<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 23%" />
<col style="width: 15%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 26%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><p><strong>U.S. Agency For International
Development</strong></p>
<h2 id="bureau-for-economic-growth-agriculture-and-trade">Bureau For
Economic Growth, Agriculture And Trade</h2>
<p><strong>Office of Education</strong></p>
<h1 id="medical-history-and-examination-for-foreign-applicants">MEDICAL
HISTORY AND EXAMINATION FOR FOREIGN APPLICANTS</h1>
<p><strong>(Medical History To Be Completed By
Applicant)</strong></p></td>
</tr>
<tr class="even">
<td colspan="10"><p>1. LAST NAME – FIRST NAME – MIDDLE NAME</p>
<p>     </p></td>
<td><p>2. DATE OF BIRTH (MO/DAY/YR)</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3"><p>3. NATIONALITY</p>
<p>     </p></td>
<td><p>4. SEX</p>
<p> Male</p>
<p> Female</p></td>
<td colspan="7"><p>5. ADDRESS FOR CONTACT</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="4"><p>6. TRAINING LOCATION <em>(City, State,
Country)</em></p>
<p>     </p></td>
<td colspan="6"><p>7. LENGTH OF TRAINING</p>
<p><em>(Weeks, Months, Years)</em></p>
<p>     </p></td>
<td><p>8. ESTIMATED DATE TO BEGIN</p>
<p>TRAINING <em>(Month/Year)</em></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="11"><p>9. I<strong>MPORTANT NOTICE</strong></p>
<blockquote>
<p>Before You Complete The Medical History Questionnaire, You Are Hereby
Notified That:</p>
</blockquote>
<ul>
<li><p>USAID does not provide medical insurance for dependents who
accompany the applicant.</p></li>
</ul>
<ul>
<li><p>A Medical condition resulting from an undisclosed pre-existing
condition may not be financially compensated for by USAID and may result
in termination of your training program.</p></li>
<li><p>I understand that by accepting USAID sponsorship I hereby waive
any privacy rights that I have to such medical claims and agree to
permit my insurance provider or its authorized representatives to
release all information related to such claims to USAID. Such
notification will include the date of the claim, the nature of the claim
and copies of all documentation related to the claim. USAID shall use
such claims information for reviewing its entire insurance program. I
understand that I have the right to revoke this authorization by
providing written notice to USAID. Such revocation will result in
automatic termination of USAID's sponsorship of the program, unless
USAID otherwise agrees in writing.</p></li>
</ul>
<blockquote>
<p>I Understand And Accept The Terms Of This Notice. Yes No</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="11">10. CHECK EACH ITEM “YES” OR “NO,” EVERY ITEM CHECKED
“YES” MUST BE FULLY EXPLAINED IN BLANK SPACE ON RIGHT</td>
</tr>
<tr class="odd">
<td>YES</td>
<td>NO</td>
<td colspan="5" rowspan="2"><p>a. Have you had any significant or
serious illness or injury?</p>
<p><em>(if hospitalized, give place &amp; dates)</em></p></td>
<td colspan="4" rowspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5"><p>b. Have you had any operations or advised by a
physician</p>
<p>to have an operation? <em>(Give place &amp; dates)</em></p></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="5"><p>c. Do you currently use any drugs for treatment
of</p>
<p>a medical condition? <em>(Give name of &amp; dose)</em></p></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5"><p>d. Have you ever been a patient in a mental hospital
or sani-</p>
<p>tarium or treated by a Psychiatrist? <em>(Give place &amp;
dates)</em></p></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="11">11. DO YOU NOW HAVE YOU EVER HAD THE CONDITIONS LISTED
BELOW? <em>(Indicate “Yes” or “No” To Each Item)</em></td>
</tr>
<tr class="odd">
<td>YES</td>
<td>NO</td>
<td colspan="4"><em>(Check Each Item)</em></td>
<td>YES</td>
<td>NO</td>
<td colspan="3"><em>(Check Each Item)</em></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">a. Epilepsy, convulsions, “fits”</td>
<td></td>
<td></td>
<td colspan="3" rowspan="2"><p>m. Tropical disease (malaria, bilharzia,
amoeblasis,</p>
<p>leprosy, filariasis, yaws, etc.)</p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">b. Eye disease, vision defect in both or either eye</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">c. Tooth or gum disease (periodontal disease)</td>
<td></td>
<td></td>
<td colspan="3" rowspan="2"><p>n. Depression, excess worry, attempted
suicide, or</p>
<p>other psychological symptoms</p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">d. Asthma, emphysema, or other lung conditions</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">e. Tuberculosis or live with anyone who has
tuberculosis</td>
<td></td>
<td></td>
<td colspan="3" rowspan="2"><p>o. Drug or narcotic habit such as
marijuana, cocaine,</p>
<p>heroin, LSD, or any derivatives</p></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">f. High blood pressure, heart disease</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">g. Stomach, liver (hepatitis), gallbladder disease</td>
<td></td>
<td></td>
<td colspan="3">p. Bleeding disorder, blood disease (sickle cell
anemia)</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">h. Hernia (rupture)</td>
<td></td>
<td></td>
<td colspan="3">q. Acquired Immune Deficiency Syndrome (AIDS)</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">i. Kidney or bladder disease, stone or blood in
urine</td>
<td></td>
<td></td>
