Form PC-262-1 Allergy Treatment Form

OMB Control No. 0420-xxx

Expiration Date xx/xx/xxxx

Peace Corps

ALLERGY TREATMENT FORM

Note to the Peace Corps Applicant: You have indicated that you are currently receiving allergy shots. The Peace Corps is not able to arrange for Volunteers to receive allergy shots during their Peace Corps service. Peace Corps Volunteers generally serve in areas that are isolated and have limited access to Western-trained providers and health care systems.

Before answering the following questions, please discuss with your allergist whether you will be able to live overseas for 27 months of Peace Corps service without receiving allergy shots.

Date allergy shots began: _____________________________________________________

I have discussed stopping allergy shots with my physician, who agrees that the allergy shots can be stopped without unreasonable risk of substantial harm to my health.*

I understand that, should I subsequently require allergy shots in order to avoid unreasonable risk of substantial harm to my health, I may no longer be allowed to serve in the Peace Corps.*

*Both boxes above must be checked and both the Physician and Applicant must sign below.

I certify the information above with regard to allergy shot treatment is complete and accurate.

Applicant Name/Signature

I certify this information with regards to allergy shot treatment is complete and accurate for the applicant listed above.

Physician Signature/Title (MD or DO as required by state law)

Physician Name (Print)

Date Physician License Number/State

Physician Address

Burden Statement:

Public reporting burden for this collection of information is estimated to average 10 minutes per applicant and 20 minutes per mental health professional per response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20^th Street, NW, Washington, DC 20526 ATTN: PRA (0420 - ####). Do not return the completed form to this address.

PC-262-1 (rev. 02/22/2011)