Form FS-1800-3 YCC Medical History

FS-1800-3 (v12/2016)
OMB No. 0596-0084
Exp.xx/xx/20xx

United States Youth Conservation Corpss
Crew Member Medical History Form

NOTE: The collection of this information is authorized by Public Law 93-408. The purpose of this data is to safeguard the health,
safety and welfare of the enrollees of the YCC programs and may be provided to a physician in the event medical treatment is
necessary. This information is requested on a voluntary basis; however, failure to complete this form may result in exclusion from the
program.

Medical History
Please answer the following questions regarding your background, contact and other information.
First name

Middle name

Last name

Gender ☐ Male ☐ Female
Date of Birth (MM/DD/YYYY)
Transgender

☐

☐ Other/Does not identify
Address
City
Street

Email

Age

State

Home Phone

Do you have Health Insurance?
☐ No ☐ Yes
Physician Name

Suffix

Zip

Cell Phone
If yes, provide insurance company name and policy number.
Physician Phone Number

Address

City

Street

State

Zip

Have you had or are you having any of the following health conditions?
Enter X where appropriate and describe on page 3.
Allergies
☐ Hay fever
☐ Asthma
☐ Poison ivy or oak
☐ Insects stings
☐ Skin condition
☐ Other (Identify)

Frequent infections
☐ Cold
☐ Sore throat
☐ Ear ache
☐ Bladder or intestinal
infection
☐ Other (Identify)

Other health conditions
☐ Chest pains
☐ Convulsions
☐ Diabetic
☐ Difficulty with balance
☐ Fainting
☐ Heart condition
☐ Hernia

Are you currently taking any medication?
☐ Yes. If yes, explain on separate page.
☐ No

☐ Sleepwalking
☐ Rheumatism or arthritis
☐ Swollen or painful
☐ Loss of weight
joints
☐ Lyme disease
☐ Ulcers
☐ Mental health condition
☐ Other (Identify)
☐ Persistent cough
☐ Shortness of breath
☐ Problem with blood not clotting

Are you allergic to any medication?
☐ Yes. If yes, explain on separate page.
☐ No

Immunization history
Enter X where appropriate and dates as indicated. A Tetanus and Diphtheria shot is required unless you have received one
or a booster within the last ten years. You may attach your immunization record as a separate document.
Date of the original series

Date of last booster to ensure immunization

(MM/DD/YYYY)

(MM/DD/YYYY)

Tetanus, Diphtheria, Pertussis (Tdap)
Polio Vaccine (IPV)
Measles, Mumps, Rubella (MMR)
Meningococcal Conjugate Vaccine (MCV)
To my knowledge, I have not been exposed to a contagious or infectious disease in the past three weeks, and I am in
a state of health which would allow full participation in all YCC activities.
Signature:

Date:

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United States Youth Conservation Corpss
Crew Member Medical History
To be completed by Parent/Guardian
Emergency Contact First Name

Address
Street
Email

Last Name

Relationship

City

State

Phone 1

Zip

Phone 2

Please clearly outline any medications that the applicant is taking including the name and dosage. If necessary, please also outline
specific instructions for any medications that a YCC Program Staff will need to administer to the YCC Crew Member. Please use the
space below or continue on page 3.

Please identify on page 3, any condition below that would restrict full participation and describe any special care or treatment that
may be required.

Basic functional requirements for outdoor work

a. Heavy lifting, 45 pounds and over
b. Heavy carrying, 45 pounds and over
c. Straight pulling
d. Pulling hand over hand
e. Pushing
f. Reaching above shoulder

g. Use of fingers
h. Both hands required
i. Walking
j. Standing
k. Crawling
l. Kneeling

a. Outside
b. Excessive heat
c. Excessive cold
d. Excessive humidity
e. Excessive dampness or chilling

f. Dry atmospheric conditions
g. Excessive noise, intermittent
h. Dust
i. Slippery or uneven walking surfaces

m. Repeated bending
n. Climbing, legs only
o. Climbing, use of legs and arms
p. Both legs required
q. Far vision correctable in one eye to
20/20 and to 20/40 in the other
r. Hearing (aid permitted)

Environmental Factors
j. Working around moving objects or
vehicles
k. Working on ladders or scaffolding
l. Working with hands in water
m. Working closely with others
n. Working alone

I certify that I am familiar with the Youth Conservation Corps Program and that I give my consent to my son/daughter/ward to
participate in the program as a YCC member. I understand that I will not hold the United States Government responsible for
any nonprogram accident or illness, and I authorize first aid, or emergency medical care, to be performed at the nearest, most
adaquate facility approved by the YCC.
Parent/Guardian Signature

Date (MM/DD/YYYY)

PRIVACY ACT STATEMENT FOR THE YCC MEDICAL HISTORY FORM (FS-1800-3) 10/94
The following information is provided to comply with the Privacy Act of 1974 (PL-579). 5 U.S.C 301 and 7 CFR 260 authorize acceptance of the information requested on this form. Collecting this
information is necessary to assist the agency in safeguarding the health, safety, and welfare of the enrollees of the YCC programs and may be provided to a physician in the event medical treatment
is necessary. This information is requested on a voluntary basis, failure to complete this form will result in exclusion from the program. Privacy Act System of Records USDA/FS-27 Enrollee Medical
Records covers the collection and storage of, and access to these records.
BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0596-0084. The time required to complete this information collection is estimated to average 14 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs,
sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information
(Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Reviewing Officer's Signature

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Date (MM/DD/YYYY)

United States Youth Conservation Corpss
Crew Member Medical History

Additional Information
Please use this space to provide any additional information.

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