Form DI-4015 Medical History Form

Youth Conservation Corps Application and Medical History Forms

DI-4015 YCC Medical History Form updated 10282020

DI-4015, Youth Conservation Corps Medical History Form

OMB: 1093-0010

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Form DI-4015 (Rev. 10/2020) OMB Control No. 1093-####

U.S. Department of the Interior Expires ##/##/####

UNITED STATES YOUTH CONSERVATION CORPS

MEDICAL HISTORY FORM


To be Completed by Youth Conservation Corps (YCC) Program Applicants Only





NOTE: This information is collected under the authority of Public Law 93-408. It will be used primarily for the purpose of determining your eligibility for Youth Conservation 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 Youth Conservation Corps member.



APPLICANT MEDICAL HISTORY

Please answer the following questions regarding your background, contact and other information


Name:




First:

Middle

Last

Suffix

Gender:

Male

Female

Date of Birth:

mm/dd/yyy ____/_____/______

Age_______


Contact Information




Address:




Street

City

State Zip

Emajl:

Phone 1

Phone 2




Are you covered under your family or any other type of health insurance?

Yes No If yes, name of insurer and policy number


Primary Care Provider Name: Address:



Have you had or are you having any of the following health conditions? (Enter X where appropriate and describe on page 3.)


Allergies

Frequent Infection

Other health condition

Hay fever

Cold

Chest pain

Rheumatism

Shortness of breath

Asthma

Sore throat

Convulsion

Loss of weight

Sleepwalking

Poison Ivy

Earache

Diabetic

Lyme disease

Swollen/painful joints

Insect stings

Skin condition

Bladder or Intestinal infection

Difficulty with balance

Fainting

Ulcers

Persistent Cough

Mental Health Conditions

Skin condition

Intestinal infection

Problem with blood not clotting


Heart Condition

Other (identify)



Are you currently taking and medication?

Are you allergic to any medications?

Yes – if yes, explain on page 2

No

Yes – if yes, explain on page 2

No



Immunization history – Enter X where appropriate and dates as indicated. A Tdap shot is required unless you have received one or a booster within the last ten years. You may attach a copy of your immunization record as a separate document Check here if immunization records are attached as a separate document.



Date of Series

mm/dd/yyyy

Date of Last Booster to Ensure Immunization

mm/dd/yyyy

Tetanus Toxoid, Diptheria, Pertussis (Tdap)



Polio Vaccine (IPV)



Measles, Mumps, Rubella (MMR)



Meningococcal Conjugate Vaccine (MCV)




To my knowledge, I have not been exposed to a contagious or infectious disease in the past three weeks, and I am in a state of health which would allow full participation in all YCC activities

.

Applicant Name Applicant Signature Date


Medical and Physical Abilities and Limitations

The requested below will be kept strictly confidential and safeguarded. This information will only be disclosed in accordance with the requirements of the Department of Labor’s regulations and other applicable federal laws.

  1. Please use the table below to identify any medication(s) that the applicant is currently taking. Include the name, dosage and any specific instructions that a YCC Program Staff would need to administer medication (if necessary).

Medication Name

Dosage

Instructions













Allergic to which medications


  1. Below is a list of typical activities and environmental factors required for outdoor work. Please check any of the items below that may limit full participation in the YCC program.

Physical and functional Requirements


Heavy lifting, 45 pounds and over

Use of fingers

Repeated bending

Heavy carrying, 45 pounds and over

Use of both hands

Climbing, legs only

Straight pulling

Walking

Climbing, use of legs and arms

Pulling hand over hand

Standing

Use of both legs

Pushing

Crawling

Hearing (aid permitted

Reaching above shoulder

Kneeling

Corrected vision in one eye (20/20 to 20/40)



Environmental Factors


Outside

Dry atmospheric conditions

Working around moving objects

Excessive heat

Excessive or intermittent noise

Working on ladders or scaffolding

Excessive cold

Dust

Working with hands in water

Excessive humidity

Slippery or uneven walking surfaces

Working closely with others



Working alone

Please use this space to identify any of the conditions listed above that would restrict full participation or require special care or treatment,






TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN OF THE APPLICANT

I certify that I am familiar with the Youth Conservation Corps Program and that I give my consent to my son/ daughter/ward to participate in the program as a YCC member. I understand that I will not hold the United States Government responsible for any non-program accident or illness, and I authorize first aid, or emergency medical care, to be performed at the nearest, most adequate facility approved by the YCC.

Name



Parent/Legal Guardian Name Parent/Legal Guardian Signature Date



Address:



Street City State Zip


Contact Information



Email Emergency Contact Number #1 Emergency Contact Number #2



TO BE COMPLETED BY REVEWING OFFICER



Reviewing Officer's Name Reviewing Officer's Signature Date



Additional Information. Please use this space to provide any additional information needed to complete the application.


NOTICES


PRIVACY ACT STATEMENT


Authority: 16 USC 1701-1706, Chapter 37 – Youth Conservation Corps and Public Lands Corps, Subchapter I – Youth Conservation Corps (Youth Conservation Corps Act of 1970 (P.L. 91-378; 84 Stat. 794) as amended in 1972 (P.L. 92-597) and in 1974 (P.L. 93-408).


Purpose: This information is collected from selected applicants to determine their ability to fully participate, and to allow the participating agencies to make necessary reasonable accommodations as appropriate.


Routine Uses: The information collected on this form may be shared in accordance with the Privacy Act of 1974 and the routine uses listed in the DOI Office of the Secretary (OS) System of Records Notices INTERIOR/OS-25, YCC Enrollee Records available at https://www.doi.gov/privacy/os-notices.


Disclosure: Furnishing this information is voluntary; however, failure to provide the requested information may disqualify acceptance into the YCC program.


PAPERWORK REDUCTION ACT STATEMENT


In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Department of the Interior and the U.S. Department of Agriculture – Forest Service, collects information necessary to assist the agencies in safeguarding the health, safety, and welfare of the enrollees of the YCC programs. Your response is voluntary, but failure to complete this form will result in exclusion from participation in the YCC Program. According to the Paperwork Reduction Act of 1995, 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. OMB has approved this collection of information and assigned Control No. 1093-####.


ESTIMATED BURDEN STATEMENT


We estimate public reporting for this collection of information to average 14 minutes, including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Departmental Information Clearance Officer, U.S. Department of the Interior, 1849 C Street, NW Washington, DC 20240, or via email at [email protected]. Please do not send your completed form to this address.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleNPS Form 10-29
Authordhaas
File Modified0000-00-00
File Created2021-01-13

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