HEALTH EDUCATION, AND WELFARE
Public Health Service
washington 25, D.C.
DIVISION OF INDIAN HEALTH CIRCULAR NO. 61-06
April 27, 1961
PHYSICAL EXAMINATIONS OF RELOCATEES AND THEIR DEPENDENTS
HEADQUARTERS IHS CIRCULAR FORMAT
- PURPOSE. This circular prescribes procedures for preparation of form BIA-5-442, Statement of Medical Examination, in conducting physical examinations of relocatees and their dependents in accordance with Section 5.1-4B(l) of the Indian Health Manual.
- BACKGROUND. Effective May 1, 1961, the Bureau of Indian Affairs will initiate new procedures for, securing physical examinations for relocatees and their dependents. Division of Indian Health staff will cooperate with Bureau of Indian Affairs officials in providing the physical examinations.
- When the Bureau of Indian Affairs Agency Relocation Officer approves an applicant and his dependents for relocation, he makes the necessary appointment and refers them to the Division of Indian Health facility for the physical examinations. The Bureau of Indian Affairs Relocation Officer forwards a copy of the previously completed form BIA 5-441, Statement of Medical History (Attachment #l), and an original and two copies of form BIA 5-442, Statement of Medical Examination (Attachment #2) with the top portion completed to the Division of Indian Health facility.
- Examinations of relocatees and their dependents should be completed within 30 days prior to the departure date indicated in the "Date Scheduled" space in the upper right corner of form BIA 5-442.
- The Division of Indian Health examining physician shall fill in applicable portions of form BIA 5-442 which is self-explanatory. Upon completion of the examination the original and one copy of the completed form shall be forwarded to the BIA Agency Relocation Officer. The remaining copy of form BIA-5-442 and form BIA 5-441 shall be filed in the Head of Household's unit record at the hospital.
- The continuation sheet (Attachment #3) is used for families of three or more, or when form BIA 5-441 indicates a physical condition or an illness which might warrant considerable written explanation. Distribution is the same as the basic form BIA 5-442.
/James R.. Shaw/
James R. Shaw, M.D.
Assistant Surgeon General
Chief, Division of Indian Health
Attachments (3) Contact your Area Directive, Delegations and Control Officer for a copy of these attachments
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