D-4015 Youth Conservation Corps Medical History Form

Form DI-4015 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1093-0010
Expires 10/30/2023

UNITED STATES YOUTH CONSERVATION CORPS
MEDICAL HISTORY FORM
To be Completed by Youth Conservation Corps (YCC) Program Applicants Only

NOTE: This information is collected under the authority of Public Law 93-408. It will be used primarily for the purpose of
determining your eligibility for Youth Conservation 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 Youth
Conservation Corps member.
APPLICANT MEDICAL HISTORY
Please answer the following questions regarding your background, contact and other information
Name:
First:

Middle

Last

Gender:

 Male

Date of Birth:

mm/dd/yyy ____/_____/______

Suffix

 Female
Age_______

Contact Information
Address:
Street

City

Email:

State

Phone 1

Zip

Phone 2

Are you covered under your family or any other type of health insurance?
 Yes  No If yes, name of insurer and policy number
Primary Care Provider Name:

Address:

Have you had or are you having any of the following health conditions? (Enter X where appropriate and describe on page
3.)
Allergies

Frequent Infection

Other health condition

 Hay fever
 Asthma

 Cold
 Sore throat

 Chest pain
 Convulsion

 Rheumatism
 Loss of weight

 Shortness of breath
 Sleepwalking

 Poison Ivy

 Earache

 Diabetic

 Lyme disease

 Swollen/painful joints

 Insect stings
 Skin condition
 Skin condition

 Bladder or
Intestinal infection
 Intestinal infection

 Difficulty with balance
 Fainting
 Problem with blood not
clotting

 Ulcers
 Persistent Cough

 Mental Health
Conditions
 Heart Condition

Other (identify)

Are you currently taking any medications?

Are you allergic to any medications?

 Yes – if yes, explain on page 2
 No

 Yes – if yes, explain on page 2
 No

Form DI-4015 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1093-0011
Expires 11/30/2023

Immunization history – Enter X where appropriate and dates as indicated. A Tdap shot is required unless you have
received one or a booster within the last ten years. You may attach a copy of your immunization record as a separate
 Check here if immunization records are attached as a separate document.
document
Date of Series
mm/dd/yyyy

Date of Last Booster to Ensure Immunization
mm/dd/yyyy

 Tetanus Toxoid, Diptheria, 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

Applicant Name

Applicant Signature

Date

Medical and Physical Abilities and Limitations
The requested below will be kept strictly confidential and safeguarded. This information will only be disclosed in
accordance with the requirements of the Department of Labor’s regulations and other applicable federal laws.
1. Please use the table below to identify any medication(s) that the applicant is currently taking. Include the name, dosage
and any specific instructions that a YCC Program Staff would need to administer medication (if necessary).
Medication Name

Dosage

Instructions

Allergic to which medications

2. Below is a list of typical activities and environmental factors required for outdoor work. Please check any of the
items below that may limit full participation in the YCC program.
Physical and functional Requirements

 Heavy lifting, 45 pounds and over
 Heavy carrying, 45 pounds and over
 Straight pulling
 Pulling hand over hand
 Pushing
 Reaching above shoulder

 Use of fingers
 Use of both hands
 Walking
 Standing
 Crawling
 Kneeling

 Repeated bending
 Climbing, legs only
 Climbing, use of legs and arms
 Use of both legs
 Hearing (aid permitted
 Corrected vision in one eye (20/20 to 20/40)

Environmental Factors

 Outside
 Excessive heat
 Excessive cold
 Excessive humidity

 Dry atmospheric conditions
 Excessive or intermittent noise
 Dust
 Slippery or uneven walking surfaces

 Working around moving objects
 Working on ladders or scaffolding
 Working with hands in water
 Working closely with others
 Working alone
Page 2 of 4

Form DI-4015 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1093-0011
Expires 11/30/2023

Please use this space to identify any of the conditions listed above that would restrict full participation or require special
care or treatment,

TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN OF THE APPLICANT
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 non-program accident or illness, and I authorize first aid, or emergency medical care,
to be performed at the nearest, most adequate facility approved by the YCC.
Name
Parent/Legal Guardian Name

Parent/Legal Guardian Signature

Date

Address:
Street

City

State

Zip

Contact Information
Email

Emergency Contact Number #1

Emergency Contact Number #2

TO BE COMPLETED BY REVEWING OFFICER

Reviewing Officer's Name

Reviewing Officer's Signature

Date

Additional Information. Please use this space to provide any additional information needed to complete the application.

Page 3 of 4

Form DI-4015 (Rev. 10/2020)
U.S. Department of the Interior

OMB Control No. 1093-0011
Expires 11/30/2023

NOTICES
PRIVACY ACT STATEMENT
Authority: 16 USC 1701-1706, Chapter 37 – Youth Conservation Corps and Public Lands Corps, Subchapter I – Youth
Conservation Corps (Youth Conservation Corps Act of 1970 (P.L. 91-378; 84 Stat. 794) as amended in 1972 (P.L. 92-597) and in
1974 (P.L. 93-408).
Purpose: This information is collected from selected applicants to determine their ability to fully participate, and to allow the
participating agencies to make necessary reasonable accommodations as appropriate.
Routine Uses: The information collected on this form may be shared in accordance with the Privacy Act of 1974 and the routine
uses listed in the DOI Office of the Secretary (OS) System of Records Notices INTERIOR/OS-25, YCC Enrollee Records available
at https://www.doi.gov/privacy/os-notices.
Disclosure: Furnishing this information is voluntary; however, failure to provide the requested information may disqualify
acceptance into the YCC program.
PAPERWORK REDUCTION ACT STATEMENT
In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), the U.S. Department of the Interior, National Park Service and
U.S. Fish and Wildlife Service, collects information necessary to assist the agencies in safeguarding the health, safety, and welfare
of the enrollees of the YCC programs. Your response is voluntary, but failure to complete this form will result in exclusion from
participation in the YCC Program. 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 currently valid OMB control number. OMB has
approved this collection of information and assigned Control No. 1093-0010.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 14 minutes, including time for reviewing instructions,
gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any
other aspect of the form to the Departmental Information Clearance Officer, U.S. Department of the Interior, 1849 C Street, NW
Washington, DC 20240, or via email at doi-pra@ios.doi.gov. Please do not send your completed form to this address.

Page 4 of 4