JCOC Medical Document

Joint Civilian Orientation Conference
(JCOC 92)
Medical Form
OMB CONTROL NUMBER: 0704-0562
OMB EXPIRATION DATE: 2/29/2020
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, Office of Information Management, at . 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 up to 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.

Disclaimer: This is the standard medical JCOC form. It does not necessarily reflect the
activities of this particular JCOC.

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.