JCOC Medical Form

Medical Form

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 [Insert OMB Control Number]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

The Joint Civilian Orientation Conference program is a vigorous program that can be physically challenging for those wishing to participate in the military related activities. Although participants will not be asked to participate in any demonstration they deem uncomfortable they should be able to:

• Easily climb eight flights of stairs/ladders without stopping.

• Endure 10-12 hours of activities in a day, to include early mornings and late nights.

• Endure a field environment (rain or shine) for 10 hours.

• Endure six consecutive days of flying on different types of military aircraft.

• Handle their own luggage (one bag per participant).

• Pull Gs on a military flight.

Health care provider, please consider:

• Your patient's medical history and current health.

• JCOC travels without a dedicated medical officer.

• Although there are medical facilities at military installations around the world, these are only available to JCOC participants for emergency situations.

• Participants are expected to attend the entire JCOC trip.

• Participants may be aboard ships, aircraft, numerous vehicles, and simulators. Please discuss motion sickness options with your patients.

As the health care provider for _____________________________________________________

(Full name of JCOC participant)

• Yes, I find him/her physically fit and able to meet the physical requirements of JCOC.

• No, I do not believe he/she is able to meet the physical requirements for JCOC.

Health care provider Name: ________________________________________

Address: ________________________________________________________

Phone: _________________________ Email: __________________________

Signature: _______________________________________________________

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 113, Secretary of Defense; DoD Directive 5122.05, Assistant Secretary of Defense for Public Affairs (ASD/PA); DoD Directive 5410.18, Public Affairs Community Relations Policy; and DoD Instruction 5410.19, Public Affairs Community Relations Policy Implementation.

PRINCIPAL PURPOSE(S): To administer the Joint Civilian Orientation Conference (JCOC) Program; to verify the eligibility of nominators and candidates and to select those nominated individuals for participation in JCOC.

ROUTINE USE(S): Applicable Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use. The DoD Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices may apply to this system. The complete list of DoD Routine Uses can be found online at:

http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx.

The applicable system of records notice is DPA 03, Joint Civilian Orientation Conference (JCOC) Program and can be found online at: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570580/dpa-dcra-01/

DISCLOSURE: Voluntary; however, failure to provide the required information may delay or result in not being accepted into the JCOC Program.