Lds Missionary Physical Form Details

Missions are a critical piece of the Christian church. As believers, we are called to go into all the world and preach the gospel. There are many different types of missions, and each one carries its own set of unique challenges. One important part of any missionary's journey is obtaining a mission recommendation letter from their local church. This document provides proof that the individual has been approved by their home church to embark on their mission trip. In order to make the process as smooth as possible, your church can use a missionary recommendation checklist form to keep track of all the required information. such a form can be found online or in your local Christian bookstore.

Below, you will find some specifics of missionary recommendation checklist PDF. You may want to learn its length, the typical time to fill out the form, the blanks you'll have to fill in, and so on.

QuestionAnswer
Form NameMissionary Recommendation Checklist
Form Length21 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min 15 sec
Other namesmissionary recommendation form, church jesus missionary recommendation, missionary form template, missionary form

Form Preview Example

Checklist for Full-Time Missionary Recommendation

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

To the Bishop or Branch President

Review the Church Handbook of Instructions, Book 1: Stake Presidencies and Bishoprics, and the First Presidency letters of 12 December 2000 and 11 December 2002 for information on qualifications, terms of service, requirements for special clearance, and other instructions on calling missionaries.

The missionary recommendation packet for young missionaries should be submitted to the Missionary Department not more than 90 days before the candidate's availability date. Couples' packets may be submitted up to five months in advance. The date given in the “Date available to serve” field should not be earlier than the birthday when the missionary reaches the minimum age for service. Normally about two to four months are allowed between the issuing of the call and the beginning of the mission.

If the candidate has been living away from home, the home bishop or branch president and the away-from-home bishop or branch president must confer regarding worthiness and the procedures for submitting the recommendation forms (see the Church Handbook of Instructions, Book 1).

Conduct a thorough, searching interview with the candidate to determine

worthiness, qualifications, and the individual's physical and emotional capability to serve. Confirm that the candidate has an understanding and testimony of the Savior and His Atonement, the Restoration and Joseph Smith' role in it, the Book of Mormon (having read it), and the singular privilege of serving the Savior as a missionary.

Give the candidate the missionary recommendation packet.

Review these forms after the candidate completes them. Ensure that any serious concerns are resolved, including completion of recommended tests or treatment, before the forms are submitted. Give special attention to emotional, behavioral, and learning problems. If the candidate is on medication for a chronic condition, encourage him or her to continue the medication throughout the mission.

Conduct a final interview with the candidate before submitting the forms. Make sure that all requested information has been provided, and fill in the Unit Information for Missionary Candidate form including the candidate's record number. Discuss with the candidate important information requested on the forms, such as visa or citizenship documentation and information about special medical problems, diets, or medications.

Ensure that after the contribution from the missionary and family, the ward or branch missionary fund can meet the financial obligation for the missionary.

For countries where supplemental financial support from the General Missionary Fund is authorized: If the candidate cannot be supported fully from personal, family, ward or branch, or stake or district funds, complete a Request for Supplemental Financial Assistance for Full-Time Missionary form (31964), and send it to the area office with the missionary recommendation packet. Do not request assistance from the General Missionary Fund until the missionary, the family, and the ward or branch and stake or district have committed themselves to provide all the financial support they can.

Ensure that family members and others contributing to the Church's missionary funds are aware that contributions belong to the Church for use in its discretion to further missionary work and are not refundable even if the missionary is unable to complete the full term of his or her mission.

On the Priesthood Leaders' Comments and Suggestions form, provide pertinent information on the candidate' qualifications and abilities. Add comments on the candidate' experience, leadership capability, potential, interests, talents, or limitations that should be considered in determining the mission assignment.

The picture that accompanies the recommendation form should be current and should show the candidate dressed and groomed according to missionary standards.

Sign the Priesthood Leaders' Comments and Suggestions form and send all required forms to the stake president. When you sign this form, you are stating that in your opinion this individual is worthy to serve a mission. You are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically and emotionally able to serve a mission.

Do not recommend members who are in debt and have not made definite arrangements to meet their financial obligations.

To the Stake or Mission President

Review the Church Handbook of Instructions, Book 1: Stake Presidencies and Bishoprics, and the First Presidency letters of 12 December 2000 and 11 December 2002 for information on qualifications, terms of service, requirements for special clearance, and other instructions on calling missionaries.

Conduct a thorough, searching interview. Confirm that the candidate has an understanding and testimony of the Savior and His Atonement, the Restoration and Joseph Smith's role in it, the Book of Mormon (having read it), and the singular privilege of serving the Savior as a missionary.

Add your comments on the Priesthood Leaders' Comments and Suggestions form.

Make sure that all concerns have been resolved or adequately explained either on the Priesthood Leaders' Comments and Suggestions form or, if confidential, in a separate letter.

Review all forms for accuracy and completeness.

Sign the Priesthood Leaders' Comments and Suggestions form, and send all forms to the Missionary Department (at the address above). When you sign this form, you are stating that in your opinion this individual is worthy to serve a mission. You are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically and emotionally able to serve a mission.

Missionary Recommendation

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Full legal name (first)

(middle)

(last)

(suffix)

 

Date available to

 

 

 

 

 

 

serve

 

 

 

 

 

 

 

 

Home street address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State or province

Postal code

 

 

 

 

 

 

 

 

Country

 

 

District (if any)

 

Airport

 

 

 

 

 

 

 

Home phone (include area code)

 

 

E-mail address (optional)

 

 

 

 

 

 

 

 

Other states, provinces, or countries where you have lived recently (or for extended periods)

Address where your call should be sent, if different from home address

City

State or province

Postal code

 

 

 

 

 

Country

District (if any)

 

 

 

 

 

 

Phone (include area code)

Date of birth

Gender

 

 

 

Female

Male

 

 

 

 

Attach with tape one (1) photograph of the

missionary candidate dressed and groomed according to missionary standards.

Confirmation date

Current marital status

Have you ever been

 

 

 

 

 

 

 

Single

Married

Widowed

Divorced

 

 

 

 

 

 

 

 

 

 

Have ever been arrested (If yes to any of these, explain, including date of arrest, charge, and resolution.)

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have ever had a police record

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have ever been convicted of a crime

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship at birth

 

 

Place of birth (city, state, or

Birth

Current country of citizenship

If dual citizenship, indicate second

 

 

 

 

province)

 

 

country

 

 

 

country of citizenship.

 

 

 

 

 

 

 

 

You have an official birth certificate

 

 

Currently a documented citizen of your resident country (If no, indicate your current status in your country of residence.)

