ETA 9215 Physical Examination Form

U.S. Department of Labor Employment and Training Administration Office of Job Corps

ETA FORM 9215 OMB Control No. 1205-0219 Expiration Date: 05/31/2025

Physical Examination Form

Instructions: This form must be completed by the appropriate Health and Wellness staff and signed off by the appropriate clinician, within 14 days of a student’s arrival to the Job Corps center.

Legal Name		Center
Date of Birth		Sex	☐ Male ☐ Female
Student ID #		Race

1. HT	2. WT	3. BMI	4.Waist circum.	5.BP	6.Heart rate	7.Resp rate	8.Temp*	9.O2 Sat (%)*	10.Peak flow*
*If clinically indicated.

11. Vision: refer to optometry for any value of 20/40 or J6 or higher

Distant Vision

Near Vision

Uncorrected

Corrected

Uncorrected

Corrected

Right

20/

Corr to 20/

Jaeger-

Corr to Jaeger-

Left

20/

Corr to 20/

Jaeger-

Corr to Jaeger-

12. Color vision result (check one):

☐ Pass ☐ Fail

13. Hearing Screening at 25 decibels: A fail at any HZ requires further evaluation

HZ

1000

2000

4000

Right

☐ Pass ☐ Fail

☐ Pass ☐ Fail

☐ Pass ☐ Fail

Left

☐ Pass ☐ Fail

☐ Pass ☐ Fail

☐ Pass ☐ Fail

14. Dental Readiness Inspection (check all that apply)

Completed by:

Date:

☐ No obvious oral health findings

☐ Reports oral pain ☐ Mild ☐ Moderate ☐ Severe

☐ Intraoral Swelling ☐ Extraoral Swelling

☐ Sore in mouth or on lips

☐ Bleeding in mouth

☐ Hole in tooth

☐ Oral Piercing

Location of finding: ☐ Right Side ☐ Left Side ☐ Lower ☐ Upper ☐ Front

Other:

15. Required Clinical Evaluation. If clinical examination is unremarkable, check “normal.” If anything is notable, describe the finding in detail. Use extra sheets if necessary. If an area is not examined, include an explanation.

Normal

Describe notable findings or abnormalities

General appearance

Ears

Eyes

Nose and sinuses

Mouth and throat

Neck (lymph nodes and thyroid)

Chest

Breasts

Lungs

Heart (rate, rhythm, sounds)

Abdomen and viscera

External genitalia

Pelvic (if indicated)

Anus and rectum (if indicated)

Vascular system (pulses)

Extremities

Spine

Skin (include identifying marks, scars, tattoos, piercings)

Neurologic

Psychiatric/Mental status

35. Which document(s) have been reviewed?

☐ Job Corps Health History Form

☐ Immunization records

☐ Laboratory tests

Action or follow-up required:

36. Acute and/or chronic disease assessment and plan

Assessment

Plan (e.g., CCMP, medication management)

37. Follow Up Appointment

☐ Follow-up visit (e.g., # of weeks/months) for (reason)

38. Referrals

Referred to (Mental health, TEAP, TUPP, HEALs, dentist):

Notes

39. Clearance for Participation in Organized Contact for Rigorous Sports

Participation in sports (check one)

Comments

☐ Cleared for participation in sports

☐ Cleared with the following restrictions

☐ Not cleared pending further evaluation

☐ Not cleared for participation in sports

Clinician: I the undersigned, certify that all information on this form is accurate.
SIGNATURE:	DATE:
Nurse: I the undersigned, certify that all information on this form is accurate.
SIGNATURE:	DATE:
Other Health Professional: I the undersigned, certify that all information on this form is accurate.
SIGNATURE:	DATE:

Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 113-128). Public reporting burden is estimated to average 30 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 to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0219). Please do not submit completed forms to this address.

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Student name: Center:

DOB: Sex (M/F):

ID #: Race/ethnicity: