Fillable Phs-6379 FORM PHS 6379

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Phs-6379 FORM PHS 6379

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OMB No. 0990-0324; OMB Approval Expires 05/31/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
SUPPLEMENTAL MEDICAL HISTORY RECORD REQUIRED OF APPLICANTS TO OR
OFFICERS OF THE PUBLIC HEALTH SERVICE COMMISSIONED CORPS
(This information is for official and medically confidential use only and will not be released to unauthorized persons.)
(See Privacy Act Statement for Form PHS-6379)
(Please Print)
Last Name First Name Middle Initial Social Security No.
EVERY ITEM CHECKED "YES" MUST BE FULLY EXPLAINED IN THE BLANK SPACE PROVIDED BELOW.
DO YOU NOW OR HAVE YOU EVER:
YES NO
1. had a high risk exposure to HIV (AIDS virus)?
2.
had a positive test for HIV antibody (test positive for AIDS virus infection)?
3.
used without prescription: marijuana, cocaine, hashish, narcotics, stimulants,
depressants, hallucinogenics, steroids, inhalants, or other dangerous or illegal
drugs?
4. felt you ought to cut down on your drinking?
5. had people criticized your drinking?
6. felt bad or guilty about your drinking?
7.
had a drink first thing in the morning to steady your nerves or get rid of a hangover?
8.
had alcohol or other substance use ever interfere with your performance or
attendance at school or work?
9.
had alcohol or other substance use cause you to have an accident or contribute
to your arrest?
10.
had a history of alcohol or drug or substance abuse?
11.
had, or been advised to have, evaluation or treatment for alcohol or drug or
substance abuse?
ANY/ALL OTHER CONDITIONS:
12. had any illness/injury other than those noted on form DD-2807-1, "Report of Medical History," which
may require future evaluation and treatment? If yes, please specify when and where and provide
details in the space below.
Note: If you are uncertain whether a medical condition will require evaluation or treatment in the future, please list it so that the
Medical Evaluation Staff, Division of Commissioned Corps Personnel & Readiness, can determine its significance.
EXPLAIN IN DETAIL ALL "YES" RESPONSES TO QUESTIONS HERE: (Use reverse side if necessary)
I certify that I have reviewed all information supplied on this form and that it is true and complete to the best of my knowledge.
(Nondisclosure or falsification can be cause for disqualification or termination of appointment.)
Applicant Signature Date
PHS-6379 (Rev. 05/17) PAGE 1
PSC Publishing Services (301) 443-6740
EF
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
Privacy Act Statement
PHS-6379 "Supplemental Medical History Record Required of Applicants
to the Public Health Service Commissioned Corps"
Authority:
Our authority to collect this information is 42 U.S.C. 202 et seq and Executive Order 10450.
Purpose and Use of Information : The information you provide on this form will be used to determine whether you
meet the medical standards that apply to Public Health Service (PHS) Commissioned Corps officers. This is a
critical evaluation because you must be physically and mentally fit to perform satisfactorily in national or worldwide
health and defense emergencies. In addition, the information will be used to begin monitoring your health and
fitness for duty on an ongoing basis if you are appointed. It may be provided to other Federal Agencies that furnish
you medical care, when needed to ensure continuity of care or to evaluate your eligibility for benefits from that
Agency based on your medical condition. It may also be provided to health care practitioners in the private sector
in the event you receive emergency medical care or to ensure continuity of care.
In very rare circumstances this information may be provided to: a congressional office at your request; officials of
this Department or the Department of Justice to prepare an effective defense when the Department or any of its
employees are the subject of litigation; or your legal guardian if you are found mentally incompetent by a court of
law.
More information about how these records are maintained is contained in the Privacy Act System Notice of
Records number 09-40-0002, "PHS Commissioned Corps Medical Records," HHS/PSC/HRS, a copy of which may
be obtained from the office to which you submit this form.
Information Regarding Disclosure of Your Social Security Number (SSN): Disclosure of the SSN is mandatory
under provisions of the Social Security Act, since PHS Commissioned Corps officers are under social security
covered employment and taxes must be withheld from their salaries. The SSN is also used as an identifier
throughout an officer’s career. It is used primarily to identify an officer’s pe
rsonnel, leave, and pay records and
to related one to the other. The SSN is also used in connection with lawful requests for information from former
employers, educational institutions, and financial or other organizations. The information gathered through the
use of the number will be used only as necessary in personnel administration processes carried out in
accordance with established regulatio
ns and published notices of systems of records. The use of the SSN is
made necessary because of the large number of present and former active, inactive, and retired officers and
applicants who have identical names and birth dates, and whose identities can only be distinguished by the
SSN.
Effects of Nondisclosure: Failure to provide the information requested on these forms will eliminate your
application from further consideration. If you withhold or falsify information about your medical condition, your
appointment will be terminated, you will lose any benefits provided to you based on the false information, and you
may be subject to criminal or civil prosecution.
PHS-6379 (Rev. 05/17) PAGE 2
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Completed 28 February 2020

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