Yes

No

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship status imposes restrictions on traveling outside

 

Nationalities of ancestors

 

 

 

 

 

the country where you live

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You have a current passport

 

 

Expiration date:

 

 

 

Name (exactly as it appears on the passport)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passport Number

 

 

Country of Issue

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father's Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father's full name

 

 

Father is a member

 

 

 

Father is deceased

 

 

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Father's birthplace (city, state, or province)

 

 

Father's occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father's street address, if different from your home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State or province

 

 

 

Postal code

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

District (if any)

 

 

 

 

 

 

Home phone (include area code)

E-mail address (optional)

Check here if you do NOT want your father to be contacted at all.

Missionary Recommendation

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Mother's Information

Mother's full name

 

 

 

Mother is a member

Mother is deceased

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

Mother's birthplace (city, state, or province)

 

Mother's occupation

 

 

 

 

 

 

 

Mother's street address, if different from your home address

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

State or province

Postal code

 

 

 

 

 

 

 

 

 

Country

 

 

 

 

District (if any)

 

 

 

 

 

 

 

Home phone (include area code)

 

 

E-mail address (optional)

Check here if you do NOT want your mother to be

 

 

 

 

 

 

 

contacted at all.

 

 

 

 

 

 

 

Residence and Caregiver Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You live with:

 

 

 

 

 

 

 

 

Both parents

Mother only

Father only

Other (name)

 

(relationship)

 

 

 

 

 

 

 

 

 

 

If you do not live with both parents, please explain why.

 

 

 

 

 

 

 

 

 

Address of caregiver, if other than parents and different from home address

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

Postal code

 

Country

 

 

 

 

 

 

 

 

State or province

 

 

 

District (if any)

 

 

 

 

 

 

 

Home phone (include area code)

 

 

E-mail address (optional)

Check here if you do NOT want this person to be

 

 

 

 

 

 

 

contacted at all.

 

 

 

 

 

Other Family Members Who Have Served or Are Serving Missions

 

 

 

 

 

 

Father has served a mission (If yes, give name of mission.)

Mother has served a mission (If yes, give name of mission.)

Grandparents have served missions (If yes, give name of

Yes

No

 

 

 

Yes

No

missions.)

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

Relationship and location of immediate family members currently serving missions (parents, brother, sister, grandparents)

Priesthood Leaders' Comments and Suggestions

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionary candidate's name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Final Evaluation (Items to be reviewed by priesthood leaders)

Check the following when they are complete:

I have reviewed all forms completed by the candidate.

I have discussed and resolved my concerns, if any, with the candidate.

The candidate is worthy to hold a temple recommend.

The candidate is willing to serve where called and in any assignment that might be given.

Has the candidate lived outside your ward for any significant time in the last year? (School, Military, Employment, etc.)

If yes, enter the date on which you conferred with the candidate's former bishop.

Bishop's or Branch President's Recommendation Provide information on the qualifications and abilities of the missionary candidate. Comment on the experience, leadership capability, potential, interests, talents, or limitations of the candidate that should be considered in determining the mission assignment. Confidential comments should be discussed in a separate letter.

Please evaluate the missionary candidate's leadership capability.

Low

1

2

3

4

5

High

 

 

 

 

 

Bishop or Branch President's Confidential Comments

When you sign this form, you are stating that in your opinion this individual has a testimony of the gospel and is worthy and willing to serve a mission wherever called. You are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically and emotionally able to serve a mission.

Bishop or branch president's signature

Telephone (include area code)

Date submitted

 

 

 

Print name

Unit name

Unit number

 

 

 

Priesthood Leaders' Comments and Suggestions

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionary candidate's name (first)

(middle)

(last)

(suffix)

Check the following when they are complete:

I have reviewed all forms completed by the candidate.

I have discussed and resolved my concerns, if any, with the candidate.

The candidate is worthy to hold a temple recommend.

The candidate is willing to serve where called and in any assignment that might be given.

Age

Gender

Female Male

Stake or Mission President's Recommendation Provide information on the qualifications and abilities of the missionary candidate. Comment on the experience, leadership capability, potential, interests, talents, or limitations of the candidate that should be considered in determining the mission assignment. Confidential comments should be discussed in a separate letter.

When you sign this form, you are stating that in your opinion this individual has a testimony of the gospel and is worthy and willing to serve a mission wherever called. You are also confirming that you have reviewed the medical information and conducted a thorough personal interview, which has convinced you that this person is physically and emotionally able to serve a mission.

Stake or Mission President's Confidential Comments

Stake or mission president's signature

Telephone (include Area Code)

Date submitted

 

 

 

Print name

Unit name

Unit number

 

 

 

If English is not the candidate's native language, have a native English speaker evaluate his or her English-speaking ability. The evaluators should use the following questions to interview the candidate and check the appropriate ranking, paying particular attention to the candidate' ability to use correct verb tenses, to answer appropriately, and to use sentences.

What did you do to prepare for your mission? What will you do on your mission to ensure that you are successful? Tell me about your favorite scripture. Key: Nonfunctional — Does not respond to questions.

Partially Functional — Has difficulty resonding to questions; does not use complete sentences or appropriate verb tense. Functional — Responds appropriately to questions; uses complete sentences; generally uses proper verb tense.

Fluent — Understands and speaks with near-native ability; mostly uses proper verb tenses; responds confidently.

0

1

2

3

4

5

6

7

No English

Nonfunctional

 

Partially Functional

 

Functional

 

Fluent

Area Medical Advisor Review

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionary candidate's name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Area Medical Advisor Review Based on a review of the missionary candidate's history, the physician's health evaluation, and a review of laboratory findings, indicate the candidate's ability to function at various levels of activity as a missionary.

Level A—No limitation

Level B—Slight limitation

Level C—Moderate limitation

Level D—Marked limitation

Level E—Not appropriate

No limitation of activity in lifting,

Slight limitation of activity; slight

Moderate limitation of activity;

Marked limitation of activity or has

Conditions exist for which corrective

carrying, walking 6 or more

decrease of function or stamina,

moderate decrease of function or

special requirements, such as specific

action has not been or cannot be

miles per day, or spending 12 to

such as problems with walking

stamina; requires limited walking

climate, use of wheelchair, frequent

taken, such as severe chronic pain,

16 hours per day in missionary

(limited to 3-6 miles per day) or with

(0-3 miles per day) or sedentary

rest periods, special medical needs, or

loss of stamina, or recurring

activity.

extensive standing.

work.

medical visits.

conditions.

