Fillable CONTINUED SERVICE AGREEMENT Form DS-4147

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CONTINUED SERVICE AGREEMENT Form DS-4147

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The CONTINUED SERVICE AGREEMENT Form DS-4147 form is 1 page long and contains:

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Country of origin: US
File type: PDF

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The US Department of State (DOS) or the State Department, is the government official division that advises the President and performs international relations. Equivalent to the outside service of different nations, it was built up in 1789 as the country's first official department.

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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
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CONTINUED SERVICE AGREEMENT Form DS-4147

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Completed 20 May 2019

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