Form PC-262-11 Pap Screening Form

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

PAP SCREENING FORM (FOR FEMALE APPLICANTS)

Note to applicant: Please obtain the following screening test. A routine Pap screening exam may not be offered during your Peace Corps service. You must receive a Pap screening test within four months of your date of departure, even if you have had one within the past 12 months.

❒ PAP EXAM: My Pap results are attached. (The Peace Corps must receive the actual cytology report. A physician documenting the results, but not submitting the laboratory report, will result in an incomplete physical exam).

Frequently Asked Question

What if I have a condition that requires a Pap exam while in service? Can I receive the test?

Yes. Volunteers who need a Pap exam to monitor a health condition will be provided a Pap screening test during service.

Privacy Act Notice

This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to provide this information will result in the rejection of your application to become a Peace Corps Volunteer.

This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed in the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.

Burden Statement:

Public reporting burden for this collection of information is estimated to average 25 minutes per applicant and 15 minutes per physician 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-262-11 (rev. 2/22/2012)