 

 

 

 

 

Selected Limitations

 

 

 

 

 

 

 

 

 

Additional Comments

 

 

 

 

 

 

 

 

 

Education and Service of Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Your full legal name (first)

(middle)

 

 

(last)

 

(suffix)

 

Age

 

Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of years studied in the last 5 years

 

 

 

Language

 

 

Native speaker

 

(Complete this column for languages you do

Average grade

 

 

 

 

 

 

 

 

 

NOT speak natively.)

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language you want your call letter to be printed in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate how interested you are in learning a language.

 

 

 

 

 

 

 

 

 

 

Very interested

Moderately interested

Somewhat interested

 

Not interested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rate how successful you feel you would be in learning a language for your mission.

 

 

 

 

 

 

 

Very successful

Moderately successful

Somewhat successful

Not very successful

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Education and Work Experience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Highest education level achieved

Graduated from high school

Rate your performance at schoolwork

 

 

 

 

 

 

 

 

Yes

No

 

Extremely good

Very good

Good

Average

Not very good

Poor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Years in seminary

 

Graduated from seminary

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Post-secondary education (such as bachelor's degree)

 

 

 

 

 

 

 

 

 

 

Number of years

 

 

 

 

Degree

 

 

 

 

 

 

 

Major

School

Post-graduate education (such as master's degree, doctorate, and so on)

Number of years

Degree

Major

School

Extracurricular activities, special skills, hobbies, and special accomplishments

Previous Church callings and leadership experience

Work experience outside the home (Include number of years in each job.)

Office experience

 

 

 

 

General bookkeeping

Word processing

WPM

Computers

Details

Education and Service of Missionary Candidate

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Other Information

Driver's license

Yes No

Expiration date

Country

State or province

 

 

License has been suspended If yes, explain. (Give date and reason for suspension.) Yes No

Military Information

Current or previous military experience

Name of military organization

Yes

No

 

 

 

Member of military reserve unit (U.S. only)

Name of reserve organization

Yes

No

 

 

 

Reserve service number

Name of commanding officer

Unit mailing address

City

State or province

Postal code

Source of Funds Indicate how much money (in your local currency) will be contributed per month in support of your mission from the sources below. Enter single combined amount for a couple in “Self.”

Local currency

Self

Family

Ward or branch

Other

Total

Candidate Comments Explain any special circumstances or situations that the Brethren should consider when making your mission call.

Comments

Unit Information for Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionary candidate's record number (provided by ward or branch)

Unit Information Completed by bishop or branch president

Home ward or branch

 

Unit number

Home stake or mission

 

 

 

 

 

 

 

 

Name of home bishop or branch president

 

Name of home stake or mission president

 

 

 

 

 

 

 

Mailing address (including country)

 

Mailing address (including country)

 

 

 

 

 

 

 

Home phone (area code)

Work phone (area code)

Cell phone (area code)

Home phone (area code)

Work phone (area code)

Cell phone (area code)

 

 

 

 

 

 

E-mail address

 

Fax

E-mail address

 

Fax

 

 

 

 

 

Unit Information for Unit Submitting Recommendation If other than home unit

 

 

 

 

 

 

 

 

 

Ward or branch

 

Unit number

Stake or mission

 

 

 

 

 

 

Name of bishop or branch president

 

Name of stake or mission president

 

 

 

 

 

Mailing address (including country)

 

Mailing address (including country)

 

 

 

 

 

 

 

Home phone (area code)

Work phone (area code)

Cell phone (area code)

Home phone (area code)

Work phone (area code)

Cell phone (area code)

 

 

 

 

 

 

E-mail address

 

Fax

E-mail address

 

Fax

 

 

 

 

 

 

Instructions for Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

1. Complete all information on the Missionary Recommendation form.

 

Have the physician complete the Physician's Health Evaluation of

Type if possible, or print neatly in black ink. Write dates in day, month,

 

Missionary Candidate form and mail it and the Personal Health History

year format (15 Dec 2001).

 

of Missionary Candidate form to your bishop or branch president.

2. Complete the Education and Service of Missionary Candidate form. Fill

 

Where mail is unreliable, personally retrieve the forms.

 

 

out the Personal Health History of Missionary Candidate form

7.

Begin the hepatitis A and B immunizations and boosters for diphtheria,

completely, honestly, and accurately before your medical examination.

 

tetanus, measles, and mumps immediately. You will receive additional

3. Sign the “Authorization to Release Information” section on the

 

immunization information with your mission call.

 

 

Physician's Health Evaluation of Missionary Candidate form.

8.

Obtain a thorough dental examination. Begin early. Sign the

4. If you have had any major illness, major operation, major injury,

 

“Authorization to Release Information” section on the Dental Evaluation

 

for Missionary Candidate form, and give the form to the dentist along

prolonged treatment, or hospitalization, obtain a statement from the

 

 

with a stamped envelope addressed to your bishop or branch

professional who treated you, if possible, to explain the nature of the

 

 

president. Have the dentist fill out the form and mail it to your bishop or

problem and its current status. It is important that you provide complete

 

 

branch president. Where mail is unreliable, personally retrieve the

information about your physical condition. For example, it is not enough

 

 

forms.

to say that you had a knee injury; you must also state which knee was

 

 

 

injured and explain whether there are any persistent problems with the

9.

Have all dental work, including orthodontic work, completed before

knee.

 

submitting the missionary recommendation packet to your bishop or

5. The Physician's Health Evaluation of Missionary Candidate form must

 

branch president.

 

 

be signed by a medical doctor (MD) or doctor of osteopathy (DO). If the

10.

You are expected to be physically and emotionally capable of working

examination is done by a physician assistant (PA) or nurse practitioner

 

several hours a day. For young missionaries, this means walking

(NP), the supervising physician must verify the findings and review and

 

several miles a day six days a week. If there are reasons why this

countersign the form. An examination by any other practitioner is not

 

might not be possible, please discuss them with your bishop or branch

acceptable.

 

president.

6. Give the following forms to the physician along with a stamped envelope

11.

Before entering the MTC, correct any problems such as plantar warts,

addressed to your bishop or branch president:

 

flat feet, chronic headaches, inguinal hernias, and so on. Stabilize and

The completed Personal Health History of Missionary Candidate

 

understand the treatment for chronic problems such as asthma,

 

diabetes, seizures, emotional disorders, irritable bowel, endometriosis,

form.

 

 

and so on.

The Instructions for Physicians Evaluating Missionary Candidates.

 

 

 

The Physician's Health Evaluation of Missionary Candidate form.

12.

If you are taking prescribed medication for any chronic problem,

 

medical or emotional, do not stop taking it unless your physician

 

 

 

 

advises you to do so. Please list on the Personal Health History of

 

 

Missionary Candidate form all medications you are currently taking.

