Form PC-262-3 Diabetes Diagnosis Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

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

Diabetes Diagnosis Form
OMB No.: 0420-0550
Expiration Date: 1/31/2014

(Mo/Day/Year)

DIABETES DIAGNOSIS FORM
The individual listed above has applied to serve as a Peace Corps Volunteer and has reported having Diabetes Type 1 or Type 2.
This form must be completed by the Health Care Provider (MD or DO) who provides or provided medical oversight and
management of this condition.
Note to the Provider: Please be candid when answering the questions below, and consider that there are many assignments
where the Volunteer may be isolated or exposed to violence and crime, extreme poverty, or inequitable treatment. Walking
long distances on rough terrain and use of squat toilets is not uncommon. There may also be limited access to western-trained
medical professionals. There are many assignments where the Volunteer will need considerable flexibility and physical endurance
to adapt to unpredictable housing conditions, extreme changes in climate, and unreliable transportation and to exhibit the
need for heightened awareness of personal safety and increased attention to safe food and drinking water. The most accurate
medical representation of this condition is critical for the Peace Corps to make appropriate medical decisions for qualification
and placement. 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 · Diabetes Diagnosis Form

PC-262-3 (Revised 10/2012)

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Medical Case Number:

Diabetes diagnosis: □ Type 1 □ Type 2
Date of diagnosis: _ _____________________________________________________________________________________________________________________________________________________________________________
Etiology: _____________________________________________________________________________________________________________________________________________________________________________________________
List any associated medical conditions or complications associated with this condition: □ N/A
(Include any conditions, such as neuropathy, ophthalmology conditions or other problems, such as altered kidney function) Any
other body involvement will require an evaluation by a specialist for that body system. _ ______________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Date condition stabilized with normal blood sugars: ________________________________________________________________________________________________________________________
□ This condition is not yet stable and still requires ongoing monitoring and adjustments. Describe:____________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
This person uses an insulin pump to manage his/her condition □ No □ Yes
Name and model of insulin pump: _ ___________________________________________________________________________________________________________________________________________________
Expected date that insulin pump will need to be replaced or serviced: _ ________________________________________________________________________________________
(If yes, applicant must complete the information in the box below)
Please note that, if you are cleared for Peace Corps service, you will be responsible for bringing an insulin pump, and
ensuring that the pump can last throughout the entire length of Peace Corps service.
Candidate Signature: I understand that I will need to bring an insulin pump that is expected to last throughout my Peace
Corps service. ____________________________________________________________________________________________________________________________________________________________________________
The provider should complete the sections below:
Document this patient’s understanding of the disease and demonstrated ability to monitor and care for himself/herself
independently in an overseas environment:______________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Document the patient’s current cardiac status. If the patient is 40 or older, include a current EKG tracing with a detailed
interpretation:_____________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Document the current peripheral-vascular status:____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Peace Corps · Diabetes Diagnosis Form

PC-262-3 (Revised 10/2012)

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Medical Case Number:

List ALL of the signs and symptoms that have occurred in the past two years: (include episodes of high/low blood sugar that
required a medical intervention or involved a change in consciousness)
Signs and Symptoms

Was this life Severity_
threatening? (check one)

Frequency (check one)

Date of last
occurrence

Ongoing?

h Y_
hN

h Mild_
h Daily_
h Moderate_ h once or more a week_
h Severe
h once or more a month_
h Very rarely

hY_
h N

h Y_
hN

h Mild_
h Daily_
h Moderate_ h once or more a week_
h Severe
h once or more a month_
h Very rarely

hY_
h N

h Y_
hN

h Mild_
h Daily_
h Moderate_ h once or more a week_
h Severe
h once or more a month_
h Very rarely

h Y_
hN

List all medications prescribed in the last two years for this condition, either daily or as needed: It is important we know all
medications and changes, especially medication or dosage changes in the last six months.
Medication (name)

Start Date Stop Date Ongoing? Strength Dose

Frequency

List all laboratory or radiologic testing done in the past 12 months* that specific to this condition (Please attach all results):_____
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
*If no laboratory or radiologic testing has been done in the past 12 months, please provide appropriate baseline testing results
that would demonstrate to the Peace Corps medical officer the current medical baseline for this applicant. These should
have been completed within the past three months:
-FBS
-BUN
-Creatinine
-Urinalysis
-Glycohemoglobin (HgA1C) on two measurements at least two months apart
Are there any functional limitations or restrictions due to this condition?
h NO h YES
If “Yes” please describe the limitations or restrictions:_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Diabetes Diagnosis Form

PC-262-3 (Revised 10/2012)

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Medical Case Number:

What specific recommendations do you have for the management for this condition over the next three years?_
All recommendations will help determine the appropriate Volunteer placement and worksite. ____________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any concerns that would prevent this applicant from completing 27 months of Peace Corps service without disruption
due to diabetes? NOTE: Peace Corps service may be in areas that are isolated or have limited access to Western-trained
providers and health care systems. Please check one box below.
h I have no concerns. This applicant, with regard to diabetes, is healthy enough to complete 27 months of uninterrupted Peace
Corps service provided the above recommendations can be accommodated.
h I am unsure that this applicant can complete 27 months of uninterrupted service due to diabetes. I recommend a period
of stabilization for this condition and an updated assessment at a later date. (Describe and include length of time for
stabilization)__________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

h I do not believe that this applicant can complete 27 months of Peace Corps service without disruption due to diabetes.
I certify this information is, in my opinion, an accurate representation of the baseline status of diabetes for the applicant listed
above.
Physician Signature/Title (MD or DO)_______________________________________________________________________________________________________________________________________________
Physician Name (Print)________________________________________________________________________________________________________________________________________________________________________
Date__________________________ Physician License Number/State___________________________________________________________________________________________________________________
Physician Address_______________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Diabetes Diagnosis Form

PC-262-3 (Revised 10/2012)

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