<td colspan="3">r. Tumor, abnormal growth, cyst, or cancer</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">j. Diabetes (sugar in the urine)</td>
<td></td>
<td></td>
<td colspan="3">s. Skin disorder, growths, psoriasis</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4">k. Joint disease or injury, swollen or painful
joints</td>
<td></td>
<td></td>
<td colspan="3">t. Female disorder, growths, psoriasis</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="4">l. Back pain, wear a back brace or support</td>
<td></td>
<td></td>
<td colspan="3">u. Pregnancy</td>
</tr>
<tr class="even">
<td colspan="11"><h3
id="i-certify-that-i-have-read-the-above-instructions-and-answered-all-questions-truly">
I CERTIFY THAT I HAVE READ THE ABOVE INSTRUCTIONS AND ANSWERED ALL
QUESTIONS TRULY</h3>
<p><em>AND COMPLETELY TO THE BEST OF MY KNOWLEDGE.</em></p></td>
</tr>
<tr class="odd">
<td colspan="5"><p>12. PRINTED NAME OF APPLICANT</p>
<p>     </p></td>
<td colspan="4"><p>13. DATE</p>
<p>     </p></td>
<td colspan="2">14. SIGNATURE OF APPLICANT</td>
</tr>
<tr class="even">
<td colspan="11"><p>NOTE For the Examing Physician: Please review this
Medical History and make appropriate comments on the</p>
<p>Examination Form on all positive or significant comments.</p></td>
</tr>
</tbody>
</table>

#### AID 1382-1 (11/02) Page 1 

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+-----+--------+----------+------+--------+-----+---+------------------+
| 1   |        | 17\.     | 18\. |        | 1   |   |                  |
| 6\. |        | WEIGHT   | B    |        | 9\. |   |                  |
| HEI |        |          | LOOD |        | COR |   |                  |
| GHT |        |          | PRES |        | REC |   |                  |
|     |        |          | SURE |        | TED |   |                  |
|     |        |          |      |        | VIS |   |                  |
|     |        |          |      |        | ION |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        | L   |   |                  |
|     |        |          |      |        | 20: |   |                  |
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|     |        |          |      |        | 20: |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          | 21\. |        |     |   | 22\. CHEST X-RAY |
| 0\. |        |          | B    |        |     |   | REPORT (Date)    |
| U   |        |          | LOOD |        |     |   |                  |
| RIN |        |          | SERO |        |     |   |                  |
| ALY |        |          | LOGY |        |     |   |                  |
| SIS |        |          | TEST |        |     |   |                  |
| (   |        |          | FOR  |        |     |   |                  |
| Sug |        |          | SYPH |        |     |   |                  |
| ar, |        |          | ILIS |        |     |   |                  |
| blo |        |          |      |        |     |   |                  |
| od, |        |          | Posi |        |     |   |                  |
| et  |        |          | tive |        |     |   |                  |
| c.) |        |          | Nega |        |     |   |                  |
|     |        |          | tive |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          | 24\. |        |     |   |                  |
| 3\. |        |          | E    |        |     |   |                  |
| PRE |        |          | LECT |        |     |   |                  |
| GNA |        |          | ROCA |        |     |   |                  |
| NCY |        |          | RDIO |        |     |   |                  |
| T   |        |          | GRAM |        |     |   |                  |
| EST |        |          | RE   |        |     |   |                  |
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| CG) |        |          | *(if |        |     |   |                  |
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+-----+--------+----------+------+--------+-----+---+------------------+
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| 5\. |        |          |      |        |     |   |                  |
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| EV  |        |          |      |        |     |   |                  |
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| TEM |        |          |      |        |     |   |                  |
| C   |        |          |      |        |     |   |                  |
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| M   |        |          |      |        |     |   |                  |
| UST |        |          |      |        |     |   |                  |
| BE  |        |          |      |        |     |   |                  |
| FU  |        |          |      |        |     |   |                  |
| LLY |        |          |      |        |     |   |                  |
| EXP |        |          |      |        |     |   |                  |
| LAI |        |          |      |        |     |   |                  |
| NED |        |          |      |        |     |   |                  |
| IN  |        |          |      |        |     |   |                  |
| BL  |        |          |      |        |     |   |                  |
| ANK |        |          |      |        |     |   |                  |
| SP  |        |          |      |        |     |   |                  |
| ACE |        |          |      |        |     |   |                  |
