Form 1 AmeriCorps NCCC Medical Form

Campus Code-Class -CM -TL

AmeriCorps NCCC Medical/Mental Health Information Form
Instructions: Complete ALL PAGES of this form and provide your signature upon completion. This
form must be returned to us no later than the date indicated on the accompanying materials.
Incomplete forms cannot be processed. To process the required medical clearance, additional
information may be required by the Medical Screening Nurse and/or Counselor.

ANSWER ALL QUESTIONS. Incomplete forms cannot be processed and may result in your removal from
further consideration for NCCC service.
Part I.
Name (Last, First, Middle)

Date of Birth (MM/DD/YYYY)

ft.
MyAmeriCorps Applicant ID #

Height

Email Address

Part II.

in.

Gender/Identifies as

lbs
Weight

Primary Contact phone number

Shoe Size

Alternate phone number

Answer YES or NO to all questions. All NO responses must show an explanation stating "N/A". All YES responses must
have explanation in the space provided or on a separate sheet, and should include dates, details of condition, treatment
received, and current status.

During the last FIVE YEARS, have you…?
A.

□ NO
□ YES
B.

□ NO
□ YES
C.

□ NO
□ YES
D.

□ NO
□ YES

Been treated in an Emergency Room? Please provide dates, condition treated, and current status if you were treated in
an ER. If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Been admitted to a hospital? Provide dates, reason for treatment, and current status if you were admitted.
If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Been treated for ANY behavioral health conditions or mental health conditions? This includes therapy, counseling, and
medications. If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Tested positive for skin test (PPD) or had a chest x-ray for tuberculosis? If NO, write "N/A"; if YES, explain and provide
proof of clear chest x-ray or completion of medication. (If not able to send with this form, proof can be sent via email or
fax at a later time.)
Date(s)

Updated 12/2016

Explanation

All Sides of This Form Must Be Completed

Page 1 of 4

Campus Code-Class -CM -TL

Medication List:
Please list all medications you are taking, including nonprescription drugs, vitamins, and herbal supplements.
Medication Name:

Part III.

Dose and How Often

When First Precribed and Reason for Taking:

Answer YES or NO to all questions. All NO responses must show an explanation stating "N/A". All YES responses must
have explanation in the space provided or on a separate sheet, and should include dates, details of condition, treatment
received, and current status.

Do you now have/have you ever had…?
E.

□ NO
□ YES
F.

□ NO
□ YES
G.

□ NO
□ YES
H.

□ NO
□ YES
I.

□ NO
□ YES

Diabetes diagnosis or treatment? If NO, write "N/A". If YES, explain (specify Type I or Type II, date of diagnosis, and
whether you have an insulin pump).
Date(s)

Explanation

Diagnosed or treated for any heart condition, disease, heart murmur, chest pain (angina), palpitations (irregular beat),
heart attack, heart surgery, angioplasty, or a pacemaker, valve replacement, or heart transplant? If NO, write "N/A". If
YES, explain.
Date(s)

Explanation

Asthma diagnosis or treatment? If NO, write "N/A". If YES, explain (specify how often you use your rescue inhaler, and
how often you use a nebulizer).
Date(s)

Explanation

Arthritis; impaired use of arms, legs, feet, or hands; hip/knee/joint pain; or any bone or joint condition? If NO, write
"N/A". If YES, explain.
Date(s)

Explanation

History of back injury or back surgery, or any limitations that prevent you from bending, twisting, lifting, or other
repetitive movements? If NO, write "N/A". If YES, explain.
Date(s)

Updated 12/2016

Explanation

All Sides of This Form Must Be Completed

Page 2 of 4

Campus Code-Class -CM -TL
J.

□ NO
□ YES
K.

□ NO
□ YES
L.

□ NO
□ YES
M.

□ NO
□ YES
N.

□ NO
□ YES
O.

□ NO
□ YES
P.

□ NO
□ YES
Q.

□ NO
□ YES
R.

□ NO
□ YES

Seizures, syncope, blackouts, or epilepsy? If NO, write "N/A". If YES, explain (specify the date of your last seizure,
episode, or blackout).
Date(s)

Explanation

Permanent loss of hearing, or need to wear hearing aids? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Permanent loss of vision or blindness in one or both eyes? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Life-threatening allergy? If NO, write "N/A". If YES, explain (and indicate whether you have an EPI pen).
Date(s)

Explanation

Diagnosis of attention deficit disorder, ADD/ADHD? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Autism, Asperger's, or a learning/processing disorder? Attach/ Explain IEP if applicable. If NO, write "N/A". If YES,
Date(s)

Explanation

Depression or anxiety? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Bulimia, Anorexia, or Eating disorder? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Bi-Polar, Schizophrenia, or Paranoia? If NO, write "N/A". If YES, explain.
Date(s)

Updated 12/2016

Explanation

All Sides of This Form Must Be Completed

Page 3 of 4

Campus Code-Class -CM -TL
S.

□ NO
□ YES
T.

□ NO
□ YES
U.

□ NO
□ YES
V.

□ NO
□ YES
W.

□ NO
□ YES

Self-mutilation or cutting? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Attempted Suicide? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Drug or Alcohol abuse, substance treatment, or counseling? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Significant medical/mental health conditions not listed above? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

Do you require an accomodation to serve in NCCC? If NO, write "N/A". If YES, explain.
Date(s)

Explanation

X.
Are you up-to-date on all immunizations
including the MMR and DTaP?

□ NO □ YES

If NO

Are you willing to receive these vaccinations upon
your arrival to campus?

□ NO □ YES

Part IV.
I understand it is my responsibility to notify the Medical Screening Division of any changes in this information prior to my arrival to
a campus, by phone (202-606-6702) or email ([email protected]).
I certify that the information disclosed in this document is true and complete to the best of my knowledge and belief. I understand
that if any of the information submitted in the document is false or is an intentional omission, it may be a basis for immediate
disqualification from the program.

Applicant Signature

Date Signed

This form must be signed in order to be complete. Unsigned forms cannot be processed.
PRIVACY ACT NOTICE: Information is requested pursuant to 42 U.S.C.§12615(b). Purpose is to determine whether the medical/mental health history and
identifiable health risks of individual members will allow them to perform the essential functions of AmeriCorps NCCC participants with or without reasonable
accommodation. Because AmeriCorps NCCC operates a residential program that requires members to engage in activities with varying requirements, it is
important to know the medical/mental health history of the individual and whether they are qualified to perform the essential functions of an AmeriCorps
NCCC member. Information is confidential, for official use only, and will only be released to personnel on a need-to-know basis. Disclosure of this information
is voluntary, yet failure to submit this completed form may result in the individual's disqualification from further processing.

Updated 12/2016

All Sides of This Form Must Be Completed

Page 4 of 4