Form PC-262-2 Asthma Evaluation Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

Asthma Evaluation Form
OMB No.: 0420-0550
Expiration Date: 1/31/2014

(Mo/Day/Year)

ASTHMA EVALUATION FORM
The individual listed above has applied to serve as a Peace Corps Volunteer and has reported having Asthma. This form must
be completed by the Health Care Provider (MD or DO as required by State law) who provides, or provided, medical oversight
and management of this health condition.
Note to the Provider: Please be candid when answering the questions below. During Peace Corps service, a Volunteer may be
placed in a site that requires flexibility and physical endurance to adapt to unpredictable housing conditions, climate extremes,
and unreliable transportation and to exhibit a heightened awareness for personal safety and increased attention to safe food
and drinking water. Walking long distances on rough terrain is not uncommon. There may also be limited access to Westerntrained health professionals and medical care. The most accurate representation of this condition is critical for the Peace Corps
to make appropriate decisions for placement of the Volunteer. Please answer all questions or the form will be considered
incomplete and returned to the applicant.

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 of 75 minutes per applicant and 30 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 20th Street, NW, Washington, DC
20526, ATTN: PRA (0420 - 0550). Do not return the completed form to this address.

Peace Corps · Asthma Evaluation Form

PC-262-2 (Initial approval 08/2012)

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Medical Case Number:

I. Symptoms:
□ Wheezing

□ Cough

□ Shortness of breath

□ Chest tightness

□ Increased sputum

□ Exertional fatigue

□ Other:_____________________________________________________________________________________________________________________________________________________________________________________________
Date the patient first experienced symptoms: _____________________ Date of most recent symptoms:________________________________________________________
To what degree do these symptoms interfere with activity level or work?
□ None

□ Seldom

□ Frequently

Explanation of above:_________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

II. Indicators of Control:
Has this applicant experienced any of the following within the past five years?
□ Yes □ No

Nocturnal awakenings

Explanation__________________________________________________________________________

□ Yes □ No

Increased need of short-acting beta2-agonists

Explanation__________________________________________________________________________

□ Yes □ No

Urgent care/ER visits

Explanation__________________________________________________________________________

□ Yes □ No

Life-threatening exacerbations

Explanation__________________________________________________________________________

(attach discharge summary)
Smoking history: ________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

III. Provocative Factors (triggers):
□ Exercise

□ House dust-mites

□ Foods

□ OTHER:___________________________________________________________________________

□ Animal dander

□ Mold

□ Weather

Please provide details for each factor checked:_________________

□ Menses

□ Viral infection

□ Pollen

_ ____________________________________________________________________________________________

□ Emotional stress

□ Smoke (tobacco/wood)

_ ____________________________________________________________________________________________

IV. Classification (please check one of the following categories):
□ Bronchospasm

□ Exercise-Induced Asthma □ Asthma

If this applicant is classified as having Asthma, please indicate the level of severity:_______________________________________________________________________
Classification of Asthma Severity*
Check Which Level
of Severity Applies

Level of Severity

Days w/Sxs

Nights w/Sxs

FEV1

PEF variability

□

Mild Intermittent

<2/wk

<2/mo

>80%

<20%

□

Mild Persistent

3-6/wk

3-4/mo

>80%

20-30%

□

Moderate Persistent

daily

>5/mo

>60%- <80%

>30%

□

Severe Persistent

continual

frequent

<60%

>30%

*National Asthma Education Program, Expert Panel Report “Guidelines for the Diagnosis and Management of Asthma,” NIH
publication No. 98-4051. 7/97

Peace Corps · Asthma Evaluation Form

PC-262-2 (Initial approval 08/2012)

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Medical Case Number:

V. Treatment within the past five years (please complete table below):
Name of Medication

Dose

Date(s) Started Date(s)Finished # of doses per/mo

Over-the-counter inhalers, e,g. Primatene Mist
Short Acting Beta2 Agonists – inhalers, e.g.,
Proventil, Ventolin, Maxair
Long Acting Beta2 Agonists – inhalers, e.g.,
Serevent
Corticosteroids – inhalers, e.g., Azmacort,
Flovent, Vanceril
Corticosteroids – oral/injectable, e.g.,
Cortisone, Prednisone
Nebulized inhalers, e.g., Provental, Atrovent,
Intal
Non-Steroidal Anti-Inflammatory Agents –
inhalers, e.g.,Tilade, Intal
Methylxanthines – oral, e.g., Theophylline
Leukotriene modifiers, e.g., Accolate, Singulair
Immunotherapy (allergy shots)
Other
Has the applicant ever experienced a more severe form of Asthma? □ Yes □ No
If yes, when?_______________________________________________________________________________________________________________________________________________________________________________________
Please describe the optimal asthma management plan for this patient (if different from above regimen):____________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

VI. Patient Management:
Does the applicant have a good understanding of his/her respiratory condition?
□ Yes □ No Explanation:____________________________________________________________________________________________________________________________________________________
Can the applicant self-manage daily medications and exacerbations?
□ Yes □ No Explanation:____________________________________________________________________________________________________________________________________________________
Does this applicant own and know how to use a Peak Flow Meter?
□ Yes □ No Explanation:____________________________________________________________________________________________________________________________________________________
Does the applicant have any functional limitations or restrictions due to this condition?
□ Yes □ No
If “Yes” is marked, describe limitations or restrictions:_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Asthma Evaluation Form

PC-262-2 (Initial approval 08/2012)

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Medical Case Number:

What specific recommendations for medical care do you have regarding the management for this condition over the next three
years? All recommendations will help determine the Volunteer’s country and site placement____________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any concerns that would prevent this applicant from completing 27 months of Peace Corps service without disruption
because of the applicant’s respiratory condition? NOTE: Peace Corps Volunteers may serve in isolated areas or areas with
limited access to Western-trained health care providers and systems. Please check one box below.
□ I have no concerns. This applicant, with regard to Asthma, is healthy enough to complete 27 months of uninterrupted Peace
Corps service provided the above recommendations for asthma can be accommodated.
□ I am unsure that this applicant can complete 27 months of uninterrupted Peace Corps service due to Asthma. I recommend
a period of stabilization for this condition and an updated assessment at a future date. Describe and include the length of
time for stabilization: ___________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

□ I do not believe this applicant can complete 27 months of Peace Corps service without undue disruption due to Asthma.
I certify this information is, in my opinion, an accurate representation of the baseline status of Asthma for the applicant listed
above.
Physician Signature/Title (MD or DO as required by state law)________________________________________________________________________________________________________
Physician Name (Print)________________________________________________________________________________________________________________________________________________________________________
Date_______________________________Physician License Number/State______________________________________________________________________________________________________________
Physician Address_______________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Asthma Evaluation Form

PC-262-2 (Initial approval 08/2012)

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