Va Form 0926E – Fill Out and Use This PDF

The VA Form 0926E, known formally as the General Medical Information/Medical Clearance Form, serves as a critical document for Veterans aiming to participate in athletic events organized or supported by the Department of Veterans Affairs. It mandates a comprehensive medical assessment by the Veteran's VA Primary Care Provider to ensure they are medically fit to engage in the games, underscoring the importance of health and safety. Athletes are reminded through the form to carry sufficient medication and medical supplies for the duration of the event, highlighting the VA's limited provision for routine care, medication replacements, or emergency medical equipment during the games. For Veterans and providers looking to complete this form, clicking the button below offers a straightforward pathway to fulfill this requirement.

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Va Form 0926E PDF Details

The VA 0926E form is a vital document designed to ensure the safety and health of veterans participating in athletic events or games, symbolizing the U.S. Department of Veterans Affairs' commitment to promoting active and healthy lifestyles among veterans. This comprehensive form requires a thorough medical evaluation by a veteran's VA Primary Care Provider to establish medical clearance for participation. It underscores the importance of having enough medication and medical supplies for the duration of the Games, reflecting a self-sufficient approach to managing pre-existing conditions during the event. The policy against filling narcotic prescriptions and the coordination required for athletes using oxygen highlight the meticulous planning involved in catering to the medical needs of participating veterans. Furthermore, emergency and specialized medical support are outlined, ensuring that veterans have access to medical care tailored to their needs during the event. In providing detailed instructions for both medical professionals and athletes, including a checklist of conditions, medications, and equipment, the VA 0926E form serves as a critical tool in facilitating safe participation in physically demanding activities, thereby encouraging veterans to engage in recreational and competitive sports while managing their health responsibly.

Question	Answer
Form Name	Va Form 0926E
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	VAMC, OMB, 0926e, ADL

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MEDICAL CLEARANCE INSTRUCTIONS FOR ATHLETES

You must be seen by your VA Primary Care Provider to be

medically cleared to participate in the Games.

Reminder: We will not provide routine medical care, replacement medications, replacement equipment or replacement supplies for pre-existing conditions. Athletes must bring enough medication and medical supplies to last throughout the Games. Any medication or medical supplies provided on site will be charged back to Athlete's medical facility. Narcotic prescriptions will not be filled.

Athletes using oxygen must have their sponsoring VA Medical Center coordinate oxygen services, including supplies, with a local oxygen provider.

Limited medical assistance will be provided 24-hours a day at the triage clinic in the host site hotel. We will also provide first aid and medical stabilization at the events and activities. Ambulance care will be provided as needed. Should a Veteran have a problem that needs attention or treatment beyond first aid they will be sent to the

VA Western New York Healthcare System or the nearest emergency room at a local hospital.

When registering on May 30, 2013, please tell us if there have been any significant changes in your health since you completed your application. These include:

·Changes in medication

·Admissions/hospitalizations

·New diagnosis, problems or conditions

Please have your VA Primary Care Provider complete the enclosed General Medical Information/Medical Form (VA Form 0926e) enclosed in the packet.

ATHLETE NUMBER-OFFICE USE ONLY

OMB Number: 2900-0759

Respondent Burden: 20 minutes

ATHLETES MEDICAL INFORMATION

A PHYSICIAN, NURSE PRACTIONER OR PHYSICIAN ASSISTANT MUST FILL OUT AND SIGN THIS FORM

PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is voluntary. However, you will not be able to participate in the event without furnishing this information.

RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

Dear Provider,

Pending approval, the Veteran patient plans to participate in various athletic events and/or games which may be strenuous and/or dangerous depending on his/her condition. Additionally, should the Veteran patient require personal ADL assistance, please understand this will not be provided by the VA Western New York Healthcare System and would be a reason not to clear him/her unless he/she is accompanied by a caregiver.

