Va Form 0927c - Participant Registration Form - Physical Exam
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2OMB Number: 2900-0759
Respondent Burden: 20 minutes
PARTICIPANT REGISTRATION FORM -- PHYSICAL EXAM
NATIONAL VETERANS TEE TOURNAMENT
(To be completed by a Clinician. 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 20 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the forms.
Dear Examining Clinician: Your patient is planning to participate in a three-day event with moderately strenuous, sporting activities,
provided that you concur. To ensure that this is an appropriate activity for this Veteran, please conduct a detailed review of his/her
medical record. Thank you for assisting us in ensuring this participant's safety.
PATIENT'S NAME
SOCIAL SECURITY
DATE
NUMBER (Last 4 digits only)
PRIMARY DISABILITY/DIAGNOSIS: DATE OF ONSET
VISUALLY IMPAIRED
LEGALLY BLIND
TOTALLY BLIND
RESIDUAL VISION
SPINAL CORD INJURY (SCI)
COMPLETE
INCOMPLETE
- LEVEL
PARAPLEGIC
QUADRIPLEGIC
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
CVA WITH RESIDUAL
AMPUTEE
RIGHT LEG, A/K, B/K
RIGHT ARM, A/E, B/E
OTHER
LEFT LEG, A/K, B/K
LEFT ARM, A/E, B/E
PSYCHOLOGICAL CONDITIONS
PTSD
ANXIETY
DEPRESSION
SEIZURES
STROKE
OTHER CONDITION(S)
PLEASE RATE YOUR PATIENTS LEVEL OF INDEPENDENCE
INDEPENDENT ONCE ORIENTED
NEEDS SIGHTED GUIDE OCCASIONALLY AFTER ORIENTATION
NEEDS SIGHTED GUIDE CONTINUOUSLY
PATIENT NEEDS
YES
NO
PATIENT REQUIRES ATTENDANT?
IF YES, ATTENDANTS' NAME
YES
NO
USES WHEELCHAIR MAJORITY OF TIME?
YES
NO
USES OTHER ADAPTIVE EQUIPMENT?
IF YES, WHAT
0927c
VA FORM
FEB 2013
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