Form PHS-7055 Injury

PHS-7055 (3/07)

Page 1

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

PSC Graphics (301) 443-1090

EF

1. What was/were the specifi c injury(ies)?

2. When did the injury(ies) occur?

3. Please describe how the injury(ies) occurred?

4. How was/were the injury(ies) treated?

5. How long did the treatment last, (e.g., 2 weeks, 6 weeks, 2 months, 6 months, etc.)?

6. Did you or do you now require any external supports, (e.g., knee braces, lifts, ankle taping, etc.)?

Yes

No

If yes, please explain:

7. Have you ever been restricted from activities secondary to your injury(ies)?

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

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 injury(ies). Note: It is intended that this form be completed online as a link

to a ‘Yes’ answer on Item 50, Item 51, or Item 52 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 Com-

missioned 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 7 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-7055 (3/07)

Page 2

SPORTS INJURY QUESTIONNAIRE

(Continued)

8. Please provide information regarding the extent of your athletic activities during the last 12 months?

9. Please provide any additional pertinent information:

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