THIS SPACE RESERVED FOR OFFICIAL USE BY U.S. DEPARTMENT OF STATE MEDICAL STAFF ONLY
Department of State / US Embassy Medical Professional Comments (attach additional sheets if needed)
Recommend World Wide Available - Class 1 Medical Clearance
Recommend Post Specific - - Class 2 Medical Clearance
Signature of FS Regional Medical Officer / FS Medical Provider
MED USE ONLY
Recommend Full Physical Examination for Medical Clearance Determination
Printed Name Date
8. Name of Your Health Insurance Plan
Bureau/Office of assignment
2. If Family Member, Name of Employee
3. MED ID Number (if available)
1. Name of Patient (Last, First, MI)
12. Post of Assignment
a. Proposed Post
b. Present Post
c. Last 3 Posts
6. Place of Birth
5. Sex4. Date of Birth (mm-dd-yyyy)
9b. Type of Employment
PSC or other Contractor
10. Mailing Address
10. Telephone Number(where you can be reached for the next 90 days)
(for patients 18 years of age or older)
11. E-mail Address (Where You can be Reached for the Next 90 days)
(for patients 18 years of age or older)
TO BE FILLED OUT BY PATIENT ( OR PARENT/GUARDIAN )
INSTRUCTIONS: Assigned overseas: please seek assistance from the US Embassy Health Unit medical staff.
Assigned domestically: complete page 1 demographic information fields 1 - 13, complete questions on page 2 and sign.
U.S. Department of State
Office of Medical Services, M/MED, Washington, DC 20520-0102
MEDICAL CLEARANCE UPDATE
Page 1 of 2
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited on this form will be used to make appropriate medical clearance decisions.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain
the requisite medical clearance pursuant to 16 FAM 211.
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008 (GINA)
prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic information when responding to
this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical history, the results of an individual's or
family members' genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
OMB APPROVAL NO. 1405-0131
EXPIRATION DATE 05/31/2020
ESTIMATED BURDEN: 30 MINUTES*
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average 30 minutes per
response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or
documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and /or recommendation for reducing it, please send them to:
M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522