Form PHS-7054 Head Injury Questionnaire

PHS-7054 (3/07)

Page 1

PSC Graphics (301) 443-1090

EF

OMB No. xxxx-xxxx; OMB approval expires xx/xx/xx

1. How did your head injury(ies) occur?

2. How old were you when it/they happened?

3. Did you experience loss of consciousness?

Yes

No

If yes, how long:

4. Did you experience amnesia?

Yes

No

If yes, how long:

5. Were you treated at a hospital or by a medical provider?

Yes

No

If yes, what type(s) of treatment and/or tests was/were accomplished?

6. Did you have any symptoms after the injury (e.g., headaches, vomiting, disorientation, double vision, dizziness,

etc.)?

Yes

No

If yes, please explain:

(Continued)

PROOF

Department of Health and Human Services

Commissioned Corps of the U.S. Public Health Service

Offi ce of Commissioned Corps Operations

ATTN: Medical Evaluations Offi cer

Suite 100, Plaza Level

1101 Wootton Parkway

Rockville, MD 20852

HEAD INJURY QUESTIONNAIRE

PRIVACY ACT STATEMENT

AUTHORITY: 42 U.S.C. 202 et seq. and Executive Order 9397.

RECORDS SYSTEM: 09-40-0002, “PHS Commissioned Corps Medical Records,” HHS/PSC/HRS.

PRINCIPAL PURPOSE: To determine medical acceptability or update a medical fi le as part of the application process to the Commissioned

Corps of the U.S. Public Health Service.

ROUTINE USES: None.

DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper an applicant’s

candidacy. Use of the Social Security Number is used for positive identifi cation of records.

NAME

SOCIAL SECURITY NUMBER

INSTRUCTIONS: Please complete the following questions regarding history of head injury(ies). Note: It is intended that this form be completed online as

a link to a ‘Yes’ answer on Item 19 of form PHS-7060, Report of Medical History. In the event an applicant to the Commissioned Corps of the U.S. Public

Health Service cannot complete this form online, the applicant must complete the form in paper format and mail it to the Offi ce of Commissioned Corps

Operations at the above address and mark envelope “To be Opened by Medical Personnel Only.” If more space is needed (for versions of this form without

expandable fi elds), please use the applicable area on page 2.

The public reporting burden for this collection of information is estimated to

average 6 minutes per response, including the time for reviewing instruc-

tions, 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 col-

lection of information, including suggestions for reducing the burden, to

the HHS / OS Reports Clearance Offi cer, 200 Independence Avenue, SW,

Room 537-H, Washington, DC 20012 (PRA 0990-XXXX). Respondents

should be aware that notwithstanding any other provision of law, no person

shall be subject to any penalty for failing to comply with a collection of infor-

mation if it does not display a currently valid OMB control number.

PHS-7054 (3/07)

Page 2

HEAD INJURY QUESTIONNAIRE

(Continued)

7. How long did your symptoms last after your injury, if applicable?

8. Were any additional procedures accomplished (e.g., electroencephalogram, brain scan, burr holes, pneumoence

phalogram,etc.,)?

Yes

No

If yes, please explain:

CERTIFICATION: By signing below, I hereby certify that all the preceding information is true and accurate to the best

of my knowledge.

CONTINUED ANSWERS TO PRECEDING QUESTIONS (If needed when form version does not have expandable fi elds. Please specify question(s)) :

APPLICANT SIGNATURE

DATE

PROOF