Form TG-355-2 Mammogram Form

OMB Control No. 0420-xxxx Expiration Date xx/xx/xxxx Peace Corps

MAMMOGRAM FORM

___________________________________________________________________________

IMPORTANT INFORMATION ON MAMMOGRAM SCREENINGS

PLEASE COMPLETE THIS FORM AND RETURN IT

WITH YOUR REPORT OF PHYSICAL EXAMINATION

United States Preventive Services Task Force guidelines recommend that women 50 years of age and older receive regular, comprehensive screening for breast cancer, including a mammography every two years. The Peace Corps strongly supports these recommendations and can provide screening mammography at some but not all of its overseas posts.

After discussing mammogram screenings with your physician, please choose one of the two options outlined below under Instructions to Peace Corps Applicant.

Instructions to the Physician:

Please read the above statement and discuss it with your patient. Please check all of the following that apply, and sign.

• I have discussed with the above-named person the consensus medical opinion that regular, comprehensive screening for breast cancer, including screening mammography every one to two years, is medically indicated for her age group. I concur with the Peace Corps Office of Medical Services and recommend that she serve in a country where she can receive a routine screening mammogram.

• I have reviewed and assisted in the completion of the Mammogram Health Assessment Questionnaire with the above-named person.

• I have discussed with the above-named person that foregoing a routine screening mammogram for more than two years may increase her risk of delayed diagnosis of breast cancer, which could cause adverse health consequences, including death.

______________________ _______________________ _____________

(Physician Printed Name) (Physician Signed Name) (Date)

Instructions to Peace Corps Applicant: Please check one of the following and sign.

• I have attached the radiology report from my latest mammogram, along with my doctor’s interpretation of the results. After discussing these matters with my doctor, I have decided that I wish to receive a routine screening mammogram during my 27 months of Peace Corps service.

• I have attached the radiology report from my latest mammogram, along with my doctor’s interpretation of the results. After discussing these matters with my doctor, I have decided that I do not wish to receive a routine screening mammogram during my 27 months of Volunteer service. (You must complete the attached Mammogram Health Assessment Questionnaire. Depending on that information and your mammogram report, you may be placed in a country where mammograms are available.)

________________________ ________________________ ____________

(Applicant Printed Name) (Applicant Signed Name) (Date)

Mammogram Health Assessment Questionnaire

The questions below must be answered in order to make a general assessment of your statistical breast cancer risk. These questions can be answered by you and do not require additional medical tests or physician visits.

If you do not know the answer, you may consult with your physician or simply respond “no” to questions that require a “yes” or “no” answer.

Yes 	No 	Do you have a personal history of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS)?
		In order to estimate your cancer risk:
____years		At what age did you begin to have your menstrual periods?
____ years	N/A 	At what age, if applicable, did you have your first child?
#_______	N/A 	How many first-degree relatives (parent, sibling, child) have had breast cancer?
Yes 	No 	Have you ever had a breast biopsy?
#_______	N/A 	How many breast biopsies have you had (positive or negative)?
Yes 	No  N/A 	Have any of the biopsies shown atypical hyperplasia (check with your doctor if necessary)?
OPTIONAL		Understanding that race and ethnicity factor into the estimation of breast cancer risk, what is your race/ethnicity? (check all that apply)
		White
		African American
		Hispanic
		Asian, Pacific Islander, or Native Hawaiian
		American Indian or Alaskan Native
		Unknown
		Prefer not to answer

Frequently Asked Questions

What if I have a condition that requires a Mammogram while in service?

Volunteers with a condition that requires a Mammogram exam will be provided a Mammogram while in service.

Do I need to send in the actual films to the Peace Corps as part of the medical evaluation screening process?

No. Please do not send the actual films. The Peace Corps only needs a copy of the Mammogram radiology report and your doctor’s interpretation of the results.

Do I need to bring my films with me to my country of service?

Yes, bring your most recent Mammogram films with you. Should you need another Mammogram, or receive a screening exam while in service, the films serve as your baseline. It is your responsibility to bring these films with you.

I cannot remember if I said I wanted a routine screening test when I completed the Health History form at the time of my application. How can I find out?

Please send a message with this question to your nurse through your Medical Applicant Portal.

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