U.S. Department of Labor OMB Control No.: 1205-0033
Employment and Training Administration Expiration Date: xx/xx/xxxx
Job Corps Health Questionnaire (ETA 653)
PURPOSE: To determine the health and accommodation/modification needs of the applicant who has been offered enrollment in Job Corps, to obtain and verify consent for required routine medical assessments and/or consent to receive basic health care services, and to determine whether an otherwise-eligible applicant offered enrollment may pose a direct threat to self or others or has health care needs beyond the basic health care services provided by Job Corps. |
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INSTRUCTIONS: Before asking you to answer the questions on this form, Job Corps is required to tell you that:
Please
answer all of the questions to the best of your knowledge. The
collection of this information is authorized by
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1. Name (Last, First, Middle Initial)
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2. Applicant ID |
3. Sex (M/F) 4. Height (in) 5. Weight (lb)
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6 What is your general Health Condition (check one): Excellent Good Fair Poor |
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7. a. Are you or your family covered by health insurance other than Medicaid? NO YES (If YES, obtain copy of health insurance card and attach to this form.) b. Are you or your family covered by Medicaid? NO YES (If YES, obtain copy of Medicaid card and attach to this form.) |
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An answer of “Fair” or “Poor” to question 6, or a YES answer to any item in questions 8, 9, or 10 requires an explanation in question 11 on the reverse of this form. |
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8. a. Are you currently under the care of a physician, dentist, or mental health professional? NO YES How often do you go see the doctor or counselor? Daily Weekly Monthly Other |
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b. |
Are you currently taking any prescription or non-prescription medication, herbs, supplements, vitamins, etc.? |
NO |
YES |
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c. |
Do you use a medical device (e.g., prosthesis, wheelchair, CPAP, hearing aid, etc.)? |
NO |
YES |
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d. |
Do you have any known allergies (e.g., medication, food, etc.)? |
NO |
YES |
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e. |
Do you wear braces on your teeth? |
NO |
YES |
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In the past 2 years have you |
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f. |
Been refused or discharged from military service for medical or mental health reasons? |
NO |
YES |
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g. |
Had a medical professional (e.g., doctor) advise you to have a medical or surgical procedure that you have not yet received? |
NO |
YES |
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h. |
Had a medical or surgical procedure? |
NO |
YES |
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i. |
Been hospitalized or treated in an emergency room for medical, mental health, or substance use reasons? |
NO |
YES |
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j. |
Had a serious dental problem or problems (e.g., untreated dental infections, missing teeth, unresolved severe toothaches, etc.)? |
NO |
YES |
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k. |
Received counseling or treatment for a mental health issue? |
NO |
YES |
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l. |
Received counseling or treatment for drug and/or alcohol use? |
NO |
YES |
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m. |
Attempted to hurt yourself (e.g., cut yourself, deliberately overdosed on medication or other drugs)? |
NO |
YES |
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n. |
Thought about hurting yourself or planned to hurt yourself? |
NO |
YES |
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o. |
Intentionally tried to hurt someone else? |
NO |
YES |
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p. |
Been afraid that others want to physically harm you? |
NO |
YES |
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q. |
Heard voices or seen things that other people did not hear or see? |
NO |
YES |
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r. |
Believed that your thoughts were being controlled by someone or something other than yourself? |
NO |
YES |
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s. |
Lost control of your anger, or feared losing control of your anger, to the point of hurting yourself or someone else? |
NO |
YES |
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t. |
Been in a physical fight that resulted in hospitalization or significant injury of you or the other person? |
NO |
YES |
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u. |
Been removed from your home, school or job due to your behavior? |
NO |
YES |
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v. |
Stopped getting treatment and/or taking medication that a doctor or other medical professional prescribed for you? |
NO |
YES |
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w. |
Participated in a residential or day therapeutic program where you received medical, alcohol or drug abuse, or mental health care? |
NO |
YES |
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9. To your knowledge, have you EVER had or do you now have any of the following conditions? |
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a. |
Anemia (including sickle cell disease) |
NO |
YES |
s. |
Learning disabilities (e.g., dyslexia, etc.) |
