Form PC-262-6 Alcohol/Substance Abuse Current Evaluation Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

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

(Mo/Day/Year)

Alcohol/Substance Abuse
Current Evaluation Form
OMB No.: 0420-0550
Expiration Date: 1/31/2014

Alcohol/Substance Abuse Current Evaluation Form
(Confidential)

The individual listed below has applied to be a Peace Corps Volunteer and has reported a history of alcohol or substance abuse.
Note to the Health Care Professional: Please be candid when answering the questions below. During Peace Corps service,
a Volunteer may be placed in a site that requires flexibility to adapt to unpredictable housing conditions, extremes in climate
and unreliable transportation and to exhibit a heightened awareness for personal safety and increased attention to safe food
and drinking water. There may also be limited access to Western-trained mental health professionals, addiction counselors,
and medical care. Regular Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings and resources are likely not be
available. The most accurate representation of this condition is critical for the Peace Corps to make appropriate decisions for
placement of the Volunteer. 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 4 hours and 25 minutes per applicant and 3 hours per substance abuse professional
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 · Alcohol/Substance Abuse Current Evaluation Form

PC-262-6 (Initial approval 08/2012)

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Medical Case Number:

Please provide the following information based on reported history of the applicant, as well as your current assessment.  Please
be as detailed as possible and respond to all questions.
Applicant Name:_________________________________________________________________________________________________________________________________________________________________________________
Therapist’s Name:_______________________________________________________________________________________________________ Date:______________________________________________________
Professional Degree:________________________________________________________________________________________ License No.:______________________________________________________
State:_____________________ Certified Substance Abuse Counselor h Yes □ No
Address: _____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Tel: ____________________________________________ Date of evaluation sessions:________________________________________________________________________________________________________

Have you received alcohol and/or substance abuse reports for this applicant?  h Yes □ No
(Where applicable, please have the applicant include information about arrests or other disciplinary actions due to alcohol or
drug use.)
Alcohol/Substance Abuse Assessment Tools Administered
h N/A None administered
h AUDIT tool http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf
h Other (please list):_________________________________________________________________________________________________________________________________________________________________________

A. Mental Health Diagnoses: (DSM IV Codes)
Mental Health Diagnoses (DSM IV codes)

Date Given

Date Resolved

Status

Axis I:

□ Resolved_
□ Current

Axis II:

□ Resolved_
□ Current

Axis III:

□ Resolved_
□ Current

B.  Psychotropic Medication Regimen:
Medication and Dosage:_____________________________________________________________________________________________________________________________________________________________________
Start Date: __________________________  End Date: _____________or h Current
Response to Medication:____________________________________________________________________________________________________________________________________________________________________
Medication and Dosage:_____________________________________________________________________________________________________________________________________________________________________
Start Date: __________________________  End Date: _____________ or h Current
Response to Medication:____________________________________________________________________________________________________________________________________________________________________

Peace Corps · Alcohol/Substance Abuse Current Evaluation Form

PC-262-6 (Initial approval 08/2012)

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Medical Case Number:

C.  Self Harm Behavior:
Check one

□ N/A Never
Describe

DD/MM/YY

Status

h Suicide ideation
h Suicide attempt or gesture
h Other self harm behavior □ Check if alcohol/drugs were involved

□ Resolved_
□ Current

h Suicide ideation
h Suicide attempt or gesture
h Other self harm behavior □ Check if alcohol/drugs were involved

□ Resolved_
□ Current

D. History of Alcohol/Substance Abuse
* “Yes” Requires Comment

Comments

At what age did the applicant ____________Years
begin drinking?
Was the frequency and
extent considered abusive?

□ Yes_
□ No

*Report frequency and extent

History of blackouts?

□ Yes_

* Include dates and circumstances □ No

History of negative social
repercussions related to
alcohol/drug abuse?

□ Yes_
□ No

*Provide dates and circumstances

History of physical problems
related to alcohol/drug
abuse?

□ Yes_
□ No

* Include dates, diagnosis, and
treatment

History of alcohol/substance □ Yes_
abuse treatment?
□ No
*Include dates, circumstances,
and treatment

Does applicant rely on AA/
NA meetings for sobriety or
abstinence?

□ Yes_
□ No

*If yes, what is the longest length
of time the applicant has gone
without a meeting and what was
the result.

Peace Corps · Alcohol/Substance Abuse Current Evaluation Form

PC-262-6 (Initial approval 08/2012)

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Medical Case Number:

E.  Current Clinical Assessment of Alcohol/Substance Use
Current Assessment of Use

Comments

Is the applicant currently _
sober/abstinent?

□ Yes_
□ No

If yes, include the length of _
sobriety/abstinence

____________Months ____________Years

What is the applicant’s current □ NA no plan, individual is not sober and/or still using drugs.
sobriety plan?
□ Describe plan:

Does the applicant rely on AA/NA □ Yes Attends ____________ meetings each _____________
to maintain sobriety or abstinence? □ No
Please comment on the average
number of meetings/week, month
If the above answer is yes, what is
the longest time applicant has gone
without a meeting and what was
the result of that?
What is the applicant’s current
alcohol/substance use? Please
comment on amount and
frequency

□ NA currently sober/abstinent

Current Functional Assessment*

Comments

* Peace Corps service is characterized by isolation, lack of structure, and limited social supports. The ability to access_
AA/NA is unlikely. Please keep this in mind when answering the questions below.
What is the applicant’s current level
of ego strength, emotional stability,
and flexibility?
What are the applicant’s current
coping strategies to deal with
stressful situations?
What is the applicant’s current
level of functioning in interpersonal
and work relationships?
What is your evaluation of
the applicant’s overall level of
functioning?
What is the applicant’s plan for
sobriety/abstinence while serving
in the Peace Corps?
What is the applicant’s risk of
alcohol/substance abuse in a
stressful overseas environment?

□ High/Likely
□ Possible
□ Low/Unlikely

Peace Corps · Alcohol/Substance Abuse Current Evaluation Form

PC-262-6 (Initial approval 08/2012)

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Medical Case Number:

F.  Clinical Observations (applicant’s insight into alcohol/substance use, self care, etc.):____________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
G. What specific recommendations for medical care do you have regarding the management for this condition
over the next three years? All recommendations will help determine the Volunteer’s country placement: ____________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
Do you have any concerns, due to alcohol or drug/substance abuse, that would prevent this applicant from completing 27 months
of Peace Corps service without undue disruption? NOTE: Peace Corps service may be in isolated areas, with limited access to
Western-trained health care providers. Please check one box below.
□ I have no concerns. This applicant, with regard to alcohol and/or substance abuse, is healthy enough to complete 27 months
of uninterrupted Peace Corps service, provided the above recommendations can be accommodated.
□ I am unsure that the applicant can complete 27 months of uninterrupted Peace Corps service due to alcohol or substance
abuse. I recommend a period of stabilization for this condition and an updated assessment at a future date. (Describe and
include the length of time for stabilization):
□ I do not believe that this applicant can complete 27 months of Peace Corps service without undue disruption due to alcohol
or substance abuse.
I certify this information, in my opinion, is an accurate representation of my current evaluation of alcohol and/or substance
abuse for the applicant listed above.
Therapist Signature/Title___________________________________________________________________________________________________________________________________________________________________
Therapist Name (Print)_______________________________________________________________________________________________________________________________________________________________________
Date_____________________________________________________________________________________________________________________________________________________________________________________________________

Peace Corps · Alcohol/Substance Abuse Current Evaluation Form

PC-262-6 (Initial approval 08/2012)

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