Form 0926e at a glance
What it is: Medical Clearance Instructions for Athletes: you must be seen by your VA Primary Care Provider to be medically cleared to participate in the Games.
Who signs: A physician, nurse practitioner or physician assistant must fill out and sign this form.
A filled-in Form 0926e example: a physician completes the athlete's medical information
How to fill out Form 0926e, box by box
Date and VA medical center name
Fill in DATE and VA MEDICAL CENTER NAME.
Name and address
Fill in NAME (Last, First, MI) and ADDRESS (Street, City, State, Zip Code). Review veteran demographics for accuracy before you complete this form.
Social security number, age and date of birth
Fill in SOCIAL SECURITY NO. (Last 4 digits only), AGE and VETERANS DATE OF BIRTH.
Weight, height and blood pressure
Fill in WEIGHT, HEIGHT and BLOOD PRESSURE.
Active medications, last admission and allergies
Under LIST ALL ACTIVE MEDICATIONS, list the medications; fill in LAST ADMISSION, REASON FOR ADMISSION and ALLERGIES.
Tetanus toxoid and PPD dates
Fill in TETANUS TOXOID DATE, and update tetanus if not within 10 years; fill in PPD DATE, required within 12 months. If positive, send current chest X-ray report taken after positive PPD.
Caregiver name and telephone number
Mark NO or YES for IS THE VETERAN INCONTINENT OF URINE? and IS THE VETERAN INCONTINENT OF BOWEL?; if yes, provide the CAREGIVER NAME and CAREGIVER TELEPHONE NUMBER (Include area code) of the accompanying caregiver.
Provider's name, signature and telephone number
Print the PROVIDER'S NAME; sign on PROVIDER'S SIGNATURE and fill in PROVIDER TELEPHONE NUMBER (May 30 to June 4, 2013) and PROVIDER PAGER NUMBER (May 30 to June 4, 2013).
More rules for Form 0926e
Attach a 12 lead EKG (Completed within the last 6 months) (REQUIRED).
Attach a sleep study (Required if using a CPAP/BIPAP).
Athletes must bring enough medication and medical supplies to last throughout the Games.
Narcotic prescriptions will not be filled.
Athletes must bring and provide their own CPAP/BIPAP.
List any durable medical equipment or special assistive devices the veteran will be using; list special needs (e.g. feeding tube, tracheotomy, catheter, mobility, bowel and bladder care, etc.); fill in What activity restrictions do you recommend?
Should the Veteran patient require personal ADL assistance, 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.
Sources
[1] VA Form 0926e (NOV 2012), Medical Clearance Instructions for Athletes, as served (the Official source link on this page).