Form PC-262-9 Colon Cancer Screening Form

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

COLON CANCER SCREENING FORM

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 an hour and 15 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-262-9 (rev. 2/22/2012)

Please check only one box below. Please note, if your most recent colon cancer screening test was abnormal, you will need to complete all recommended follow-up to continue with the medical clearance process.

I have had:

C olonoscopy test within 10 years, which required no follow-up testing and I am submitting the results.

F ecal Occult Blood test x 3 within one year, which required no follow-up testing and I am submitting the results.

F lexible Sigmoidoscopy test within five years; which required no follow-up testing and I am submitting the results.

D ouble Contrast Barium Enema test within five years, which required no follow-up testing and I am submitting the results.

C olonography “Virtual Colonoscopy” test within five years, which required no follow-up testing and I am submitting the results.

Stool for DNA testing within one year, which required no follow-up testing and I am submitting the results.

Frequently Asked Question:

My most recent result was abnormal. What do I do?

If your most recent test was abnormal, please meet with your physician and submit a copy of the report and your physician’s recommendation for follow-up treatment.

After your pre-service nurse reviews the abnormal result, it is possible you will not pass the medical clearance. However, after you have completed any follow-up testing needed and have received a normal result, you may re-apply for Peace Corps service. You will need to complete a new application and Health History Form at that time.