 

13.

Complete all appropriate sections of the Personal Insurance

 

 

Information of Missionary Candidate form.

 

 

Instructions for Parents of Young Missionaries

5. Pay particular attention to item 11 above. This will help avoid unnecessary

1. Review the completed forms, and add any pertinent information.

problems and expenses in the MTC or the mission field.

 

 

2. Please make sure that the instructions under item 3 above are carried out

6. If you have private insurance coverage for your son or daughter, do not

discontinue it. Please note it on the Personal Insurance Information of

and that clarifying statements are submitted with the Personal Health

Missionary Candidate form with pertinent data.

History of Missionary Candidate form. Failure to do so may delay the

 

 

mission call unnecessarily.

7. During the mission, a missionary’s family must bear the costs of caring for

 

preexisting medical conditions. A preexisting condition is any chronic,

3. Encourage your son or daughter to continue to take any prescribedcongenital, or medical condition with signs or symptoms, a diagnosis, or

medications. Problems may arise when missionary candidates stop taking treatment within two years before the missionary enters the mission field, medication because they believe that being on medication might affect the

missionary assignment they receive.

regardless of whether the symptoms are present when the missionary enters the field.

4. Please make sure your son or daughter gets thorough medical and dental All donations to the Church's missionary funds become the property of the examinations. The Church is greatly concerned about the health and safety

of the missionaries. The purpose of a careful medical evaluation is to

Church to be used at the Church' sole discretion in its missionary programs. Contributions are not refundable, including any advance contributions, if the

ensure that missionaries can handle the rigors of missionary work and missionary is unable to complete the full term of the mission. receive assignments in which they can succeed. Missionaries are exposed

to many physical, environmental, social, and emotional stresses, often in areas where there is minimal medical care. It is unfortunate when a missionary must return home early because of problems that could have been avoided or stabilized before the mission.

Personal Health History of Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Please answer all of the following questions. Be honest with yourself, your physician, and the Lord. Major difficulties may result if this information is not complete and accurate. Please do not withhold or deny any medical information.

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Key: Current = is currently occurring; Previous = occurred previously, but is now resolved; Never = has never occurred

Current

Previous

Never

1.

Persisting difficulties from serious injury or deformity of your head or other body parts

 

 

 

 

 

Current

Previous

Never

2.

Sight impairment, glaucoma, or cataracts (need for glasses or contacts; chronic eye infection)

 

 

 

 

 

Current

Previous

Never

3.

Problems with hearing normal conversation (require a hearing aid)

 

 

 

 

 

Current

Previous

Never

4.

Recurrent sinusitis, sore throat, ear infections, or nasal obstruction

 

 

 

 

 

Current

Previous

Never

5.

Lung disease, emphysema, tuberculosis, shortness of breath, spitting or coughing up blood or colored sputum, or collapsed lung

 

 

 

 

 

Current

Previous

Never

6.

Hay fever or allergies

 

 

 

 

 

Current

Previous

Never

7.

Asthma

 

 

 

 

 

Current

Previous

Never

8.

High blood pressure, irregular heart rhythm, heart pain, coronary artery disease, congenital heart disease, or cardiomyopathy

 

 

 

 

 

Current

Previous

Never

9.

Varicose veins or thrombophlebitis

 

 

 

 

 

Current

Previous

Never

10.

Heartburn, reflux, ulcers, irritable bowel, chronic diarrhea, rectal bleeding, ulcerative colitis, or Crohn’s disease

 

 

 

 

 

Current

Previous

Never

11.

Gall bladder disease or stones, hepatitis, or cirrhosis or other liver problems

 

 

 

 

 

Current

Previous

Never

12.

Rupture (hernia), varicocele, or varices

 

 

 

 

 

Current

Previous

Never

13.

Diabetes

 

 

 

 

 

Current

Previous

Never

14.

Hypoglycemic attacks

 

 

 

 

 

Current

Previous

Never

15.

Thyroid or other hormonal problems or unexplained weight loss

 

 

 

 

 

 

 

 

16.

Kidney or urinary difficulties

Current

Previous

Never

 

16.1.

Kidney or urinary disease or stones, repeated urinary infections, burning or frequent urination, or difficulty urinating

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

16.2.

Incontinence or enuresis (bed wetting)

 

 

 

 

 

 

 

 

Current

Previous

Never

17.

Sexually transmitted disease

 

 

 

 

 

Current

Previous

Never

18.

Chronic skin sores, rashes, warts on feet, changing moles, lumps, or swelling

 

 

 

 

 

Current

Previous

Never

19.

Acne requiring Accutane

 

 

 

 

 

Current

Previous

Never

20.

Sensitivity to the sun

 

 

 

 

 

Current

Previous

Never

21.

Tattoos

 

 

 

 

 

Current

Previous

Never

22.

Back or neck injury, arthritis in back or neck, spondylitis, chronic back or neck pain, or difficulty lifting things

 

 

 

 

 

 

 

 

23.

Upper extremity—loss of any part or deformity, paralysis, joint pain, arthritis, or other problem in:

Current

Previous

Never

 

23.1.

Shoulder

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

23.2.

Elbow

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

23.3.

Hand or wrist

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

23.4.

Other upper extremity

 

 

 

 

 

 

 

 

 

Personal Health History of Missionary Candidate

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

24. Lower extremity—loss of any part or deformity, paralysis, joint pain, arthritis, or other problem in:

Current

Previous

Never

 

24.1.

Foot

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

24.2.

Ankle

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

24.3.

Knee

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

24.4.

Hip

 

 

 

 

 

 

 

 

Current

Previous

Never

 

24.5. Other lower extremity (such as ingrown toenails)

 

 

 

 

 

 

 

 

 

 

25. Frequent or severe headaches:

Current

Previous

Never

 

25.1.

Migraine headaches

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

25.2.

Tension headaches

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

25.3.

Frequent mild headaches

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

25.4.

Other headaches

 

 

 

 

 

 

 

 

Current

Previous

Never

26.

Unconsciousness from head injury or interference with coordination or skilled movements; weakness or sensory loss from illnesses such

 

 

 

 

as Parkinson's disease, multiple sclerosis, stroke, and so on

Current

Previous

Never

27.

Fainting, dizziness, convulsions, seizures, or hyperventilation

 

 

 

 

 

Current

Previous

Never

28.

Frequent feelings of being sick or easily tired, anemia, or bleeding tendency

 

 

 

 

 

Current

Previous

Never

29.

Chronic fatigue syndrome or fibromyalgia syndrome

 

 

 

 

 

Current

Previous

Never

30.

