Date:
( your name)
Printed Name:
U.S. Department of State
FINAL CONFIRMATION of MEDICAL CLEARANCE STATUS AND
WORLDWIDE AVAILABILITY FOR ENTRY INTO THE FOREIGN SERVICE
DS-4147
05-2014
Signature:
Date (mm-dd-yyyy)
At the time of your pre-employment medical clearance examination, you received a Class 1,
Worldwide Available Medical Clearance, which is required to become a Foreign Service employee for
the Department of State.
From:
HR/REE
(mm-dd-yyyy)
To:
Subject: Confirmation that your Physical and Mental Health Have Not Changed
Please sign this statement and return to HR/REE:
I
confirm that I have
had no changes in my physical or mental health that could change my medical clearance status to
NOT worldwide available. I have had no new or previously undisclosed chronic or acute medical or
mental health diagnoses or treatment. I take no new medication since my pre-employment medical
clearance examination.
Date of Birth:
(mm-dd-yyyy)
If you have had a significant change in your medical status that may affect your medical clearance
and worldwide availability since your pre-employment medical clearance exam, please send an
e-mail to with a self-report of any new or previously undisclosed
medical or mental health problems. If you have a medical report from your health practitioner, include
it. Someone from the Office of Medical Clearances will advise you if the information will impact your
Class 1, Worldwide Available status.
MedClearances@state.gov
click to sign
signature
click to edit
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