DI-4015 YCC Medical History Form

Form DI-4015 (Rev. 10/2020)

U.S. Department of the Interior

OMB Control No. 1093-0010

Expires 10/30/2023

U NITED 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. Furnishing this information is voluntary; however, failure to provide the requested information may disqualify acceptance into the Youth Conservation Corps program.

APPLICANT MEDICAL HISTORY

1. Please answer the following questions regarding your background, contact, and other information

Name:

First: ________________________ Middle: ___________________ Last: ______________________ Suffix: _________

2. Gender:  Male  Female  Non-Binary  Self-identify as: __________________  Prefer not to disclose

3. Date of Birth: mm/dd/yyyy / /

Contact Information

4. Address:

Age:

Street ____________________________________________________ City _____________________ State ________ Zip _______

Email ____________________________________________ Phone 1 ______________________ Phone 2 _____________________

5. Are you covered under your family or any other type of health insurance?

 Yes  No If yes, list name of insurer and policy number: _____________________________________________

Primary Care Provider Name: __________________________________ Address: __________________________________________

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

Allergies Recent or Recurring Other health conditions

Infections

 Hay fever  Cold  Chest pain  Rheumatism  Shortness of breath

 Asthma  Sore throat  Convulsion  Loss of weight  Sleepwalking

 Poison ivy  Earache  Diabetic  Lyme disease  Swollen/painful joints

 Insect stings  Bladder infection  Difficulty with balance  Ulcers  Mental health

 Skin condition  Intestinal infection  Fainting  Persistent cough conditions

 Problem with blood not  Heart condition

clotting

Other (identify) _________________________________________________________________________________________________

7. Are you currently taking any prescribed medications? Are you allergic to any medications?

• Yes – if yes, explain on page 2

• No

• Yes – if yes, explain on page 2

• No

8. Immunization history – Applicants must have received a Tdap immunization (Tetanus Toxoid, Diphtheria, Pertussis) or booster within the last ten years to participate in the YCC program.

Date of Tdap immunization or last booster (mm/dd/yyyy): ____________________________

Medications

9. 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

10. List any over-the-counter medications that YCC program staff have approval to administer if needed (i.e., ibuprofen):

__________________________________________________________________________________________

11. List all medications to which you are allergic:

Medical and Physical Abilities and Limitations

12. Below is a list of typical activities and environmental factors required for outdoor work. Please check any of the items below that may limit your participation in certain types of projects within the YCC program. The YCC site will work with you to adjust projects and accommodate any limitations to the best of their ability.

Physical and Functional Limitations

 Heavy lifting, 45 pounds and over  Use of fingers  Repeated bending

 Heavy carrying, 45 pounds and over  Use of both hands  Climbing, legs only

 Straight pulling  Walking  Climbing, use of legs and arms

 Pulling hand over hand  Standing  Use of both legs

 Pushing  Crawling  Hearing

 Reaching above shoulder  Kneeling  Corrected vision in one eye (20/20 to 20/40)

Environmental Factors

 Outside  Dry atmospheric conditions  Working around moving objects

 Excessive heat  Excessive or intermittent noise  Working on ladders or scaffolding

 Excessive cold  Dust  Working with hands in water

 Excessive humidity  Slippery or uneven walking surfaces  Working closely with others

• Working alone

Please use this space to further explain any factors listed above that would require additional care or treatment.

TO BE COMPLETED BY THE APPLICANT IF 18 YEARS OLD

13. I certify that I am familiar with the Youth Conservation Corps (YCC) program and am ready 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. I authorize the sharing of pertinent medical information with a medical care provider in the event first aid or emergency medical care is needed.

Name
Applicant Name	Applicant/ Signature (digital signature is acceptable)		Date (mm/dd/yyyy)
Emergency Contact Information

Name Email Emergency Contact Number #1 Emergency Contact Number #2

TO BE COMPLETED BY THE PARENT OR LEGAL GUARDIAN IF THE APPLICANT IS UNDER THE AGE OF 18

14. I certify that I am familiar with the Youth Conservation Corps (YCC) program and that I give my consent for my child/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. I authorize the sharing of pertinent medical information with a medical care provider in the event first aid or emergency medical care is needed.

Name
Parent/Legal Guardian Name	Parent/Legal Guardian Signature (digital signature is acceptable)			Date (mm/dd/yyyy)
Address:
Street Contact Information	City	State		Zip

Email Emergency Contact Number #1 Emergency Contact Number #2

TO BE COMPLETED BY REVIEWING 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.

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 and the U.S. Department of Agriculture – U.S. Forest Service collect 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.