NO |
YES |
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b. |
Asthma |
NO |
YES |
t. |
Attention Deficit/Hyperactivity Disorder (ADD or AD/HD) |
NO |
YES |
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c. |
Visual impairment/trouble seeing |
NO |
YES |
u. |
Mental Retardation (MR)/ Intellectual Disability/ Developmental Disability |
NO |
YES |
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d. |
Hearing impairment/trouble hearing |
NO |
YES |
v. |
Depression |
NO |
YES |
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e. |
Obesity |
NO |
YES |
w. |
Anxiety or Trauma and Stress-Related Disorders (e.g., generalized anxiety disorder, panic disorder, post-traumatic stress disorder, etc.) |
NO |
YES |
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f. |
Diabetes (high blood sugar) |
NO |
YES |
x. |
Obsessive-Compulsive Disorder |
NO |
YES |
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g. |
Heart condition |
NO |
YES |
y. |
Disruptive and Impulse Control Disorders (e.g., oppositional defiant disorder, fire-setting, intermittent-explosive disorder, etc.) |
NO |
YES |
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h. |
High blood pressure |
NO |
YES |
z. |
Schizophrenia |
NO |
YES |
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i. |
Kidney, bladder, or urinary problems |
NO |
YES |
aa. |
Conduct Disorder |
NO |
YES |
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j. |
Speech problem (e.g., stuttering, etc.) |
NO |
YES |
bb. |
Traumatic Brain Injury |
NO |
YES |
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k. |
Tuberculosis (TB) or positive TB skin test |
NO |
YES |
cc. |
Bipolar Disorder |
NO |
YES |
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l. |
Ulcer of stomach or intestines or colitis |
NO |
YES |
dd. |
Personality Disorders (e.g., anti-social, borderline, etc.) |
NO |
YES |
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m. |
Epilepsy, seizures, convulsions |
NO |
YES |
ee. |
Autism Spectrum Disorders (i.e., Asperger’s or Autism) |
NO |
YES |
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n. |
Hepatitis |
NO |
YES |
ff. |
A mental health problem or concern |
NO |
YES |
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o. |
Cancer/malignancy |
NO |
YES |
gg. |
A drug and/or alcohol problem or concern |
NO |
YES |
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p, |
Sleep Apnea |
NO |
YES |
hh. |
Other health problems or concerns |
NO |
YES |
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q. |
Organ transplant |
NO |
YES |
ii. |
FEMALES: Are you pregnant? If YES, approximate date last menstrual period began. ____________________ |
NO |
YES |
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r. |
Muscle or bone disorder |
NO |
YES |
10. If you are a person with a disability, you may request accommodations (changes in the way things are done, or other types of extra support to help you participate in the Job Corps program). Would you like, or do you think you will need, any of these extra supports? |
NO |
YES |
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11. Provide explanation below of any YES responses to items in questions 8, 9, or 10. If additional space is needed, attach separate sheet. If the applicant offered enrollment is not sure whether he/she had one of the conditions mentioned in question 9, or whether he/she needs an accommodation, include whatever information the applicant offered enrollment provides. If the applicant offered enrollment declines to give additional information, indicate in this section that the applicant offered enrollment declined to respond. |
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Explanation |
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All disability-related or other medical information that is contained in this health questionnaire, or that is obtained through the authorizations contained in this document, will be collected and maintained separately from other information regarding the applicant offered enrollment, and will be kept strictly confidential. This information will only be disclosed in accordance with the requirements of the Department of Labor’s regulations. The confidentiality requirements expressed in the above paragraph are separate and different from the confidentially requirements for health information imposed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under the Department of Labor’s regulations related to discrimination on the basis of disability, the disclosure of medical and disability-related information about a particular individual is only permitted in accordance with those regulations, even if a recipient, such as a Job Corps contractor or center operator, obtains a signed release form explicitly authorizing disclosure that is or would be inconsistent with those regulations. |
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Applicant Signature: |
Date: |
Parent/Guardian Signature (if applicant offered enrollment is a minor): |
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 and expiration date. Public reporting burden for this collection of information, which is required to obtain or retain benefits (29 USC 3199), is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. This information collection is for program management. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the US Department of Labor, Office of Job Corps, Room N-4507, Washington, D.C. 20210 (OMB Control No. 1205-0033).
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ETA 653 (rev 5/2017)
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | PURPOSE: To determine the health and accommodation/modification needs of the Job Corps applicant |
Author | bgrove |
File Modified | 0000-00-00 |
File Created | 2021-01-22 |