CSA
8229 Boone Blvd Suite 700
Vienna, VA 22182-2623
Fax: 703 288-5482
Sincerely,
Peggy Carlson, MD
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, and in
my opinion check one:
The individual is able to safely perform the essential functions of a
Wildland Firefighter
The individual is not 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 Interagency Wildland Firefighter Medical Qualification Standards
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 Human Resources Officer, or Agency
representative
For: _________________________
Social Security Number: xxx-xx-_____
01/08
———————–
THIS REPORT WILL NOT BE COMPLETE WITHOUT THIS INFORMATION
