3 - JCOC93 Medical Form

JOINT CIVILIAN ORIENTATION CONFERENCE 93
MEDICAL FORM
OMB CONTROL NUMBER:
0704-0562
OMB EXPIRATION DATE: 3/31/2026
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:
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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).

Health care provider, please consider the following:
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Your patient's medical history and current health.
JCOC travels without a dedicated medical officer.
Although military installations have medical facilities, they are only available in 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: ______________________________________________________________________
Note: This is the standard JCOC medical form. It does not necessarily reflect the activities of this particular JCOC.
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.