Form PC-262-11 Cervical Cancer Screening Form

Peace Corps – Cervical Cancer Screening Form | PC-262-11 [Rev. Aug 2020]

Cervical Cancer Screening

Prior to starting service, an individual’s cervical cancer screening may fall within a shorter interval than what the American Society for Colposcopy and Cervical Pathology recommends. This is to ensure the individual will not need to be screened within the first year of service. Screening Peace Corps Volunteers during their first year of service can be challenging due to limited health care resources.

Requirements for the health care provider:

1. Complete this form.

2. Provide required reports and documentation to the individual, unless they have never completed screening:

   1. Most recent cytology and HPV results.

   2. Clinical notes and pathology report if colposcopy/other biopsy was performed.

   3. If any abnormalities were detected on the most recent gynecologic physical examination, please explain/attach documentation.

   4. History of abnormal results, including date of finding, specify abnormal results, follow-up or treatment

performed.

If you have questions, please contact the Peace Corps Medical Office at 202-692-1504 or pre- [email protected].

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 an hour and 15 minutes per applicant and 15 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.

Applicant Name (Last, First) Date of Exam

Option 1: The individual completed Pap &/or HPV screening. Please check one:

• Within the past 2 years OR

• Within the past 4 years (applicable for some women 30-65 years of age who have had an HPV test)

Option 2: The individual did not complete screening. Please check the reason and explain:

• The individual discussed cervical cancer screening with me and I recommend against screening. OR

• The individual discussed the indications for cervical cancer screening and risks of forgoing screening with me and the individual has opted to decline recommended screening.

Reason the provider or individual decided against screening:

History of abnormal screening results?

[ ] Yes

[ ] No

[ ] Never been screened

What testing is needed in the next three years?

[ ] Cytology only	[ ] Cytology and colposcopy	[ ] No testing
[ ] Cytology and HPV	[ ] Cytology, HPV & colposcopy	[ ] Other:

Testing date due:

Frequency of testing:

[ ] Every 3 years	[ ] Every 1 year until negative x 2
[ ] Every 6 months until negative x 2	[ ] Other:

Provider Signature and Title

Provider Name (Print) Date

Provider License Number/State Provider Address and Phone Number

Peace Corps – Cervical Cancer Screening Form | PC-262-11 [SORN PC-17] Page 2 of 4