Form Aid 1420 62 – Fill Out and Use This PDF

USAID Contractor Employee Physical Examination Form

PAPERWORK REDUCTION ACT NOTICE: Public reporting burden for this collection of information is estimated to average 1 hour, 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 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 U.S. Agency for International Development, M/OP/P, Rm 7.08-082U, RRB 1300 Pennslyvania Ave, NW, Washington, D.C. 20523-7801.

PAPERWORK REDUCTION ACT INFORMATION: The information requested by this form is necessary to determine the physical ability of the individual to perform duties overseas. The Physician Statement at the end of the form may be used by USAID contractors and USAID contracting officers to make such a determination with regard to work overseas on a USAID contract. Medical Information provided may be used by embassy health units to approve or disapprove the use of the health unit by USAID contractors and their dependents. Failure to provide the information requested by this form may result in an individual being denied overseas employment under a USAID contract and/or access to the U.S. embassy health room in a cooperating country.

TO BE COMPLETED BY EXAMINEE (Please print all sections in INK or use TYPEWRITER)

12.FAMILY HISTORY (If relative has a chronic disease, specify)

ANSWER ALL QUESTIONS Do Not use “PA” (Previously Answered)

PRIVACY ACT STATEMENT: This information is requested for the purpose of assisting the physician to determine your medical status. Failure to provide full information concerning your health could result in the hampering of the medical review process. The information on this form is used solely for medical and administrative purposes. No one other than the reviewing physician and staff will have access to the medical form and information without your written authorization.

CHECK EACH ITEM “YES” OR “NO”, EACH ITEM CHECKED “YES” MUST BE FULLY EXPLAINED IN BLANK SPACE ON RIGHT

YES NO

18.Have you had any significant illness or injury not noted elsewhere? (specify condition and dates)

19.Have you ever been a patient in a mental hospital or sanatorium, or been treated by a psychiatrist or psychologist? (Give date, name of doctor and/or hospital, and type of illness)

20.Have you been denied life insurance? (Give details)

21.DO YOU NOW HAVE OR HAVE YOU EVER HAD THE SYMPTOMS LISTED BELOW? (Indicate “Yes” or “No” to Each item)

Date of last Menses:

I CERTIFY THAT I HAVE READ THE ABOVE INSTRUCTIONS AND ANSWERED ALL QUESTIONS TRUTHFULLY AND COMPLETELY TO THE BEST OF MY KNOWLEDGE.

NOTE For the Examining Physician: Please review the Medical History and make appropriate comments on all positive historical data. You are required to inform the examinee of any abnormality which you have noted and/or which may require medical attention.

23.SIGNIFICANT AND/OR INTERVAL HISTORY: (Note: the examining physician MUST COMMENT on all items checked “Yes” in items 16-21).

TELEPHONE

PHYSICIAN STATEMENT

(To Be Completed and Signed By The Examining Physician)

Guidelines for Examining Physician: Please complete the following medical opinion based on the results of the REPORT OF

MEDICAL EXAMINATION.

Guidelines for Examinee: USAID contractor employees must submit to the appropriate USAID contractor a copy of the

medical opinion for the employee and each dependent.

IN MY OPINION, THE EMPLOYEE ___________________________ IS PHYSICALLY QUALIFIED TO ENGAGE IN THE

TYPE OF ACTIVITY FOR WHICH HE/SHE IS EMPLOYED, AND EMPLOYEE AND/OR DEPENDENT