Form PC-355-2 Mammogram Waiver Form

Applicant Name

(Last, First, Middle Initial)

Date of Birth___________/_________ /___________

(Month/Day/Year)

MAMMOGRAM WAIVER FORM

According to your Health History Form response, you indicated a wish to waive routine mammography.

Please complete this form and return it with your report of physical examination.

United States Preventive Services Task Force guidelines recommend that women 50 years of age and older receive regular, comprehensive screening for breast cancer, including mammography every two years. The Peace Corps strongly supports these recommendations and can provide screening mammography at some but not all of its overseas posts. Note: The Peace Corps may not be able to support you in your country of invitation.

Instructions to the physician:

Please read the above statement and discuss it with your patient. Please check all of the following that apply, and sign.

• I have discussed with the above-named person that foregoing a routine screening mammogram for more than two years may increase her risk of delayed diagnosis of breast cancer, which could cause adverse health consequences, including death.

Physician Printed Name _______________________________________________________________________________

Physician Signed Name _______________________________________________________ Date ____________________

Instructions to Peace Corps applicant:

After discussing mammogram screenings with your physician, please choose one of the two options below and sign.

• After discussing these matters with my doctor, I have decided I want to receive a routine screening mammogram during my 27 months of Peace Corps service.

• After discussing these matters with my doctor, I have decided I do not want to receive a routine screening mammogram during my 27 months of Volunteer service. You must complete the Mammogram Health Assessment Questionnaire below. Depending on that information and your mammogram report, you may be placed in a country where mammograms are available.

Applicant Printed Name _______________________________________________________________________________

Applicant Signed Name_________________________________________________________Date___________________

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 service 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 or failure to disclose relevant information may 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 U.S.C. 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, licensed clinical social worker 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 one hour and 45 minutes per applicant and one hour 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 20^th Street, NW, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete from to this address.

Peace Corps Mammogram Form PC‐355-2 (Previous editions are obsolete) Page 1 of 3

Mammogram Health Assessment Questionnaire

The questions below must be answered in order to make a general assessment of your statistical breast cancer risk. These questions can be answered by you and do not require additional medical tests or physician visits.

If you do not know the answer, you may consult with your physician or simply respond “no” to questions that require a “yes” or “no” answer.

 Yes	 No	Do you have a personal history of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS)?
		In order to estimate your cancer risk:
____years		At what age did you begin to have your menstrual periods?
____years	 N/A	At what age, if applicable, did you have your first child?
#_______	 N/A	How many first-degree relatives (parent, sibling, child) have had breast cancer?
 Yes	 No	Have you ever had a breast biopsy?
#_______		How many breast biopsies have you had (positive or negative)?
 Yes	 No  N/A	Have any of the biopsies shown atypical hyperplasia (check with your doctor if necessary)?
OPTIONAL		Understanding that race and ethnicity factor into the estimation of breast cancer risk, what is your race/ethnicity? (check all that apply)
		White
		African American
		Hispanic
		Asian, Pacific Islander, or Native Hawaiian
		American Indian or Alaskan Native
		Unknown
		Prefer not to answer

Closing Signatures

Provider Signature/Title_____________________________________________________________________________

Provider Name (Print) __________________________________________ Date _______________________________

Provider License Number/State ______________________________________________________________________

Provider Address and Phone Number__________________________________________________________________

________________________________________________________________________________________________

If evaluation completed by other than MD, DO, or NP licensed to practice independently, must be signed or co-signed by a licensed MD or DO.

Co-signature, if required in your state _________________________________________________________________

License Number ___________________________________________________________________________________

Peace Corps Mammogram Form PC‐355-2 (Previous editions are obsolete) Page 2 of 3

Frequently Asked Questions

What if I have a condition that requires a mammogram while in service?

Volunteers with a condition that requires a mammogram exam will be placed in a country with mammogram capability.

Do I need to send in the actual films to the Peace Corps as part of the medical screening process?

No. Please do not send the actual films. The Peace Corps only needs a copy of the mammogram radiology report and your doctor’s interpretation of the results.

Do I need to bring my films with me to my country of service?

Yes. Bring a copy of your most recent mammogram films (on a disk) with you. If you need another mammogram, or receive a screening exam while in service, the films serve as your baseline. It is your responsibility to bring these films with you.

I cannot remember if I said I wanted a routine screening test when I completed the Health History Form at the time of my application. How can I find out?

Please send a message with this question to your nurse through the Medical Applicant Portal.

Peace Corps Mammogram Form PC‐355-2 (Previous editions are obsolete) Page 3 of 3