Form ETA-653 Job Corps Health Questionnaire

Job Corps Health Questionnaire
PURPOSE: To determine the health and accommodation/modification needs of the
applicant who has been offered enrollment in Job Corps, and to determine whether an
otherwise-eligible applicant offered enrollment may pose a direct threat to self or others.

OMB Approval No. 1205-0033
Expiration Date: xx/xx/xxxx

INSTRUCTIONS: Before asking you to answer the questions on this form, Job Corps is required to tell you that:
= Providing the information that this form asks for is voluntary - in other words, you may choose not to answer any or all of the

questions on this form, or to sign the authorizations at the end of the form that allow Job Corps to receive other medical
and/or disability-related information about the individual (person) whose name appears in Section 1 below.
= At the same time, providing the information and authorizations that this form asks for is a requirement for participation in Job

Corps. Therefore, if you do not provide the information or sign the authorizations, the person whose name appears in
Section 1 below may be denied enrollment in Job Corps; however, neither you nor that person will receive any other
unfavorable treatment.
= All disability-related and/or other medical information that you provide in response to the questions on this form, or that Job

Corps receives because you sign the authorizations that appear at the end of this form, will be collected and stored
separately from any other information about the person whose name appears in Section 1 below.
= The medical and/or disability-related information described above will be kept strictly confidential. This information will only

be disclosed in accordance with the requirements of the Department of Labor's regulations and other applicable Federal
laws.
= The information will only be used in accordance with Federal law.

Please answer all of the questions to the best of your knowledge. The collection of this information is authorized by
Pub. L. 105-220, as amended by Pub. L. 105-277.
1. Name (Last, First, Middle Initial)

,

2. Student ID

3. Sex (M/F)

6. What is your General Health Condition? (check one):

Excellent

4. Height (in)
Good

7. a. Are you or your family covered by health insurance?
(If YES, obtain a copy of health insurance card and attach to this form.)
b. Are you or your family covered by Medicaid?
(If YES, obtain a copy of Medicaid card and attach to this form.)

5. Weight (lb)
Fair

Poor
NO

YES

NO

YES

An answer of "Fair" or "Poor" to question 6, or a YES answer to any item in questions 8, 9, or 10 requires an
explanation in question 11 on the reverse of this form.
8. a.

b.

Are you currently under the care of a physician, dentist, or mental health professional?
How often do you go see the doctor or counselor? Daily
Weekly
Monthly
Are you currently taking any prescription or non-prescription medication, herbs,

NO
Other

YES

NO

YES

supplements, vitamins, etc.?
c.

Do you use a medical device (e.g., prosthesis, wheelchair, etc.)?

NO

YES

d.

Do you have any known allergies (e.g., medication, food, etc.)?

NO

YES

e.

Do you wear braces on your teeth?

NO

YES

In the past two years have you
f.

Been refused or discharged from military service for medical or mental health reasons?

NO

YES

g.

Had a medical professional (e.g., doctor) advise you to have a medical or surgical
procedure that you have not yet received?

NO

YES

h.

Been hospitalized or treated in an emergency room for medical or mental health reasons?

NO

YES

i.

Had a serious dental problem or problems (e.g., untreated dental infections, missing teeth,
unresolved severe toothaches, etc.)?

NO

YES

j.

Received counseling or treatment for a mental health issue?

NO

YES

k.

Received counseling or treatment for drug or alcohol use?

NO

YES

ETA 6-53 (rev. 01/2007)

l. Attempted to hurt yourself (e.g., cut yourself, deliberately overdosed on medication or other
drugs)?
m. Thought about hurting yourself or planned to hurt yourself?
n.
o.
p.
q.

Intentionally tried to hurt someone else?
Been afraid that others want to physically harm you?
Heard voices or seen things that other people did not hear or see?
Believed that your thoughts were being controlled by someone or something other
than yourself?
r. Lost control of your anger, or feared losing control of your anger, to the point of hurting
yourself or someone else?
s. Been in a physical fight?
t. Been expelled from school, fired from a job, or convicted of a crime?
u. Been removed from your home by authorities due to your behavior (e.g., charges of
disorderly conduct, assault, etc.)?
v. Stopped getting treatment and/or taking medication that a doctor or other medical
professional wanted you to have?
w. Participated in a residential or day therapeutic program where you received medical or
mental health care?
9. To your knowledge, have you EVER had or do you now have any of the following conditions?
a. Anemia (including sickle cell disease)
NO
YES
q. Mental Retardation (MR)
/Intellectual Disability/
Developmental Disability
r. Depression
b. Asthma
NO
YES

NO

YES

NO

YES

NO
NO
NO
NO

YES
YES
YES
YES

NO

YES

NO
NO
NO

YES
YES
YES

NO

YES

NO

YES

NO

YES

NO

YES

c. Visual impairment/trouble seeing

NO

YES

s. Anxiety Disorder

NO

YES

d. Hearing impairment/trouble hearing

NO

YES

NO

YES

e. Obesity

NO

YES

NO

YES

f. Diabetes (high blood sugar)

NO

YES

t. Obsessive-Compulsive
Disorder
u. Impulse Control Disorders (e.g.,
fire-setting,intermittentexplosive disorder, etc.)
v. Schizophrenia

NO

YES

g. Heart condition

NO

YES

w. Conduct Disorder

NO

YES

h. High blood pressure

NO

YES

x. Traumatic Brain Injury

NO

YES

NO

YES

NO

YES

i. Kidney, bladder, or urinary problems

NO

YES

y. Bipolar Disorder

j. Speech problem (e.g., stuttering, etc.)

