FS-1800-3 Youth Conservation Corps Medical History

Youth Conservation Corps Application and Medical History

FS_1800_3 v05-20-2013

Youth Conservation Corps (YCC)- Forest Service

OMB: 0596-0084

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

OMB No. 0596-0084

Expires XX/XX/201X

Picture 2

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

  1. Heavy lifting, 45 pounds and over

  2. Heavy carrying, 45 pounds and over

  3. Straight pulling

  4. Pulling hand over hand

  5. Pushing

  6. Reaching above shoulder

  1. Use of fingers

  2. Both hands required

  3. Walking

  4. Standing

  5. Crawling

  6. Kneeling

  1. Repeated bending

  2. Climbing, legs only

  3. Climbing, use of legs and arms

  4. Both legs required

  5. Far vision correctable in one eye to 20/20 and to 20/40 in the other

  6. Hearing (aid permited)

Environmental factors

  1. Outside

  2. Excessive heat

  3. Excessive Cold

  4. Excessive humidity

  5. Excessive dampness or chilling

  1. Dry atmospheric conditions

  2. Excessive noise, intermittent

  3. Dust

  4. Slippery or uneven walking surfaces

  5. Working around moving objects or vehicles

  1. Working on ladders or scaffolding

  2. Working with hands in water

  3. Working closely with others

  4. 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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