Insomnia or difficulty sleeping

 

 

 

 

 

Current

Previous

Never

31.

Tumors, cancers, leukemia, chemotherapy, radiation therapy, or organ transplantation

 

 

 

 

 

Current

Previous

Never

32.

Reaction or allergy to drug or medication

 

 

 

 

 

Current

Previous

Never

33.

Taking medications (prescriptions, over the counter drugs, or vitamins and supplements)

 

 

 

 

 

Current

Previous

Never

34.

Other diseases or problems with your physical health not already noted, including family history of tuberculosis or other disease

 

 

 

 

 

Current

Previous

Never

35.

Surgery, hospitalization, or injuries not listed above

 

 

 

 

 

 

 

 

36.

Learning difficulties:

Current

Previous

Never

 

36.1.

ADD or ADHD

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

36.2.

Dyslexia

 

 

 

 

 

 

 

 

Current

Previous

Never

 

36.3. Pervasive developmental disorder (Asperger’s disorder, autism)

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

36.4.

Reading disorder

 

 

 

 

 

 

 

 

Current

Previous

Never

 

36.5. Other learning disorders (including speech disorders)

 

 

 

 

 

 

 

 

 

 

 

37.

Emotional difficulties:

Current

Previous

Never

 

37.1.

Anxiety

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.2.

Bipolar disorder

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.3.

Depression

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.4. Obsessive-compulsive disorder

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.5.

Panic attacks

 

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.6.

Separation anxiety (homesickness)

 

 

 

 

 

 

 

 

Current

Previous

Never

 

37.7. Other changing moods, anxieties, nervousness, or depressions

 

 

 

 

 

 

 

 

 

Personal Health History of Missionary Candidate

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

Current

Previous

Never

38.

Difficulty in relationships due to temper, moods, or habits (fights or aggressive behavior)

 

 

 

 

 

Current

Previous

Never

39.

Schizophrenia or psychosis

 

 

 

 

 

Current

Previous

Never

40.

Eating disorders—anorexia, bulimia, or obesity

 

 

 

 

 

Current

Previous

Never

41.

Abuse of or dependency on prescription or over-the-counter medications, recreational drugs, or alcohol

 

 

 

 

 

Current

Previous

Never

42.

Been a victim of physical, sexual, or emotional abuse

 

 

 

 

 

Current

Previous

Never

43.

Undiagnosed aches and pains

 

 

 

 

 

Current

Previous

Never

44.

Counseling, treatment, or hospitalization for emotional problems

 

 

 

 

 

Current

Previous

Never

45.

Other emotional problems

 

 

 

 

 

Current

Previous

Never

46.

Endometriosis, painful menstruation, abnormal vaginal discharge, uterine or ovarian tumors or cysts

 

 

 

 

 

Yes

No

 

47.

Can work 12 to 15 hours per day, walk 6 to 8 miles per day, ride a bicycle 10 to 15 miles per day, and climb stairs daily

 

 

 

 

 

 

 

 

Yes

No

 

48.

Will receive immunizations

 

 

 

Delcaration and Authorization by Missionary Candidate

I declare that the statements made in the Personal Health History of Missionary Candidate are a complete and honest report of my health history. No personal health information has been withheld or misrepresented.

I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church purposes my personal data, including explicit sensitive data, in accordance with the Church Data Privacy Policy.

Missionary candidate's signature

Date

Parent or guardian's signature

Date

Instructions for Physicians Evaluating Missionary Candidates

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionaries for The Church of Jesus Christ of Latter-day Saints serve in various environments and cultures throughout the world. They are normally expected to engage in missionary activities many hours per day, including walking many miles a day, six days a week. The rigors of a mission usually exacerbate any prior difficulties. Please use the following guidelines in examining the missionary candidate:

1.The Physician's Health Evaluation of Missionary Candidate form must be signed by a medical doctor (MD) or doctor of osteopathy (DO). If the examination is done by a physician assistant (PA) or nurse practitioner (NP), the supervising physician must verify the findings and review and countersign the form. An examination by any other practitioner is not acceptable.

2.Please perform a thorough physical examination to ensure that missionaries receive assignments in which they can succeed. It is unfortunate when a missionary must return home early because of problems that could have been avoided or stabilized before the mission.

3.Correct any problems such as plantar warts, flat feet, chronic headaches, or inguinal hernias before the missionary candidate leaves for his or her mission. Explain to the candidate any problems that do not need correcting, such as a deviated nasal septum, varicocele, pilonidal disease, and so on, in case a physician in his or her mission insists that such a condition must be surgically corrected.

4.Stabilize chronic problems such as asthma, diabetes, seizures, emotional disorders, irritable bowel, endometriosis, and so on. Carefully instruct the candidate on the treatment for these problems, and explain personal care under diverse circumstances. Also explain the importance of continuing to take any prescribed medications.

5.Do not sign the Physician's Health Evaluation of Missionary Candidate form without reviewing the Personal Health History of Missionary Candidate form with the candidate. Please comment on each abnormality listed by the candidate.

6.When a major illness, operation, injury, hospitalization, or prolonged treatment is mentioned, please obtain a summary report of the incident from the professional who treated the case. This report should accompany the candidate's application.

7.Obtain necessary consultations to clarify the candidate's ability to function in the mission field as well as his or her current physical and emotional status where advisable.

8.Complete all specified laboratory tests. Everyone, including those who have had BCG vaccine or a chest X ray, should have a PPD skin test. Only those already known to be positive are exempted.

9.Please mark the appropriate box indicating the candidate's overall ability to function in the mission field on the “Missionary Fitness Report: Overall Assessment of Functional Ability.”

Physician's Health Evaluation

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

To the physician: Please type, print, or write legibly in black ink when completing this form. Attach additional information if necessary. When you have completed the form, mail it and a copy of the Personal Health History of Missionary Candidate form directly to the candidate's bishop or branch president, using the envelope provided by the candidate. Your thorough evaluation and completion of all requested forms, information, and recommendations will be greatly appreciated. Where mail is unreliable, give the forms in a sealed envelope to the missionary candidate.

Missionary candidate's name (first)

(middle)

 

(last)

 

(suffix)

Age

 

Gender

 

 

 

 

 

 

 

 

 

 

 

 

Female

Male

 

 

 

 

 

 

 

 

 

Height (in inches or centimeters)

Weight (in pounds or kilograms)

Blood pressure

Pulse

 

Vision (with corrective lenses, if required)

 

in.

cm.

 

lbs.

kg.

/

 

 

Left

 

Right

 

 

 

 

 

 

 

 

 

 

 

 

 

1. General appearance

 

 

If abnormal, give specific details and indicate functional capacity (referring to item number).