NO

YES

z. Anti-Social Personality Disorder

k. Tuberculosis (TB) or positive TB skin
test

NO

YES

aa. Pervasive Developmental
Disorders (i.e., Asperger's or
Autism)

NO

YES

l. Ulcer of stomach or intestines

NO

YES

bb. A mental health problem or
concern

NO

YES

m. Epilepsy, seizures, convulsions

NO

YES

cc. A drug or alcohol problem or
concern

NO

YES

n. Learning disabilities (e.g., dyslexia,
etc.)

NO

YES

dd. Other health problems or
concerns

NO

YES

o. Attention Deficit/Hyperactive Disorder
(ADD or AD/HD)

NO

YES

NO

YES

p. Hepatitis

NO

YES

ee. FEMALES: Are you pregnant?
If YES, approximate date last
menstrual period began.

10. If you are a person with a disability, you may request accommodations (changes in the way things
NO
YES
are done, or other types of extra support to help you participate in the Job Corps program). Would
you like, or do you think you will need, any of these extra supports?
11. Provide explanation below of any YES responses to items in questions 8, 9, or 10. If additional space is needed, attach
separate sheet. If the applicant offered enrollment is not sure whether he/she had one of the conditions mentioned in
question 9, or whether he/she needs an accommodation, include whatever information the applicant offered enrollment
provides. If the applicant offered enrollment declines to give additional information, indicate in this section that the applicant
offered enrollment declined to respond.

ETA 6-53 (rev 01/2007)

Item

Explanation

ETA 6-53 (Rev. 01/2007)

= I (we) understand that failure to answer any or all of the questions may result in the above-named individual being denied

enrollment in Job Corps.
= I (we) authorize the Job Corps to receive from doctors, dentists, mental health professionals, clinics, hospitals, or other

sources, medical information from the health records of the above-named individual regarding the specific conditions
identified in any question in section 8 or 9 of this form to which a "yes" response has been provided. I understand that this
form does not authorize Job Corps to ask for any records regarding any other health conditions. I also understand that Job
Corps is asking for these records to determine (1) the health needs of the above-named individual; (2) whether he/she needs
a specific type of extra supports (known as reasonable accommodations) to participate in Job Corps; and (3) whether he/she
has a health condition that would pose a direct threat to the individual or others if he/she participates in Job Corps.
= I (we) authorize Job Corps to provide the above-named individual with an ENTRANCE MEDICAL EXAMINATION that

includes blood testing to identify conditions such as anemia, syphilis, and HIV infection; and urine testing to identify conditions
such as diabetes, nephritis, and pregnancy, and to screen for the unlawful use of controlled substances.
= I (we) authorize Job Corps to provide the above-named individual with a CURSORY ORAL INSPECTION and a

MANDATORY ORAL EXAMINATION that includes x-rays and checking the teeth, gums, and tissues of the mouth for
disease.
= I (we) authorize Job Corps to provide the above-named individual with basic routine health care and emergency health care

while he/she is enrolled in the Job Corps program. The types of care that are considered "basic routine health care" are listed
in the Policy and Requirements Handbook. (A current copy of this list is attached to this form.)
= I (we) authorize Job Corps to provide the above-named individual with basic oral care, which may include procedures such as

teeth cleaning, fillings, and extractions that will relieve pain and help prevent or decrease dental problems.
= I (we) understand the reasons for the medical and oral examinations and health testing and have had the opportunity to ask

questions.
= I (we) authorize Job Corps to provide the above-named individual with all immunizations that Job Corps determines are

necessary for that individual.
= I (we) authorize Job Corps to administer a skin test for tuberculosis to the above named individual.
= I (we) certify that the information that has been provided on this medical form is true and complete to the best of my (our)

knowledge.
= I (we) understand that any false statement or dishonest answers may be grounds for separation from Job Corps for the

above-named individual.
= I (we) understand that protected health information will only be released in accordance with the Privacy Act of 1974, any

other applicable Federal laws (see discussion below), and the current Job Corps Privacy Rule Authorization and Notice.
All disability-related or other medical information that is contained in this health questionnaire, or that is obtained through the
authorizations contained in this document, will be collected and maintained separately from other information regarding the
applicant offered enrollment, and will be kept strictly confidential. This information will only be disclosed in accordance with
the requirements of the Department of Labor's regulations: see 20 CFR 638.537 and 29 CFR Part 70.
The confidentiality requirements expressed in the above paragraph are separate and different from the confidentially
requirements for health information imposed under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Under the Department of Labor's regulations related to discrimination on the basis of disability, the disclosure of medical and
disability-related information about a particular individual is only permitted in accordance with those regulations, even if a
recipient, such as a Job Corps contractor or center operator, obtains a signed release form explicitly authorizing disclosure
that is or would be inconsistent with those regulations.
Applicant Signature:

Date:

Parent/Guardian Signature (if applicant offered enrollment is a minor)

Date:

Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number. Public reporting burden for this collection of information is estimated to
average 5 minutes 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room N4463 200 Constitution Avenue, NW, Washington, DC 20210 (1205-0033), Washington, DC 20503. (Paperwork
Reduction Project 1205-0033).

ETA 6-53 (Rev. 01/2007)