| ON  |        |          |      |        |     |   |                  |
| RIG |        |          |      |        |     |   |                  |
| HT) |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| NOR | (CHECK |          | ABNO | DE     |     |   |                  |
| MAL | EACH   |          | RMAL | SCRIBE |     |   |                  |
|     | ITEM)  |          |      | AB     |     |   |                  |
|     |        |          |      | NORMAL |     |   |                  |
|     |        |          |      | FI     |     |   |                  |
|     |        |          |      | NDINGS |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Head,  |          |      |        |     |   |                  |
|     | Nose,  |          |      |        |     |   |                  |
|     | Mouth  |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Ears,  |          |      |        |     |   |                  |
|     | H      |          |      |        |     |   |                  |
|     | earing |          |      |        |     |   |                  |
|     | Acuity |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Lungs  |          |      |        |     |   |                  |
|     | and    |          |      |        |     |   |                  |
|     | Chest  |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Heart, |          |      |        |     |   |                  |
|     | Rhythm |          |      |        |     |   |                  |
|     | &      |          |      |        |     |   |                  |
|     | Sounds |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Va     |          |      |        |     |   |                  |
|     | scular |          |      |        |     |   |                  |
|     | S      |          |      |        |     |   |                  |
|     | ystem, |          |      |        |     |   |                  |
|     | Varico |          |      |        |     |   |                  |
|     | sities |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Ab     |          |      |        |     |   |                  |
|     | domen, |          |      |        |     |   |                  |
|     | H      |          |      |        |     |   |                  |
|     | ernia, |          |      |        |     |   |                  |
|     | etc.   |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Hemorr |          |      |        |     |   |                  |
|     | hoids, |          |      |        |     |   |                  |
|     | F      |          |      |        |     |   |                  |
|     | istula |          |      |        |     |   |                  |
|     | Pr     |          |      |        |     |   |                  |
|     | ostate |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | U      |          |      |        |     |   |                  |
|     | rinary |          |      |        |     |   |                  |
|     | System |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Spine, |          |      |        |     |   |                  |
|     | Arms,  |          |      |        |     |   |                  |
|     | Legs,  |          |      |        |     |   |                  |
|     | etc.   |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Skin,  |          |      |        |     |   |                  |
|     | Lymph  |          |      |        |     |   |                  |
|     | Nodes, |          |      |        |     |   |                  |
|     | Scars  |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Neurol |          |      |        |     |   |                  |
|     | ogical |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
|     | Emo    |          |      |        |     |   |                  |
|     | tional |          |      |        |     |   |                  |
|     | Sta    |          |      |        |     |   |                  |
|     | bility |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          |      |        |     |   |                  |
| 6\. |        |          |      |        |     |   |                  |
| THE |        |          |      |        |     |   |                  |
| PHY |        |          |      |        |     |   |                  |
| SIC |        |          |      |        |     |   |                  |
| IAN |        |          |      |        |     |   |                  |
| M   |        |          |      |        |     |   |                  |
| UST |        |          |      |        |     |   |                  |
| C   |        |          |      |        |     |   |                  |
| OMM |        |          |      |        |     |   |                  |
| ENT |        |          |      |        |     |   |                  |
| ON  |        |          |      |        |     |   |                  |
| ALL |        |          |      |        |     |   |                  |
| IT  |        |          |      |        |     |   |                  |
| EMS |        |          |      |        |     |   |                  |
| MAR |        |          |      |        |     |   |                  |
| KED |        |          |      |        |     |   |                  |
| "Y  |        |          |      |        |     |   |                  |
| ES" |        |          |      |        |     |   |                  |
| IN  |        |          |      |        |     |   |                  |