DATE			VA MEDICAL CENTER NAME

NAME (Last, First, MI)			ADDRESS (Street, City, State, Zip Code)

SOCIAL SECURITY NO.	VETERANS DATE	AGE
(Last 4 digits only)	OF BIRTH

PLEASE REVIEW VETERAN DEMOGRAPHICS FOR ACCURACY BEFORE YOU COMPLETE THIS FORM.

WEIGHT

PROBLEM LIST (Active Problems)

I HAVE REVIEWED THE ACTIVE PROBLEMS AND

COPD

HEART FAILURE

HYPERTENSION

CONFIRM THAT THIS LIST IS CURRENT

YES

HEIGHT

DIABETES

OTHER (List below)

I HAVE ATTACHED A 12 LEAD EKG (Completed within the last

6 months) (REQUIRED)

YES

BLOOD PRESSURE

I HAVE ATTACHED SLEEP STUDY (Required if using a

CPAP/BIPAP)

YES

LIST ALL ACTIVE MEDICATIONS

I HAVE REVIEWED THE MEDICATIONS LISTED AND THE

VETERAN IS TAKING THEM AS DIRECTED

YES

LAST ADMISSION

REASON FOR ADMISSION

ALLERGIES

IS THE VETERAN VISUALLY IMPAIRED? (Legally blind)

YES

IS THE VETERAN HEARING IMPAIRED?

YES

TETANUS TOXOID DATE

PLEASE UPDATE TETANUS IF NOT WITHIN 10 YEARS

PPD DATE

REQUIRED WITHIN 12 MONTHS

IF POSITIVE, SEND CURRENT CHEST X-RAY REPORT TAKEN

AFTER POSITIVE PPD

IS THE PATIENT FREE OF COMMUNICABLE DISEASES? (If no, explain)

YES

CAN HE/SHE TAKE HIS/HER OWN MEDICATIONS? (If no, explain)

YES

PLEASE ADVISE VETERAN OF THEIR RESPONSIBILITY FOR BRINGING

ENOUGH MEDICATION FOR THE TRIP AND THE WEEK.

VA WESTERN NEW YORK HEALTHCARE SYSTEM WILL NOT PROVIDE NARCOTIC REFILLS FOR ANY REASON.

The cost of any medical expenses and/or medications will be charged back to the veteran or the veteran's originating facility.

DOES THE VETERAN NEED ASSISTANCE WITH THE FOLLOWING ADL'S?
AMBULATION	TRANSFER	FEEDING	GROOMING	TOILETING



IS THE VETERAN INCONTINENT OF URINE? (If yes, please provide the name and telephone number of the accompanying caregiver)					YES	NO


IS THE VETERAN INCONTINENT OF BOWEL? (If yes, please provide the name and telephone number of the accompanying caregiver)					YES	NO

CAREGIVER NAME

CAREGIVER TELEPHONE NUMBER (Include area code)

VA FORM 0926E NOV 2012

IF THE VETERAN USES A WHEELCHAIR, CAN HE/SHE TRANSFER WITHOUT ASSISTANCE?	YES	NO

LIST ANY DURABLE MEDICAL EQUIPMENT OR SPECIAL ASSISTIVE DEVICES THE VETERAN WILL BE USING

IF YES TO ANY ONE OF THE ABOVE QUESTIONS, EQUIPMENT MUST BE INSPECTED AND CERTIFIED BY THEIR SPONSORING MEDICAL FACILITY.

IS THE VETERAN ON PORTABLE OXYGEN? (If yes, Rx i.e., 2L/min.)		YES	NO


IS THE VETERAN ON CPAP/BIPAP? (If yes, pressure setting)		YES	NO


ATHLETES MUST BRING AND PROVIDE THEIR OWN CPAP/BIPAP
IF YES TO ANY ONE OF THE ABOVE QUESTIONS, SPONSORING VA MEDICAL CENTER MUST COORDINATE OXYGEN
SERVICES, INCLUDING SUPPLIES AND EQUIPMENT, WITH A LOCAL OXYGEN PROVIDER.

