Form DI-4015 YCC Medical History Form

OMB Control No. 1093-0010
Expires XX/XX/20XX

Form DI-4015 (Rev. 7/2023)
U.S. Department of the Interior

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. Furnishing this information is voluntary; however,
failure to provide the requested information may disqualify acceptance into the Youth Conservation Corps
program.
The information requested below will be kept strictly confidential and safeguarded, and it will be shredded and properly
disposed of when it is no longer needed. In addition, this information will only be disclosed when necessary and will be
done so in accordance with the requirements of the Department of Labor’s regulations and other applicable federal laws.

APPLICANT MEDICAL HISTORY
Please answer the following questions regarding your background, contact, and other information
1. Name: First: ______________________ Middle: _____________________
2. Gender:

 Male

 Female

 Self-identify as
_______________________

3. Date of Birth (mm/dd/yyyy): ______/______/______
4. Address: ________________________________
5. Email: _____________________________

Last: _______________________

 Non-Binary

 Prefer not to disclose

Age ________

City: _______________

Phone 1: ________________

State: _______ Zip ___________
Phone 2: ____________________

6. Are you covered under your family or any other type of health insurance?
 Yes

 No If yes, list name of insurer and policy number: ______________________________________

Primary Care Provider Name: ____________________________________________________
Address: _____________________________________________________________________

7. Have you had or are you having any of the following health conditions? (Enter X below where appropriate.
Use the “Additional Information” section on Page 3 to describe)
 Hay fever
 Asthma
 Poison ivy
 Insect stings
 Skin condition
 Cold

 Sore throat
 Earache
 Bladder infection
 Intestinal infection
 Chest pain
 Convulsion

 Diabetic
 Difficulty with balance
 Fainting
Problem with blood
not Clotting
 Rheumatism

 Loss of weight
 Lyme disease
 Ulcers
 Persistent cough
 Shortness of breath
 Sleepwalking

 Swollen/painful joints
 Mental health conditions
 Heart condition

Other (Identify) ____________________________________________________________________________________

8. Are you allergic to any medications?  Yes  No – if yes, explain on page 2
9. Immunization history – Applicants must have received a Tdap immunization (Tetanus Toxoid, Diphtheria,
Pertussis) or booster within the last ten years to participate in the YCC program.
Date of Tdap immunization or last booster (mm/dd/yyyy): ____________________________
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OMB Control No. 1093-0010
Expires XX/XX/20XX

Form DI-4015 (Rev. 7/2023)
U.S. Department of the Interior

UNITED STATES YOUTH CONSERVATION CORPS
MEDICAL HISTORY FORM
To be Completed by
Youth Conservation Corps (YCC) Program Applicants Only

Medications
10. Are you currently taking any prescribed medications?  Yes – if yes, explain 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

_________________________________________

__________

______________________________________

_________________________________________

__________

______________________________________

_________________________________________

__________

______________________________________

_________________________________________

__________

______________________________________

11. List any over-the-counter medications that YCC program staff have approval to administer if needed
(i.e., ibuprofen):
_________________________________________________________________________________________

12. List all medications to which you are allergic
___________________________________________________________________________________________
Medical and Physical Abilities and Limitations
13. Below is a list of typical activities and environmental factors required for outdoor work. Please check any
of the items below that may limit your participation in certain types of projects within the YCC program.
The YCC site will work with you to adjust projects and accommodate any limitations to the best of their
ability

Physical and Functional Limitations
 Heavy lifting, 45 pounds and over
 Heavy carrying, 45 pounds and over
 Straight pulling
 Pulling hand over hand
 Pushing
 Reaching above shoulder








Use of fingers
Use of both hands
Walking
Standing
Crawling
Kneeling








Repeated bending
Climbing, legs only
Climbing, use of legs and arms
Use of both legs
Hearing
Corrected vision in one eye (20/20 to 20/40)

Environmental Factors





Outside
Excessive heat
Excessive cold
Excessive humidity

 Dry atmospheric conditions
 Excessive or intermittent noise
 Dust
 Slippery or uneven walking surfaces

 Working around moving objects
 Working on ladders or scaffolding
 Working with hands in water
 Working closely with others
 Working alone

14. Please use this space to explain any factors listed above that would restrict full participation or require special
care or treatment.

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OMB Control No. 1093-0010
Expires XX/XX/20XX

Form DI-4015 (Rev. 7/2023)
U.S. Department of the Interior

UNITED STATES YOUTH CONSERVATION CORPS
MEDICAL HISTORY FORM
To be Completed by
Youth Conservation Corps (YCC) Program Applicants Only

TO BE COMPLETED BY THE APPLICANT IF 18 YEARS OLD
I certify that I am familiar with the Youth Conservation Corps (YCC) program and am ready 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. I authorize the sharing of pertinent medical information with a medical care provider in the event first aid or
emergency medical care is needed.

Name

___________________________________
Applicant Name

___________________________________________
Applicant/ Signature (digital signature is acceptable)

__________

Date (mm/dd/yyyy)

Emergency Contact Information :

___________________________ _____________________________

_______________

______________

Name

Emergency Contact Number #1

Emergency Contact Number #2

Email

TO BE COMPLETED BY THE PARENT OR LEGAL GUARDIAN IF THE APPLICANT IS UNDER THE AGE OF 18
I certify that I am familiar with the Youth Conservation Corps (YCC) program and that I give my consent for my child/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. I authorize the sharing of pertinent medical information with a medical care provider in the
event first aid or emergency medical care is needed.
Name

_______________________________________
Parent/Legal Guardian Name

_______________________________________

_________

_________________________

_________

_________

_______________________________

_______________________________

Parent/Legal Guardian Signature (digital signature is acceptable)

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

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OMB Control No. 1093-0010
Expires XX/XX/20XX

Form DI-4015 (Rev. 7/2023)
U.S. Department of the Interior

UNITED STATES YOUTH CONSERVATION CORPS
MEDICAL HISTORY FORM
To be Completed by
Youth Conservation Corps (YCC) Program Applicants Only

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 National Park Service
and
U.S. Fish and Wildlife Service and the U.S. Department of Agriculture – U.S. Forest Service collect 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. 1093-0010.
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.

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