| THE |        |          |      |        |     |   |                  |
| H   |        |          |      |        |     |   |                  |
| IST |        |          |      |        |     |   |                  |
| ORY |        |          |      |        |     |   |                  |
| AND |        |          |      |        |     |   |                  |
| C   |        |          |      |        |     |   |                  |
| OMM |        |          |      |        |     |   |                  |
| ENT |        |          |      |        |     |   |                  |
| ON  |        |          |      |        |     |   |                  |
| ANY |        |          |      |        |     |   |                  |
| CON |        |          |      |        |     |   |                  |
| DIT |        |          |      |        |     |   |                  |
| ION |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
| D   |        |          |      |        |     |   |                  |
| ISC |        |          |      |        |     |   |                  |
| OVE |        |          |      |        |     |   |                  |
| RED |        |          |      |        |     |   |                  |
| DUR |        |          |      |        |     |   |                  |
| ING |        |          |      |        |     |   |                  |
| THE |        |          |      |        |     |   |                  |
| EXA |        |          |      |        |     |   |                  |
| MIN |        |          |      |        |     |   |                  |
| ATI |        |          |      |        |     |   |                  |
| ON. |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          |      |        |     | R |                  |
| 7\. |        |          |      |        |     | E |                  |
| S   |        |          |      |        |     | C |                  |
| UMM |        |          |      |        |     | O |                  |
| ARY |        |          |      |        |     | M |                  |
| OF  |        |          |      |        |     | M |                  |
| ANY |        |          |      |        |     | E |                  |
| D   |        |          |      |        |     | N |                  |
| EFE |        |          |      |        |     | D |                  |
| CTS |        |          |      |        |     | A |                  |
| AND |        |          |      |        |     | T |                  |
| DIA |        |          |      |        |     | I |                  |
| GNO |        |          |      |        |     | O |                  |
| SIS |        |          |      |        |     | N |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     | M |                  |
|     |        |          |      |        |     | e |                  |
|     |        |          |      |        |     | d |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | c |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | y |                  |
|     |        |          |      |        |     | Q |                  |
|     |        |          |      |        |     | u |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | f |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | e |                  |
|     |        |          |      |        |     | d |                  |
|     |        |          |      |        |     | f |                  |
|     |        |          |      |        |     | o |                  |
|     |        |          |      |        |     | r |                  |
|     |        |          |      |        |     | T |                  |
|     |        |          |      |        |     | r |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | n |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | n |                  |
|     |        |          |      |        |     | g |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     | N |                  |
|     |        |          |      |        |     | o |                  |
|     |        |          |      |        |     | t |                  |
|     |        |          |      |        |     | M |                  |
|     |        |          |      |        |     | e |                  |
|     |        |          |      |        |     | d |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | c |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | y |                  |
|     |        |          |      |        |     | Q |                  |
|     |        |          |      |        |     | u |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | l |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | f |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | e |                  |
|     |        |          |      |        |     | d |                  |
|     |        |          |      |        |     | f |                  |
|     |        |          |      |        |     | o |                  |
|     |        |          |      |        |     | r |                  |
|     |        |          |      |        |     | T |                  |
|     |        |          |      |        |     | r |                  |
|     |        |          |      |        |     | a |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | n |                  |
|     |        |          |      |        |     | i |                  |