 

Normal

Abnormal

 

 

 

 

 

 

 

 

 

 

2.Skin

Normal Abnormal

3.Eyes

Normal Abnormal

4.Ears (audiogram and balance if necessary)

Normal Abnormal

5.Nose, throat, neck, and thyroid

Normal Abnormal

6.Chest and lungs

Normal Abnormal

7.Heart and blood vessels (murmurs)

Normal Abnormal

8.Abdomen (masses, liver, and spleen)

Normal Abnormal

9.1. Rectal area, varicocele, and hernia

Normal Abnormal

10.Back (history of pain, disability, treatment; also pilonidal disease)

Normal Abnormal

11.Upper extremities

Normal Abnormal

12.Lower extremities

Normal Abnormal

13.Neurological system

Normal Abnormal

14.(Women only) breasts

Normal Abnormal

15.(Women only) pelvic area, including Pap test (if over 40 or indicated by history)

Normal Abnormal

16.Comment on abnormalities noted in history or physical exam regarding:

16.1.Epilepsy

16.2.General medical problems

16.3.Surgical problems

16.4.Learning, memory, or communication disorders

16.5.Emotional, psychological, or psychiatric disorders

16.6.Abuse of prescription medicines, illegal drugs, or alcohol

16.7.Consultations requested

17.Urinalysis (tests for specific gravity, protein and sugar are all required) Specific gravity (required)

Dipstick—protein (required)

Dipstick—sugar (required)

Microscopic (if protein abnormal)

18.Hemoglobin or hematocrit (circle the type and enter the test result)

Hematocrit

Hemoglobin

 

 

 

 

 

 

19. Blood

Type

 

Rh factor

 

 

 

 

 

 

20.PSA (males over 50)

Physician's Health Evaluation

Missionary candidate's name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

21.Mammogram (within last year for females over 40)

22Tuberculosis testing (PPD-10TU)—required for all (including those who had BCG vaccine and those who are known to be positive)

Millimeters of induration (required) _______________

Negative

Positive

(If 10 or greater, chest X ray required)

23.Chest X ray taken

Yes No

24.INH is prescribed

Yes No

If INH is prescribed for a PPD converter, treatment should be started as soon as possible. If active disease is found, missionary service must be delayed until treatment is completed. If prescribed, date when treatment will be completed:

If abnormal, please give specific details and indicate functional capacity (referring to item number).

25. Immunization Dates

 

 

 

 

 

 

Tetanus/diphtheria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR2

 

 

 

MMR1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

 

 

 

 

Hepatitis A #1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND hepatitis B #1

#2

 

#3

 

 

 

 

 

 

 

 

OR combined hepatitis A and B #1

#2

 

#3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Missionary Fitness Report: Overall Assessment of Functional Ability Based on a review of the missionary candidate's history, your personal interview, a physical examination, and a review of laboratory findings, indicate the candidate' ability to function at various levels of activity as a missionary below.

Level A—No limitation

Level B—Slight limitation

Level C—Moderate limitation

Level D—Marked limitation

Level E—Not appropriate

 

 

 

 

 

No limitation of activity in lifting,

Slight limitation of activity; slight

Moderate limitation of activity;

Marked limitation of activity or has

Conditions exist for which

carrying, walking 6 or more miles

decrease of function or stamina,

moderate decrease of function or

special requirements, such as

corrective action has not been or

per day, or spending 12 to 16 hours

such as problems with walking

stamina; requires limited walking

specific climate, use of wheelchair,

cannot be taken, such as severe

per day in missionary activity.

(limited to 3-6 miles per day) or with

(0-3 miles per day) or sedentary

frequent rest periods, special

chronic pain, loss of stamina, or

 

extensive standing.

work.

medical needs, or medical visits.

recurring conditions.

Additional comments

 

 

 

 

Physician's signature

 

Name of physician

The exam was performed within

MD

DO

 

 

the last 12 months.

 

 

 

 

 

 

 

Physician’s office address

 

City

State or province

 

 

 

 

Country

 

Postal code

District (if any)

 

 

 

 

Office phone (with area code)

 

E-mail address (if available)

 

 

 

 

 

Authorization to Release Information

I authorize the examining physician to release the information contained in the Personal Health History of Missionary Candidate and the Physician's Health Evaluation of Missionary Candidate to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by physicians. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the examining physician from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.

Missionary candidate's signature

Date

Witness's signature

Date

Dental Evaluation for Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Missionary candidate's name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

To the priesthood leaders:

1.All dental treatment, including active orthodontic treatment, must be completed before a prospective missionary begins missionary service.

2.Active orthodontic treatment is defined as any one of the following:

a.Bonded or banded braces on the teeth.

b.Invisalign treatment trays.

c.Removable appliances requiring periodic adjustments.

3.Wearing a final retainer appliance after active orthodontic treatment is completed is not considered active treatment.

To the missionary candidate:

1.Have your dental examination early (6 months) to allow plenty of time to complete all dental treatment, including active orthodontic treatment. Your application will not be processed until all necessary treatment has been completed or scheduled.

2.Give your dentist a stamped envelope addressed to your bishop or branch president.

3.Your dentist will retain this evaluation form, and will not send it to your bishop or branch president until all needed dental treatment, including active orthodontic treatment, has been completed.

To the examining dentist:

1.As you evaluate this missionary candidate’s dental condition, please be aware that he/she might be assigned to serve for two years in an area of the world with limited or inadequate professional dental care. Third molar complications are the most common medical-dental problem in the mission field today.

2.Please help this candidate understand the role of plaque in dental disease and the importance of daily personal oral hygiene to maintain dental health. Please correct overhangs and rough interproximals that would make flossing difficult or impossible.

3.The missionary candidate will give you a stamped envelope addressed to his/her bishop or branch president. When you are satisfied that all treatment has been completed or scheduled, mail this form to the missionary’s bishop or branch president. Where mail is unreliable, give the form in a sealed envelope to the missionary candidate.

Dental Evaluation

1.

Has the missionary candidate had a complete oral examination with bite wing x-rays within the last six months?

Yes

No

 

 

 

 

 

 

2.

Has a full-mouth set of x-rays or panoramic x-ray been taken within last twelve months?

Yes

No

 

 

 

 

 

 

3.

Have all third molars that were likely to become problematic during the next two years been extracted?

Yes

No

 

 

 

 

 

 

4.

Has all dental decay and gum infection been resolved?

Yes

No

 

 

 

 

 

 

5.

If this candidate has undergone orthodontic treatment, has active treatment been completed at this time?