LIST SPECIAL NEEDS (e.g. feeding tube, tracheotomy, catheter, mobility, bowel and bladder care, etc.)


LIST THOSE NEEDS WITH WHICH THE VETERAN REQUIRES ASSISTANCE


BEHAVIORAL NEEDS


COGNITIVE NEEDS


IF YES TO ANY ONE OF THE ABOVE QUESTIONS, ACCOMPANYING CAREGIVER MUST BE ABLE TO PROVIDE THE
ASSISTANCE NEEDED.

WHAT ACTIVITY RESTRICTIONS DO YOU RECOMMEND?


THE VETERAN IS PHYSICALLY CAPABLE OF PARTICIPATING IN THESE AEROBIC EVENTS
	CYCLING	YES	NO

	SWIMMING	YES	NO
	SWIMMING	YES	NO

PLEASE SELECT THE EVENTS THE VETERAN CAN OR CANNOT PARTICIPATE IN
AIR RIFLE	YES	NO	GOLF	YES		NO

BOWLING	YES	NO	HORSESHOES	YES	NO

CHECKERS	YES	NO	NINE-BALL	YES		NO

CROQUET	YES	NO	SHOT PUT	YES		NO

DISCUS	YES	NO	SHUFFLEBOARD	YES		NO

DOMINOES	YES	NO	TABLE TENNIS	YES		NO

JAVELIN	YES	NO
JAVELIN	YES	NO

IN YOUR OPINION, CAN THE VETERAN MAKE THE TRIP AND PARTICIPATE IN THE NATIONAL VETERANS GOLDEN				YES		NO

AGE GAMES?



DOES THE VETERAN HAVE AN ADVANCED DIRECTIVE? (Attach copy)				YES		NO

MEDICAL ORDERS FOR LIFE-SUSTAINING TREATMENT (MOLST)? (Attach copy)				YES		NO
				YES		NO

PROVIDER'S NAME (Please print)

PROVIDER'S SIGNATURE

PROVIDER TELEPHONE NUMBER

PROVIDER PAGER NUMBER

(May 30 to June 4, 2013)

VA FORM 0926e, NOV 2012, page 2

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2. Once your current task is complete, take the next step – fill out all of these fields - SOCIAL SECURITY NO Last digits, VETERANS DATE OF BIRTH, PLEASE REVIEW VETERAN DEMOGRAPHICS, WEIGHT, PROBLEM LIST Active Problems, HEIGHT, DIABETES, OTHER List below, COPD, HEART FAILURE, HYPERTENSION, BLOOD PRESSURE, LIST ALL ACTIVE MEDICATIONS, I HAVE REVIEWED THE ACTIVE, and YES with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

BLOOD PRESSURE, WEIGHT, and COPD in 2011

3. Completing CAN HESHE TAKE HISHER OWN, YES, PLEASE ADVISE VETERAN OF THEIR, ENOUGH MEDICATION FOR THE TRIP AND, VA WESTERN NEW YORK HEALTHCARE, The cost of any medical expenses, DOES THE VETERAN NEED ASSISTANCE, AMBULATION, TRANSFER, FEEDING, GROOMING, TOILETING, IS THE VETERAN INCONTINENT OF, IS THE VETERAN INCONTINENT OF, and YES is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

4. All set to fill out the next form section! In this case you'll get all of these IF THE VETERAN USES A WHEELCHAIR, YES, LIST ANY DURABLE MEDICAL EQUIPMENT, IF YES TO ANY ONE OF THE ABOVE, IS THE VETERAN ON PORTABLE OXYGEN, IS THE VETERAN ON CPAPBIPAP If yes, YES, YES, ATHLETES MUST BRING AND PROVIDE, LIST SPECIAL NEEDS eg feeding tube, LIST THOSE NEEDS WITH WHICH THE, and BEHAVIORAL NEEDS form blanks to do.

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BOWLING, COGNITIVE NEEDS, and YES in 2011

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Va Form 0926E – Fill Out and Use This PDF

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