|     |        |          |      |        |     | n |                  |
|     |        |          |      |        |     | g |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          |      |        |     |   |                  |
| 8\. |        |          |      |        |     |   |                  |
| N   |        |          |      |        |     |   |                  |
| AME |        |          |      |        |     |   |                  |
| AND |        |          |      |        |     |   |                  |
| A   |        |          |      |        |     |   |                  |
| DDR |        |          |      |        |     |   |                  |
| ESS |        |          |      |        |     |   |                  |
| OF  |        |          |      |        |     |   |                  |
| E   |        |          |      |        |     |   |                  |
| XAM |        |          |      |        |     |   |                  |
| ING |        |          |      |        |     |   |                  |
| PHY |        |          |      |        |     |   |                  |
| SIC |        |          |      |        |     |   |                  |
| IAN |        |          |      |        |     |   |                  |
| (   |        |          |      |        |     |   |                  |
| Ple |        |          |      |        |     |   |                  |
| ase |        |          |      |        |     |   |                  |
| Pr  |        |          |      |        |     |   |                  |
| int |        |          |      |        |     |   |                  |
| or  |        |          |      |        |     |   |                  |
| Ty  |        |          |      |        |     |   |                  |
| pe) |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+
| 2   |        |          |      |        |     | 3 |                  |
| 9\. |        |          |      |        |     | 0 |                  |
| SIG |        |          |      |        |     | . |                  |
| NAT |        |          |      |        |     |   |                  |
| URE |        |          |      |        |     | D |                  |
| OF  |        |          |      |        |     | A |                  |
| EXA |        |          |      |        |     | T |                  |
| MIN |        |          |      |        |     | E |                  |
| ING |        |          |      |        |     |   |                  |
| PHY |        |          |      |        |     |   |                  |
| SIC |        |          |      |        |     |   |                  |
| IAN |        |          |      |        |     |   |                  |
|     |        |          |      |        |     | O |                  |
|     |        |          |      |        |     | F |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     | E |                  |
|     |        |          |      |        |     | X |                  |
|     |        |          |      |        |     | A |                  |
|     |        |          |      |        |     | M |                  |
|     |        |          |      |        |     | I |                  |
|     |        |          |      |        |     | N |                  |
|     |        |          |      |        |     | A |                  |
|     |        |          |      |        |     | T |                  |
|     |        |          |      |        |     | I |                  |
|     |        |          |      |        |     | O |                  |
|     |        |          |      |        |     | N |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
|     |        |          |      |        |     |   |                  |
+-----+--------+----------+------+--------+-----+---+------------------+

#### AID 1382-1 (11/02) Page 2 

+------------------------------+-----------+--------------+-----------+
| ##### ADMINISTRATIVE R       |           |              |           |
| EVIEW OF MEDICAL EXAMINATION |           |              |           |
|                              |           |              |           |
| **(For Use By Post Training  |           |              |           |
| Office)**                    |           |              |           |
+------------------------------+-----------+--------------+-----------+
| 1\. NAME OF CANDIDATE:       |           |              |           |
| *(Last, First, Middle)*      |           |              |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+
| **MEDICAL CLEARANCE ACTION** |           |              |           |
+------------------------------+-----------+--------------+-----------+
| ACTION BY SPONSORING UNIT OR |           |              |           |
| DESIGNEE                     |           |              |           |
|                              |           |              |           |
| Recommend Approval of        |           |              |           |
| Applicant's Entry Into       |           |              |           |
| Training Program             |           |              |           |
|                              |           |              |           |
| Recommend Disapproval of     |           |              |           |
| Applicant's Entry Into       |           |              |           |
| Training Program             |           |              |           |
|                              |           |              |           |
