Form PC-1790S Report of Physical Examination

Peace Corps Report of Physical Examination
Name (Last, First, Middle Initial)

/

Current Address Until

Telephone No. (

Sex

/

M ❐ F ❐

PC-OMS-1790 S
OMB No.: 0420-xxxx
Expiration Date:

Date of Birth (MO / DAY / YR)

/

/

Home/Permanent Address

)

Email

Telephone No. (

)

Guide to Completing the Report of Physical Examination
The Physical Examination is one of the final pre-service requirements for individuals applying for Peace Corps service.
Most Peace Corps countries have limited access to Western-trained health professionals, and medical resources
are seldom as advanced, or as available, as they are in the United States. In many assignments a Volunteer may be
geographically isolated and without easy access to medical care. It would not be in a Volunteer’s best interest to be placed
in an area where adequate support is not available for existing health problems or new health needs. In order for the Peace
Corps to be able to make appropriate medical decisions regarding qualification and placement, it must have the most
accurate and complete description of the applicant’s current health status and the medical support that will be needed
over the next three years.

Privacy Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for
the purpose of determining your eligibility for Peace Corps service and, if you are invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to provide this information will result in the rejection of your application to become
a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed
in the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff 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 or other medical personnel treating you or
involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website
at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.

Burden Statement:
Public reporting burden for this collection of information is estimated to average 90 minutes per applicant response and
45 minutes per physician 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 Officer, Peace Corps, 1111
20th Street, NW, Washington, DC 20526 ATTN: PRA (0420-####). Do not return the completed form to this address.

Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 01/2012)

Page 1 of 4

Application Case ID

Health History
A copy of the applicant’s health history is included in this packet. Please check one of the boxes below:
❒ The medical history is complete and accurate
❒ The medical history is not complete and/or not accurate (List changes, including unreported past history and/or new
medical events since the applicant completed this Health History): ___________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________
Physician's Signature

Measurements and Other Findings
Height

Weight

Blood Pressure

Gross Vision

Pulse

Right 20/_____
Left
feet/inches

lbs.

(resting)

bpm (resting)

20/_____

❏ Corrected
❏ Uncorrected

complete prescription for eyeglass form if
uncorrected vision of 20/40 or greater

Clinical Examination

All Sections MUST be completed by examining physician
Check each item in appropriate column. All systems must be examined.

Please check either normal or abnormal for all applicable questions. The only questions that may not be applicable are the gender and age-specific
questions (Nos. 12 and 15).
Describe each abnormality in detail. Enter item number before each comment. Use additional sheets if necessary.

Normal Abnormal

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1. Head and neck
2. Nose, sinuses
3. Mouth and throat
4. Thyroid
5. Ears
6. Eyes (include fundoscopic exam)
7. Lungs and chest
8. Breasts
9. Cardiac (rate, rhythm, heart sounds)
10. Peripheral pulses
11. Abdomen
12. Prostate exam (men over 50 only)
13. Anus and rectum
14. Genitalia (include hernia)
15. Pelvic exam (females only)
16. Spine
17. Musculoskeletal
18. Neurologic
19. Skin, lymphatics
20. Identifying marks, scars, tattoos
21. Psychiatric (specify any significant cognitive or behavioral observations)

Prior to this visit have you provided medical care to this Candidate? ❏ yes ❏ no
If yes, how many times in the past 12 months have you seen this Candidate? _______
Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 01/2012)

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Application Case ID

Medications

Please check one box below. Note that medications include prescribed, over the counter, and any herbal remedies.
❒ The medications list is complete and accurate, including the dose and frequency.
❒ The medications listed are not complete and/or not accurate: (Provide a complete list of medications, including dose,
frequency, and route for all medications the applicant is currently taking).
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________

Functional Abilities
Please check one box below.

❒ I have reviewed the positive health history answers that reported decreased functional ability. I believe this is an
accurate representation of the functional abilities of the applicant to meet his or her Activities of Daily Living.
❒ There are no reported functional limitations reported on the health history. I believe this is an accurate representation
of no functional limitations of the applicant to meet his or her Activities of Daily Living.
❒ I am reporting functional limitations that were not reported on the Health History: ________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________

Laboratory Evaluation
Documentation of results must be included for this Physical Exam to be complete. (Please use cover sheet provided).
Abnormal lab results require an explanation, a treatment plan or, if chronic abnormality exists, historical results with a plan for
follow up.
Tuberculin Test

Other Required Lab Tests

TB test performed no more than six months prior to physical exam

Lab report peformed no more than six months prior to the physical
exam MUST be attached

❏ 5 TU PPD
Date read _______________________________

❏ HIV (bloodwork or rapid oral test)

Size of induration must be recorded in box below.

❏ CBC

Do not report “Negative”

❏ Hepatitis B surface Antigen

mm of induration

❏ Hepatitis C Antibody
❏ G6PD titer

OR

❏ Basic Metabolic Panel

A blood test was done in lieu of the PPD
❏ T SPOT. TB (negative or postive)
❏ QuantiFERON® - TB gold (lab report must be attached)

❏

negative

❏

❏ Urinalysis

positive

Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 01/2012)

Page 3 of 4

Application Case ID

Summary of the Medical Examination and Additional Comments
Provide your summary and assessment of the medical examination. Comment on all abnormal findings, including recommendations
for evaluation and/or treatment required for the next three years of service in a developing country. If additional pages are
required, include Candidate’s name and social security number on each page.
Recommendations for evaluation and/or treatment required for
the next thee years of service

List all active and/or applicant’s chronic
Conditions

1 ___________________________________________________________________________________________________________
2 ___________________________________________________________________________________________________________
3 ___________________________________________________________________________________________________________
4 ___________________________________________________________________________________________________________
5 ___________________________________________________________________________________________________________
6 ___________________________________________________________________________________________________________

Do you have any medical concerns about the applicant that might limit his/her assignment to a specific geographic area
(e.g., mountainous terrain, high altitude, sun exposure, harsh environmental or climatic conditions, etc.)? YES ❏ NO ❏ If yes, specify:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Understanding that health care resources may be very limited and potentially hours away from his/her living or working site,
do you have any concerns about this applicant serving safely in the Peace Corps? YES ❏ NO ❏ If yes, specify:____________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________

* Important

(Must be signed or co-signed by a licensed M.D. or D.O. if exam
performed by other than M.D. or D.O.)

Medical examination is complete only when:
(Please check all boxes)

____________________________________________

❒ Candidate has signed and dated HIPPA statement on Page 1.

Physician Signature/Title
Physician Name (Print)

❒ Examining Provider has signed and dated Page 4.

Date

❒ All required laboratory results are provided and reviewed, in addition to
clinically significant abnormal results (include recommendations for follow up).

❒ I have performed the physical exam as noted.

____________________________________________
____________________________________________
Physician License Number/State

____________________________________________
____________________________________________
____________________________________________
____________________________________________
Physician Address and Phone Number

INCOMPLETE FORMS WILL BE RETURNED TO THE Candidate AND WILL DELAY PROCESSING!
Peace Corps – Report of Medical Examination

Previous Editions are Obsolete

PC-OMS-1790S (Rev. 01/2012)

Page 4 of 4