Form PC-262-10 Insulin Depended Diabetic Supplemental Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

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

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

(Mo/Day/Year)

DISEASE DIAGNOSIS EVALUATION FORM
Note to the Peace Corps Candidate: You have informed Peace Corps that you have the diagnosis of Diabetes. Please be
candid when responding to the requests below. Answer all the questions completely. There are many assignments where the
Volunteer will need considerable flexibility and physical endurance to adapt to unpredictable housing conditions, extremes of
climate, unreliable transportation, the need for heightened awareness of personal safety, and increased attention to safe food
and drinking water. Walking long distances on rough terrain and use of squat toilets is not uncommon. During Peace Corps
service there may be limited access to Western trained health professionals. Medical care and resources compared to US health
care standards are limited and, in the case of specialty physicians, is mostly non-existent. The most accurate representation of
this condition is critical in order for the Peace Corps to make appropriate medical decisions for qualification and placement.
Please send us a record of the most recent 6 weeks of glucose monitoring test results.
Please write a detailed statement of your understanding of your disease. Include a plan for monitoring your blood sugar
and medication (s), a foot care program, maintenance of nutritional needs and status, and how you plan to handle diabetic
emergencies in an overseas environment.
*Please note that if cleared for Peace Corps service with an Insulin pump, you will be responsible for bringing an Insulin
pump that should last throughout your tour of duty, without the need for replacement.

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 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 ·Candidate.Diabetes

PC-262-5 (Initial approval 08/2012)

Page 1 of 3

Medical Case Number:

Please meet with your treating specialist to discuss and complete the enclosed document and have them provide specific
recommendations for the optimal management of your diabetes in the Peace Corps environment. Submit this documentation
within two to four weeks after your acceptance of a formal invitation to serve.

Insulin Dependent Diabetic Supplemental Documentation
Dear Provider:
Your patient has been provisionally medically qualified for Peace Corps service. Peace Corps is committed to maintaining the
good health of all its Volunteers. We are certain that your care of this Peace Corps Applicant has been competent and we
recognize that many, if not all, of the issues we are asking you to discuss with the Applicant have likely been addressed in the
past. Regardless, every Applicant with diabetes is unique and he/she will be facing a very dramatic change in living conditions,
diet and level of physical activity. We ask you to review the issues below with your patient and provide Peace Corps with your
written recommendations.
Thank you,
Office of Volunteer Support
U.S. Peace Corps
□ I have recently discussed recommendations with this Applicant regarding insulin strategies to be used when adjusting to a
new diet. (Since hypoglycemia is much more threatening in the short term than mild loss of glycemic control, please consider
that the Applicant be instructed to temporarily reduce his/her sliding scale dosing until a better understanding of the local
diet is achieved.) Recommendations:__________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

□ I have recently discussed recommendations with this Applicant regarding insulin strategies be used during a “sick day,”
particularly those days when, due to gastrointestinal symptoms there is decreased oral intake and a potential for increased
fluid losses. Recommendations:

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Med.Candidate.Diabetes

PC-262-5 (Initial approval 08/2012)

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Medical Case Number:

□ (For Applicants on Continuous Subcutaneous Insulin Infusion) I have recently discussed recommendations with this Applicant
regarding switching to a Multiple daily injection (MDI) regimen in the event of a pump failure. Recommendations:

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

_ _____________________________________________________________________________________________________________________________________________________________________________________________________

□ I have recently discussed recommendations with this Applicant regarding proper care and maintenance of all of his/her
diabetes related monitors and equipment. Below is a list of those devices and necessary disposables:
Device/Disposables

Manufacturer/Model Number

Provider Signature______________________________________________________________________________________________________________________________________________________________________________
Provider Name____________________________________________________________________________________________________________________________________________________________________________________
Address_______________________________________________________________________________________________________________________________________________________________________________________________
Telephone___________________________________________________________________________________________________________________________________________________________________________________________
Email____________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Med.Candidate.Diabetes

PC-262-5 (Initial approval 08/2012)

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