| Recommend waiver of          |           |              |           |
| Applicant's medical          |           |              |           |
| ineligibility for the        |           |              |           |
| following reasons. Health    |           |              |           |
| cost liability for           |           |              |           |
| pre-existing medical         |           |              |           |
| conditions                   |           |              |           |
|                              |           |              |           |
| will be assumed by the       |           |              |           |
| Mission or other responsible |           |              |           |
| party.                       |           |              |           |
+------------------------------+-----------+--------------+-----------+
| REASON FOR REJECTION /       |           |              |           |
| WAIVER OF INELIGIBILITY      |           |              |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+
| SIGNATURE                    | PRINTED   |              | DATE      |
|                              | NAME      |              |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+
| REVIEWED BY:                 |           |              |           |
+------------------------------+-----------+--------------+-----------+
| SIGNATURE                    | PRINTED   |              |           |
|                              | NAME      |              |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+
| **MEDICAL WAIVER ACTION**    |           |              |           |
+------------------------------+-----------+--------------+-----------+
| > Applicants rejected for    |           |              |           |
| > training because of        |           |              |           |
| > medical problems may be    |           |              |           |
| > re-evaluated for training  |           |              |           |
| > with a waiver of H.A.C.    |           |              |           |
| > coverage                   |           |              |           |
| >                            |           |              |           |
| > for specified pre-existing |           |              |           |
| > condition.                 |           |              |           |
| >                            |           |              |           |
| > The USAID Mission may      |           |              |           |
| > determine to grant a       |           |              |           |
| > waiver when:               |           |              |           |
| >                            |           |              |           |
| > 1\. It is felt that the    |           |              |           |
| > period of training will be |           |              |           |
| > of short duration and      |           |              |           |
| > medical condition is       |           |              |           |
| > unlikely to be activated   |           |              |           |
| >                            |           |              |           |
| > or aggravated during that  |           |              |           |
| > period; or                 |           |              |           |
| >                            |           |              |           |
| > 2\. The training is        |           |              |           |
| > considered essential to    |           |              |           |
| > the program objective.     |           |              |           |
| >                            |           |              |           |
| > By granting this waiver    |           |              |           |
| > request, the USAID Mission |           |              |           |
| > accepts full               |           |              |           |
| > responsibility to ensure   |           |              |           |
| > payment of all claims      |           |              |           |
| > arising from waived        |           |              |           |
| >                            |           |              |           |
| > conditions. This           |           |              |           |
| > determination by the USAID |           |              |           |
| > Director or U.S. officer   |           |              |           |
| > designee must be obtained  |           |              |           |
| > prior to further           |           |              |           |
| > processing of the          |           |              |           |
| >                            |           |              |           |
| > applicant.                 |           |              |           |
| >                            |           |              |           |
| > Waived Condition(s):       |           |              |           |
+------------------------------+-----------+--------------+-----------+
| SIGNATURE                    |           | DATE         |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+
| PRINTED NAME                 |           | POSITION     |           |
|                              |           | TITLE        |           |
|                              |           |              |           |
|                              |           |              |           |
+------------------------------+-----------+--------------+-----------+

#### AID 1382-1 (11/02) Page 3