Form PC-355-2 Mammogram Waiver Form

Peace Corps – Mammogram Waiver | PC-355-2 [Rev. Aug 2020]

Mammogram Waiver

Invitee Name (Last, First) ______________________________________ Date of Birth (M/D/Y): _______________

For the Provider: United States Preventive Services Task Force guidelines recommend that women 50 years of age and older receive a mammogram every two years. The Peace Corps is able to provide screening mammography at some but not all overseas posts. Some invitees request to waive mammography during service. However, invitees with a condition that requires a mammogram will be placed in a country with mammogram capability.

 I discussed with the individual the risks and benefits of waiving a routine screening mammogram for more than two years, including an increased risk of delayed diagnosis of breast cancer, which could cause adverse health consequences, including death.

Provider Signature and Title___________________________________________________________________________

Provider Name (Print) __________________________________________ Date _________________________________

Provider License Number/State ________________________________________________________________________

Provider Address and Phone Number____________________________________________________________________

________________________________________________________________________________________________

PRIVACY ACT NOTICE

Authority: This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq.

Purpose: It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to service as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service.

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: Your disclosure of this information is voluntary; however, your failure to provide this information or failure to disclose relevant information may result in the rejection of your application to become a Peace Corps Volunteer.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average one hour and 45 minutes per applicant and one hour 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.

Breast Cancer Risk Assessment

The questions below must be answered in order to make a general assessment of your statistical breast cancer risk. These questions can be answered by you and do not require medical tests or a physician visit. However, if you do not know the answer to a question, please consult with your provider.

Yes No	Do you have a personal history of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS)?
____years	At what age did you begin to have your menstrual periods?
____years  N/A	At what age, if applicable, did you have your first child?
#_______  N/A	How many first-degree relatives (parent, sibling, child) have had breast cancer?
Yes No	Have you ever had a breast biopsy?
#_______  N/A	How many breast biopsies have you had (positive or negative)?
Yes No N/A	Have any of the biopsies shown atypical hyperplasia?
Check all that apply	Understanding that race and ethnicity factor into the estimation of breast cancer risk, what is your race/ethnicity?
	White
	African American
	Hispanic
	Asian, Pacific Islander, or Native Hawaiian
	American Indian or Alaskan Native
	Unknown
	Prefer not to answer

Peace Corps – Mammogram Waiver | PC-355-2 [Rev. Aug 2020] Page 2 of 2