Yes

No

 

 

 

 

 

 

6.

Do you believe this candidate will be free of dental problems during the next two years if proper daily personal oral hygiene is practiced?

Yes

No

 

 

Comments

Dentist's signature

Name of dentist

Date

 

 

 

Dentist’s office address

City

State or province

 

 

 

Country

Postal code

District (if any)

 

 

 

Office phone (with area code)

E-mail address (if available)

 

 

 

 

Authorization to Release Information

I authorize the examining dentist to release the information contained in this dental evaluation to my bishop or branch president and the Missionary Department of The Church of Jesus Christ of Latter-day Saints. I am aware that the information will be screened by dentists. I am aware that the information may be used in assessing assignments as part of my missionary call. I hereby release the examining dentist from all legal liabilities that may arise from the release or use of the information by The Church of Jesus Christ of Latter-day Saints or its agents.

Missionary candidate's signature

Date

Witness' signature

Date

Personal Insurance Information of Missionary Candidate

MISSIONARY DEPARTMENT

50 E NORTH TEMPLE ST RM 345 W SALT LAKE CITY UT 84150-5400

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

You have a medical insurance provider Yes No

If yes, please give your Social Security number

If yes, indicate whether you will be covered by a group or individual health insurance plan while serving your mission.

Yes No

Insurance Company Information

Name of primary insurance company

Policyholder's name

Policyholder's Social Security number

Policyholder's date of birth

 

 

 

Effective date of coverage

This coverage will terminate while you are serving as a

If yes, give termination date (day, month, year).

 

missionary

 

 

 

Yes

No

 

 

 

 

Policyholder's ID number

Mailing address for submitting claims

 

 

 

 

City

State or province

Postal code

 

 

 

Country

District (if any)

Phone number of insurance company (include area code)

 

 

 

 

Indicate where this insurance plan will provide benefits for services incurred while you are serving as a missionary. (Check all that apply.)

At your current location and within your state or province

Full coverage Emergency coverage only

If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required

Hospitalization (inpatient or outpatient)

Medical (physician visits, lab, X ray)

Prescription drugs

Physical therapy

Emotional illness (psychotherapy)

Dental

Outside your state or province but still within your country

Full coverage Emergency coverage only

If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required

Hospitalization (inpatient or outpatient)

Medical (physician visits, lab, X ray)

Prescription drugs

Physical therapy

Emotional illness (psychotherapy)

Dental

Outside your country

Full coverage

Emergency coverage only

 

 

Personal Insurance Information of Missionary Candidate

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

If full coverage, indicate what additional benefits are provided by your plan and which of them require prior authorization. (Check all that apply.) Provided Prior authorization required

Hospitalization (inpatient or outpatient)

Medical (physician visits, lab, X ray)

Prescription drugs

Physical therapy

Emotional illness (psychotherapy)

Dental

This health plan has an annual deductible that must be met before benefits are

If yes, indicate the amount (in U.S. dollars).

provided

 

 

 

Yes

No

 

 

 

 

You have coverage from another insurance company

If yes, indicate whether you will be covered by a group or individual health insurance plan while serving

Yes

No

your mission.

 

 

 

 

 

Yes

No

 

 

 

 

Authorization for Release of Information—Young Missionary

I authorize any physician, medical practitioner, hospital, clinic, other health care provider, or insurance company to disclose to The Church of Jesus Christ of Latter-day Saints or its representatives and affiliated entities all information and records with respect to any claim, physical or mental condition, treatment, or medical history, and evaluation thereof.

I understand that if I become sick or injured during my mission, the Church will provide initial payment for my medical expenses, except for pre- mission conditions, but payment by the Church is not intended to replace my personal insurance.

I hereby authorize The Church of Jesus Christ of Latter-day Saints to collect, process, and transfer to other countries for Church purposes my personal data, including explicit sensitive data, in accordance with the Church Data Privacy Policy.

Missionary candidate's signature

Date

Authorization for Recovery from Provider—Parents of Young Missionary

By signing below, I hereby authorize and request that The Church of Jesus Christ of Latter-day Saints be reimbursed for all amounts paid to providers, which amounts are the primary obligation of the above-named insurance companies, and I authorize the Church to undertake all appropriate measures to recover said amounts.

Parent or guardian's signature

Date

Your full legal name (first)

(middle)

(last)

(suffix)

Age

Gender

Female Male

I hereby authorize The Church of Jesus Christ of Latter-day Saints, its officers, affiliated entities and departments (collectively the “Church”), to process my personal data for purposes relating to a missionary calling in the Church. This authorization includes the following understandings and consents:

1.The Church will have access to my personal and sensitive data for the purposes of evaluating my missionary application, determining my missionary assignment if my application is accepted and overseeing my mission. I consent that the Church may process my personal and sensitive data for these purposes.

2.I have informed my parents and/or caregivers that I will include some of their personal data in my missionary application.

3.My Bishop and Stake President (or Branch President, District President and Mission President, as the case may be) will provide evaluations of my qualifications to serve as a missionary. I agree that these evaluations are related to determining my worthiness and capacity to serve as a missionary. I understand that these evaluations are strictly confidential and I hereby waive any right of access to these evaluations.

4.The provision of my personal data is necessary in order for the Church to process my missionary application.

5.I authorize the transfer of my personal data, including sensitive data relating to my ethnic origin, religious beliefs, physical and emotional health, and any criminal history, to Church headquarters in the State of Utah, United States of America and to other countries with less stringent data protection laws than the country in which I reside. I understand and acknowledge that the transfer of this information is necessary for the Church to evaluate my application to serve the Church as a missionary.

6.With the exception of ecclesiastical leaders’ evaluations, I may access, upon my written request, the personal data I have provided in connection with this missionary application and I may rectify any erroneous data.

7.The Church will retain my personal data during my mission. Although some data will be destroyed after completion of my mission, other data may be retained indefinitely as part of the historical or other records of the Church. I authorize the Church to use and retain my data in its discretion.

8.Should I have questions concerning the protection of my personal data or the security of personal data processed by the Church, I have been advised that I may communicate my questions to the Church’s representative for data privacy at dataprivacyofficer@ldschurch.org.

Missionary Funds

I understand that all donations to the Church's missionary funds become the property of the Church to be used at the Church's sole discretion in its missionary program and are not refundable.

Medical Privacy Notice

Deseret Mutual Benefit Administrators (“Deseret Mutual”), through its Missionary Medical Division, helps to coordinate and administer missionary health care. Deseret Mutual is a not for profit Church-affiliated entity that has been assigned by the Church’s Missionary Department. The United States government has enacted new privacy laws and regulations with which Deseret Mutual must comply. One of the requirements is to provide you with a Medical Privacy Notice explaining how your health information will be used and disclosed.

