OMB Number: 2900-0759
ATHLETE NUMBER-OFFICE USE ONLY
Expiration Date: Xxx, 20XX
Respondent Burden: 10 minutes
GENERAL MEDICAL FORM
TO BE COMPLETED BY PARTICIPANT. PLEASE TYPE OR PRINT CLEARLY.
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary. However, you will not be able to participate in the event without furnishing this information.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 10 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
DATE
VA MEDICAL CENTER NAME
NAME (Last, First, MI)
ADDRESS (Street, City, State, Zip Code)
E-MAIL ADDRESS
SOCIAL SECURITY NO. (Last 4 digits only)
DATE OF BIRTH
TELEPHONE NUMBER (Include area code)
TEAM COORDINATOR/LEADER:
TELEPHONE NUMBER
E-MAIL ADDRESS
In Case of Emergency, Notify (Name):
TELEPHONE NUMBER
RELATIONSHIP TO PATIENT
TO BE COMPLETED BY THE EXAMINING PHYSICIAN. PLEASE TYPE OR PRINT CLEARLY.
Dear Doctor: Your detailed exam of the participant will be very helpful to the medical assistance team. If an assistant completes the
form, please countersign the exam.
VA IDENTIFICATION CARD
DIAGNOSIS/TYPE OF INJURY
DATE OF INJURY OR DIAGNOSIS
AIS:
SPINAL CORD INJURY (SCI)--LEVEL OF INJURY:
PLEASE ATTACH A COPY OF
PARAPLEGIC
QUADRAPLEGIC
VA IDENTIFICATION CARD HERE
(See below)
MULTIPLE SCLEROSIS (MS)
AMPUTEE
If you do not attach a copy of your VA IDENTIFICATION CARD
HEAD INJURY
you must fill out VA Form 10-10EZ including your full Social
OTHER (Please specify)
Security Number.
MEDICATIONS (List relevant medications only. Please do NOT submit VA medications list)
If accepted to participate in the NVWG and your medical condition changes between now and the NVWG, it is your responsibility to
check with your physician and modify your events as appropriate. The NVWG is a sports competition that requires physical exertion.
For the best outcomes and your safety, you should be training to participate in your particular events. Please consult your physician or
therapist for recommendations and assistance.
0925b
VA FORM
OCT 2016