Form FS-1800-3 YCC Medical History

USDA Forest Service FS-1800-3 (v 05/2013)

OMB No. 0596-0084

Expires XX/XX/201X

Y outh Conservation Corps Medical History FSM 1840 To be completed by YCC selected participants only

NOTE: The collection of this information is authorized by Public Law 93-408. The purpose of this data is to safeguard the health, safety and welfare of the enrollees of the YCC programs and may be provided to a physician in the event medical treatment is necessary. This information is requested on a voluntary basis; however, failure to complete this form may result in exclusion from the program.

Part I - To be completed by applicant

Name (Last, First, Middle Initial)      

Address (Street, City, State, including Zip Code)      

Date of birth (mm/dd/yyyy)      

Do you have health and accident insurance? Yes If yes, list name of insurer No

Insured by       policy number      

Primary Care Physician name       Address      

Physician phone number (     )     -    

Have you had or are you having any of the following health conditions? Enter x where appropriate and describe on back or check here if attached as a separate document

Allergies Hay fever Asthma Poison ivy or oak Insects stings Skin condition Other (Identify)      

Frequent infections Cold Sore throat Ear ache Bladder or intestinal infection Other (Identify)      

Other health conditions Chest pains Convulsions Diabetic Difficulty with balance Fainting Heart condition Hernia

Rheumatism or arthritis Loss of weight Lyme disease Mental health condition Persistent cough Problem with blood not clotting

Shortness of breath Sleepwalking Swollen or painful joints Ulcers Other(Identify)      

Are you currently taking any medication?

Yes- if yes, explain on back or check here if attached

No

Are you allergic to any medications?

Yes- if yes, explain on back or check here if attached

No

Immunization history- Enter X where appropriate and dates as indicated. A Tetanus and Diptheria shot is required unless you have received one or a booster within the last ten years. You may attach your immunization record as a separate document. Check here if immunization records are attached as a separate document.

Date of original series (mm/dd/yyy)

Date of Last Booster to ensure Immunization (mm/dd/yyy)

Tetanus Toxoid, Diptheria, Pertussis (Tdap)

     

     

Polio Vaccine (IPV)

     

     

Measles, Mumps, Rubella (MMR)

     

     

Meningococcal Conjugate Vaccine (MCV)

     

     

To my knowledge, I have not been exposed to a contagious or infectious disease in the past three weeks, and I am in a state of health which would allow full participation in all YCC activities.

Signature (Read the statement above before signing)

Date (mm/dd/yyyy)      

Part II - To be completed by parent or guardian of the applicant
This is to certify that I am familiar with the Youth Conservation Corps (YCC)and that I give my consent to my son/daughter/ward to participate with the program as a YCC member. I understand that I will not hold the United States Government responsible for any nonprogram accident or illness, and I authorize first aid, or emergency medical care, to be performed at the nearest, most adequate facility approved by the YCC program staff.
Emergency contact (Name and Relationship)      				Home Phone (     )     -    			Work Phone (     )     -    
Address (Street, City, State and Zip Code)      				Alternate or prefered form of contact i.e. email, text, alternate phone, etc. (optional)      
Signature (Parent or Guardian)							Date (mm/dd/yyyyy)      
Identify in remarks block any condition that would restrict full participation and describe any special care or treatment that may be required.
Basic functional requirements for outdoor work
Heavy lifting, 45 pounds and over Heavy carrying, 45 pounds and over Straight pulling Pulling hand over hand Pushing Reaching above shoulder		Use of fingers Both hands required Walking Standing Crawling Kneeling	Repeated bending Climbing, legs only Climbing, use of legs and arms Both legs required Far vision correctable in one eye to 20/20 and to 20/40 in the other Hearing (aid permited)
Environmental factors
Outside Excessive heat Excessive Cold Excessive humidity Excessive dampness or chilling	Dry atmospheric conditions Excessive noise, intermittent Dust Slippery or uneven walking surfaces Working around moving objects or vehicles				Working on ladders or scaffolding Working with hands in water Working closely with others Working alone
REMARKS (Enter information regarding any prescribed medication, reactions to penicillin or any drugs and/or any other health problems of which we should be made aware.)      
PRIVACY ACT STATEMENT FOR THE YCC MEDICAL HISTORY (FS-1800-3) 10/94 The following information is provided to comply with the Privacy Act of 1974 (PL-579). 5 U.S.c. 301 and 7 CFR 260 authorize acceptance of the information requested on this form. Collecting this information is necessary to assist the agency in safeguarding the health, safety, and welfare of the enrollees of the YCC programs and may be provided to a physician in the event medical treament is necessary. This information is requested on a voluntary basis, failure to complete this form will result in exclusion from the program. Privacy Act System of Records USDA/FS-27 Enrollee Medical Records covers the collection and storage of, and access to these records.
Burden Statement According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0084. The time required to complete this information collection is estimated to average 14 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
FS Reviewing officer's signature						Date (mm/dd/yyyy)      

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