Va Form 0928c - National Veterans Summer Sports Clinic General Medical/physical Exam Form - 2012

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OMB Number: 2900-0759

Respondent Burden: 20 minutes

GENERAL MEDICAL/PHYSICAL EXAM FORM

2012 NATIONAL VETERANS SUMMER SPORTS CLINIC

(To be completed by Examining Clinician)

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 Clinician: Please fill out completely the two medical pages. In addition, please include (1) a copy of a recent EKG for anyone 40 years of age

and older, (2) a recent H&P/Problem list and (3) a list of current medications and dosages. PLEASE TYPE OR PRINT CLEARLY

PATIENT'S NAME

SOCIAL SECURITY

DATE

AGE

NUMBER (Last 4 digits only)

PATIENT'S DAYTIME PHONE

VAMC WHERE PATIENT RECEIVES CARE

EVENING PHONE NUMBER

NUMBER (Include area code)