Form PC-262-7 ECG Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

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

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

(Mo/Day/Year)

ECG FORM
Please obtain the following screening test or submit the results of an ECG done within the past year.
Note to applicant: The ECG results need to be scanned and uploaded to your applicant health portal. If you mail or fax the
results, please use a photocopy of the original ECG.
h ECG (My ECG results are attached.) The actual tracing and the signed interpretation, including the physician’s signature
confirming the interpretation of the ECG, must be attached. A physician’s interpretation of the results is not sufficient
and will result in an incomplete physical exam.

Frequently Asked Question
What is the tracing? I don’t know how that is different than the interpretation.
A tracing is the paper that shows the electrical activity of your heart, and is usually printed from the ECG machine at the time
of the test. A physician will review the tracing and interpret the results. Sometimes this is written on the tracing itself, and
sometimes it is written on another part of your medical record. We need to see BOTH the tracing and the interpretation.
Can I send the results via U.S. Mail?
No. Mailed ECG tracings that have been mailed arrive and look like a black sheet of paper. This is due to government processing
of mail using anthrax detection methods. You have to copy and fax the results, or scan and upload to your Medical Applicant
Portal (MAP).

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 25 minutes per applicant and 15 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 · ECG Form

PC-262-7 (Initial approval 08/2012)

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