Form PC-262-2 Asthma Evaluation Form

Peace Corps – Asthma Evaluation Form | PC-262-2 [Rev. Aug 2020]

Applicant Name

(Last, First, Middle Initial)

Date of Birth / /

(Month/Day/Year)

ASTHMA EVALUATION FORM

The individual listed above has applied to serve as a Peace Corps Volunteer and has reported having asthma. This form must be completed by the health-care provider (MD or DO as required by state laws) who provides, or provided, medical oversight and management of this health condition.

Considerations for health-care provider:

• Your patient has applied to serve as a Peace Corps Volunteer. During Peace Corps service, most Peace Corps Volunteers face dramatic changes to living conditions, diet, and level of physical activity. Furthermore, they typically serve in remote and resource-limited environments where they are expected to live and work in conditions that parallel those in their local community. It is not uncommon for Volunteers to need to be able to use squat toilets, ambulate for miles on uneven terrain daily, haul water over some distance, and sleep on bedding that does not meet typical US comfort standards. Additionally, they may face unpredictable housing conditions, extremes of climate, unreliable transportation, the need for heightened awareness of personal safety, and increased attention to safe food and drinking water.

• When Volunteers serve with the Peace Corps, the Office of Health Services providers assume primary responsibility for their medical care during the duration of their service. However, it must be recognized that given the resource limitations of countries in which Volunteers serve, there may be limited access to Western trained health professionals. Medical care and resources comparable to U.S. health-care standards are limited and, in the case of specialty physicians, are mostly non-existent.

• In order to help the Peace Corps fully and accurately understand the current health of potential Volunteers and assess whether the Peace Corps can appropriately support and accommodate individualized health care and support needs of your patient, we ask you to review the issues below with your patient and provide us with your written assessment of your patient’s medical conditions, functional limitations, and anticipated support needs.

PRIVACY ACT NOTICE

Authority: This collection is authorized by the Peace Corps Act (22 U.S.C. 2501, et seq.) as amended.

Purpose: The information requested will be used to determine your health for entry into the Peace Corps Volunteer program.

Routine Uses: This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a(b), and the Peace Corps' Routine Uses A through N, as listed on the Peace Corps’ Privacy Program webpage, and listed in System of Records PC-17, “Volunteer Applicant and Service Records System.” 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.

Applicable SORN: System of Records PC-17, Volunteer Applicant and Service Records System.

Disclosure: Providing this information is voluntary; however, failure to provide all information may result in a delay or inability to process your application.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 75 minutes per applicant and 30 minutes 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/Privacy Officer, Peace Corps, 1275 First Street, NE, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete form to this address.

I. Symptoms
Wheezing	Cough	Shortness of breath
Chest tightness	Increased septum	Exertional fatigue

• Other: _ Date the patient first experienced symptoms: Date of most recent symptoms: To what degree do these symptoms interfere with activity level or work?

• None  Seldom  Frequently

Explanation of above: _

2. Indicators of control

Has this applicant experienced any of the following within the past five years?

Nocturnal awakenings	Yes	No	Explanation: _
Increased need of short-acting beta2-agonists	Yes	No	Explanation: _
Use of systemic steroids	Yes	No	Explanation: _
Urgent care/ER visits	Yes	No	Explanation: _
Life-threatening exacerbations	Yes	No	Explanation: _

Smoking history: _

2. Specific triggers

2. Classification (please check on of the following categories)

• Bronchospasm  Exercise-induced asthma  Asthma

If this applicant is classified as having Asthma, please indicate the level of severity below and provide recent spirometry results, if available.

Classification of Asthma Severity*

Check Which Level of Severity Applies	Level of severity	Days w/Sxs	Nights w/Sxs	FEV1	PEF variability
	Mild intermittent	<2/wk	<2/mo	>80%	<20%
	Mild persistent	3–6/wk	3–4/mo	>80%	20–30%
	Moderate persistent	daily	>5/mo	>60–<80%	>30%
	Severe persistent	continual	frequent	<60%	>30%

*National Asthma Education Program, Expert Panel Report “Guidelines for the Diagnosis and Management of Asthma,” NIH publication No. 98-4051. 7/97

2. Treatment within the past five years (please complete table below)

Name of Medication	Dose	Date(s) started	Date(s) finished	Doses per/mo
Over-the-counter inhalers
Short-acting beta2 agonists — inhalers
Nebulized beta2 agonists (not supported in Peace Corps)
Long-acting beta2 agonists — inhalers
Inhaled corticosteroids
Combination steroid/long-acting beta agonist
Oral/parenteral corticosteroids
Methylxanthines — oral
Leukotriene modifiers
Anticholinergic — inhalers
IgE blocker
Immunotherapy
Other

Please describe the optimal asthma management plan for this patient (if different from above regimen):

Within the last 5 years, has the applicant experienced a more severe episode of asthma? Yes  No

If yes, when? __

2. Patient management

Does the applicant have a good understanding of his/her respiratory condition? Yes  No

Explanation: __ Can the applicant self-manage daily medications and exacerbations? Yes  No

Explanation: __ Does this applicant own and know how to use a peak flow meter? Yes  No

Explanation: __ Document baseline peak flow reading: _ Does the applicant have any functional limitations or restriction due to this condition? Yes  No

If “Yes” is marked, describe limitations or restrictions:

What other specific recommendations for medical care do you have regarding the management for this condition over the next three years? All recommendations will help determine the Volunteer’s country and site placement.

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 – Asthma Evaluation Form | PC-262-2 [Rev. Aug 2020]

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