Form PC-262-11 Pap Screening Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

PAP Screening Form

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

(Mo/Day/Year)

PAP SCREENING FORM (FOR FEMALE APPLICANTS)
Note to applicant: Please obtain the following screening test. A routine Pap screening exam may not be offered during your Peace Corps service.
You must receive a Pap screening test within four months of your date of departure, even if you have had one within the past 12 months.
h PAP EXAM: My Pap results are attached. (The Peace Corps must receive the actual cytology report. A physician documenting the results,
but not submitting the laboratory report, will result in an incomplete physical exam).

Frequently Asked Question
What if I have a condition that requires a Pap exam while in service? Can I receive the test?
Yes. Volunteers who need a Pap exam to monitor a health condition will be provided a Pap screening test during service.

Peace Corps · PAP Screening Form

(Initial approval 08/2012)

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