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pdfU.S. Department of Labor
Employment and Training Administration
OMB Approval No. 1205-0033
Expiration Date: 11/30/2010
Job Corps Health Questionnaire (ETA 653)
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.
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
6
What is your general Health Condition (check one):
7.
a.
b.
3. Sex (M/F)
Excellent
Good
4. Height (in)
Fair
Are you or your family covered by health insurance?
(If YES, obtain copy of health insurance card and attach to this form.)
Are you or your family covered by Medicaid?
(If YES, obtain copy of Medicaid card and attach to this form.)
5. Weight (lb)
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.
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
NO
Other
YES
b.
Are you currently taking any prescription or non-prescription medication, herbs,
supplements, vitamins, etc.?
NO
YES
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 2 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
ETA 653 (rev 11/2010)
Page 1 of 4
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
l.
Attempted to hurt yourself (e.g., cut yourself, deliberately overdosed on medication or other
drugs)?
NO
YES
m.
Thought about hurting yourself or planned to hurt yourself?
NO
YES
n.
Intentionally tried to hurt someone else?
NO
YES
o.
Been afraid that others want to physically harm you?
NO
YES
p.
Heard voices or seen things that other people did not hear or see?
NO
YES
q.
Believed that your thoughts were being controlled by someone or something other than
yourself?
NO
YES
r.
Lost control of your anger, or feared losing control of your anger, to the point of hurting
yourself or someone else?
NO
YES
s.
Been in a physical fight?
NO
YES
t.
Been expelled from school, fired from a job, or convicted of a crime?
NO
YES
u.
Been removed from your home by authorities due to your behavior (e.g., charges of
disorderly conduct, assault, etc.)?
NO
YES
v.
Stopped getting treatment and/or taking medication that a doctor or other medical
professional wanted you to have?
NO
YES
w.
Participated in a residential or day therapeutic program where you received medical or
mental health care?
NO
YES
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
NO
YES
b.
Asthma
NO
YES
r.
Depression
NO
YES
c.
Visual impairment/trouble seeing
NO
YES
s.
Anxiety Disorder
NO
YES
d.
Hearing impairment/trouble hearing
NO
YES
t.
Obsessive-Compulsive
Disorder
NO
YES
e.
Obesity
NO
YES
u.
Impulse Control Disorders (e.g.,
fire-setting, intermittentexplosive disorder, etc.)
NO
YES
f.
Diabetes (high blood sugar)
NO
YES
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
i.
Kidney, bladder, or urinary problems
NO
YES
y.
Bipolar Disorder
NO
YES
j.
Speech problem (e.g., stuttering, etc.)
NO
YES
z.
Anti-Social Personality Disorder
NO
YES
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
ee.
NO
YES
p.
Hepatitis
NO
YES
FEMALES: Are you pregnant?
If YES, approximate date last
menstrual period began.
____________________
ETA 653 (rev 11/2010)
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10. If you are a person with a disability, you may request accommodations (changes in the way things
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?
NO
YES
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.
Item
Explanation
●
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.
●
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.
ETA 653 (rev 11/2010)
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●
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.
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:
Paperwork Reduction Act Public Burden Statement: Persons are not required to respond to this collection of information
unless it displays a currently valid OMB control number and expiration date. Public reporting burden for this collection of
information, which is required to obtain or retain benefits (29 USC 2881), 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 information. This information collection is for program management. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the US Department of Labor, Office of Job Corps, Room N-4507, Washington, D.C. 20210 (OMB Control No. 12050033).
ETA 653 (rev 11/2010)
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| File Type | application/pdf |
| File Title | PURPOSE: To determine the health and accommodation/modification needs of the Job Corps applicant |
| Author | bgrove |
| File Modified | 2010-11-18 |
| File Created | 2010-11-18 |