1. Understanding Your Health Record/Information

Each time you visit a hospital, physician, or other health-care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. It may also contain correspondence and other administrative documents.

Protected health information (or “PHI”) is any personally identifying information which when linked to health data could be used to identify an individual. This information may be stored or transmitted in any form (for example, paper, electronic, verbal, etc.). All of this information, often referred to as your health or medical records, serve as a:

Basis for planning your care and treatment

Means of communication among the many health professionals who contribute to your care

Legal document describing the care you received

Means by which you or a third-party payer can verify that services billed were actually provided

Tool in educating health professionals

Source of data for medical research

Source of information for public health officials charged with improving the health of the nation

Source of data for facility planning

Tool to assess and monitor the health care being provided and the outcomes achieved

2. Your Health information Rights

With respect to that portion of your health record held by Deseret Mutual, you have the right to:

Inspect and obtain a copy of your health record

Amend your health record

Request a restriction on certain uses and disclosures of your information

Obtain an accounting of disclosures of your health information (other than for purposes of treatment, payment, and health care operations)

Request communications of your health information by alternative means or at alternative locations

Revoke your authorization to use or disclose health information except to the extent that action has already been taken

3.Our Responsibilities Deseret Mutual is required to:

• Maintain the privacy of your health information

• Provide you with notice of our legal duties and privacy practices regarding information we collect and maintain about you

• Abide by the terms of this notice

• Notify you if we are unable to agree to a requested restriction

• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations

We will not use or disclose your PHI without your authorization, except for treatment, payment or health-care operations, or as provided by law.

We reserve the right to change our practices and make the new provisions effective for all PHI we maintain. If we do so, we will notify you of the changes in writing.

4. For More Information or to Report a Problem

If you have any questions or if you would like additional information, you may contact Deseret Mutual’s Compliance Specialist or Compliance Officer by telephone (1-801-578-5600 or 1-800-777-3622), by mail (60 East South Temple, Salt Lake City, UT 84111, USA) or by fax (1-801- 578-5906).

If you believe your privacy rights have been violated, you can file a complaint with Deseret Mutual’s Compliance Specialist or Compliance Officer, or with the United States Department of Health and Human Services, Office for Civil Rights (OCR). Complaints must be in writing and can be filed either by mail or electronically. OCR will provide further information on its Web site about how to file a complaint (www.hhs.gov/ocr/hipaa/). Please note that there will be no retaliation for filing a complaint.

5. Uses or Disclosures for Treatment, Payment, and Health Care Operations

Treatment, Payment, and Health Operations: We may use your health information for treatment, payment, and health care operations. For example, with respect to treatment, information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. With respect to payment, a bill may be sent to you or a third party payer. With respect to health care operations, we may use your health care information to study ways to improve utilization or reduce health care costs.

6.Uses or Disclosures Permitted or Required by Law

• To you, the individual.

• United States Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacement.

• Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with preventing or controlling disease, injury, or disability.

• Correctional Institution: If you become an inmate of a correctional institution, we may disclose to the institution or agents thereof PHI necessary for your health and for the health and safety of others.

Law Enforcement or Judicial Proceedings: We may disclose certain PHI for law enforcement purposes as required by law or in response to valid subpoena.

Authorization to Use and Disclose Protected Health Information and Authorization to Use and Disclose Psychotherapy Notes

I hereby authorize the Church and its affiliated entities to disclose the personal health information collected through the Missionary Recommendation Form as described in the Notice of Privacy Practices for Protected Health Information.

Deseret Mutual may disclose my protected health information to my local unit priesthood leaders (such as the bishop and stake president), employees of the Missionary Department, medical professionals who act as volunteers in the Missionary Department, personnel at the Missionary Training Center and BYU Student Health Center, and your mission representatives (such as your mission president).

My protected health information may also be disclosed to one or more clerks who assist my local unit priesthood leaders (such as the ward and stake clerks), and to others I identified specifically by name (such as my parents), except as I have noted to restrict contact with one or more persons. My protected health information may be disclosed to assist in treatment of an illness or injury and to assist in determining pre-mission conditions that may impact payment of treatment and the recovery of costs.

These authorizations of disclosure will expire one year (1) after my missionary service is terminated. I understand that once my protected health information has been disclosed according to this agreement and in accordance with the Notice of Privacy Practices for Protected Health Information, the recipient of my information may disclose my information to others and will no longer be protected.

The use and disclosure of protected health information authorized herein is for the purpose of the overall management and administration of my health care while a missionary for The Church of Jesus Christ of Latter-day Saints so that I can be an effective missionary on behalf of, and serve the needs of, the Church.

Insurance and Medical Expense Acknowledgement

The Church Handbook of Instructions indicates all missionaries are strongly encouraged to maintain their existing medical insurance during their missions. This conserves Church funds and helps missionaries avoid having to prove insurability after their missions. Maintaining coverage helps provide protection for past chronic or congenital problems and post-mission medical needs. This directive is consistent with the principles of self-reliance and self-sufficiency.

Couples and single sisters ages 40 and over are responsible for their own health care expenses and must have health insurance adequate for their mission assignments. If the insurance coverage of those living away from home is not adequate for their assignment, Deseret Mutual will send them information on additional insurance that they may purchase. Missionaries who need additional coverage but do not enroll in the DMBA plan must provide proof of adequate coverage before their service begins.

Acknowledgement:

I understand that if I become sick or injured during my mission, the Church may provide initial payments for my medical expenses except for pre- mission conditions. Payments in the United States will be made through Missionary Medical, a Division of Deseret Mutual, a not for profit Church affiliated entity.

These payments are made from the general funds of the Church and are gratuitous and voluntary in nature. Payments are not made from a Church insurance policy and are not intended to replace my personal health insurance.

I understand that claims will be filed with my insurance carrier. I agree to support all recovery efforts (including assisting in claims filing and reimbursement procedures) in the event the Church makes initial payment for medical expenses. I agree to support efforts by Missionary Medical to coordinate care directly with my parents (when authorized for disclosure), healthcare providers, and my insurance carrier.

I understand that if I am involved in an accident that the Church neither encourages nor discourages legal action from potentially liable or responsible third parties. I agree to reimburse the Church for medical expenses paid on my behalf in the event a settlement is reached or when a liable party makes payments.

I authorize the release of my medical information to the following individuals:

Name Relationship

Birth Date

Personal Health Information

Psychotherapy Information

Candidate's Signature

Date