Employee Self-Certification and Ability to Perform in
Emergencies (ESCAPE) Posts
PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM
DS-6570
04-2016
Page 1 of 2
Medical Provider Stamp or Print Name
Individual's Name Date of Birth ID
Dear Provider,
You have been asked to provide a full medical clearance evaluation for an individual preparing for deployment to
. One of the medical clearance requirements is to complete this 2-page form. Page two
contains multiple questions the patient is required to answer that will help you in completing a full physical examination
on this patient. Please use the information provided by the patient, the findings on your physical exam, and the
information about living and working conditions detailed below to determine whether this individual will be able to work
and live in a physically challenging and stressful environment.
Please pay special attention to any hematologic, cardiovascular, pulmonary, orthopedic, neurological, endocrine,
dermatological, psychological, visual, and auditory conditions which may present a significant risk of substantial harm to
the individual or others and/or preclude performing the functional requirements described below in the deployed setting.
Also, the amount of medications being taken and their suitability and availability in a conflict zone must be considered.
The work may require unusual physical exertion under unfavorable conditions including extreme heat, high elevations,
extremely dusty conditions and air pollution. The working and living conditions can also include the possibility of dealing
with sleep deprivation, emotional stress, and circadian disruption. If maintaining an individual's health requires avoidance
of these extremes or exertions, deployment to these areas may not be appropriate.
The individual will be required to wear Personal Protective Equipment (PPE) that may weigh up to 39 pounds (up to 4
pounds for the helmet and up to 35 pounds for the vest). The individual may need to move quickly in such gear and
carry additional equipment in an emergency - The individual should be able to perform certain emergency functions to
include responding to duck and cover alarms (which could involve quickly seeking cover in a protected bunker),
navigating a smoke-filled facility, going up and down stairs wearing PPE, and boarding/ de-boarding helicopters wearing
PPE on an independent basis, as assistance may be unavailable in exigent circumstances. Movement in the compound
requires maneuvering uneven surfaces and regularly walking up and down several flights of stairs throughout the day.
Transportation may be in off-road vehicles, helicopters, military troop transport aircraft or other military transportation
with confined seating. Clearances may be up to 36 inches off the ground with high step rails or ladder-type steps and
small entrances when accessing a helicopter. Luggage must be lifted into the helicopter and injuries can occur to
persons who are not physically capable of performing these activities.
By signing below, I acknowledge that I have read this form and I can find no apparent medical reason for this
person not to be able to live and work in the above described conditions.
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 or medical privacy regulations, 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 administration 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, failure to provide this information may result in denial
of a medical clearance.
OMB APPROVAL NO. 1405-0224
EXPIRES: 01/31/2020
ESTIMATED BURDEN: 30 MINUTES
Medical Provider Signature Date
dd mmm yyyy
dd mmm yyyy
click to sign
signature
click to edit
Instructions: Please answer each of the following questions. Be sure to attach copies of any medical reports that can
help clarify a medical condition(s). Failure to provide Medical Clearances with pertinent information will delay processing
of the medical clearance decision and post assignment approval. Scan and e-mail the completed 2-page form to
MEDMR@state.gov or fax to 202-647-0292.
Yes / No
1. Conditions that prevent the wearing of personal
protective equipment, including protective mask, ballistic
helmet, body armor, and chemical/biological protective
garments, regardless of the nature of the condition that
causes the inability?
2. Conditions that prohibit required
immunizations (other than smallpox & anthrax per current
guidance) or medications (such as anti-malarials, chemical
and biological antidotes, and other chemoprophylactic
antibiotics)?
3. Any chronic medical condition that requires
frequent clinical visits (more than quarterly) or ancillary
tests (more than twice/year), that fails to respond to
adequate conservative treatment, necessitates significant
limitation of physical activity, or constitutes increased risk
of illness, injury, or infection?
4. Any unresolved acute illness or injury that
would impair one's duty performance during the duration of
the deployment?
5. Asthma that has a Forced Expiratory Volume-1
< 50% of predicted despite appropriate therapy, that has
required hospitalization in the past 12 months, or that
requires daily systemic (not inhaled) steroids?
6. Seizure disorder, either within the last year or
currently on anticonvulsant medication for prior seizure
disorder/activity?
7. Diabetes mellitus?
8. History of heat stroke?
9. Meniere's disease or other vertiginous/motion
sickness disorder?
10. Renalithiasis (Kidney stones), recurrent or
currently symptomatic?
11. Obstructive sleep apnea (OSA)?
12. History of clinically diagnosed as having
Traumatic Brain Injury (TBI) or concussion?
13. Symptomatic coronary artery disease?
14. Chronic cough or coughing up blood?
15. Myocardial infarction within past two years?
16. Coronary artery bypass graft, coronary artery
angioplasty, carotid endarterectomy, other arterial stenting,
or aneurysm repair within 2 years?
17. Cardiac dysrhythmias or arrhythmias, either
symptomatic or requiring medication, electrophysiologic
control, or automatic implantable cardiac defibrillator?
Yes / No
18. Hypertension not controlled with medication
or that requires frequent monitoring?
19. Heart failure or history of heart failure?
20. Morbid obesity (BMI > 40) in accordance with
National Heart Lung and Blood Institute guidelines?
21. Active or chronic blood-borne diseases
(Hepatitis B, Hepatitis C, HIV)?
22. Active tuberculosis?
23. Untreated Latent tuberculosis, or is currently
undertreatment?
24. Vision loss?
25. Refractive eye surgery in last year?
26. Currently using ophthalmic steroid drops?
27. Photorefractive keratectomy (PRK) or laser
epithelial keratomileusis (LASiK) within the past 6 months?
28. Hearing loss?
29. On-going dental or orthodontic work?
30. On-going cancer therapy?
31. Precancerous lesions that have not been
treated?
32. Any medical condition that requires surgery
(e.g., unrepaired hernia) or for which surgery has been
performed and the patient requires ongoing treatment,
rehabilitation or additional surgery to remove devices (e.g.,
external fixator placement)?
33. Surgery (open or laparoscopic) within past 6
months?
34. Psychotic and Bipolar Disorders?
35. Clinical psychiatric disorders with residual
symptoms, or medication side effects?
36. History of the following: psychiatric
hospitalization; suicide attempt; substance (medication,
illicit drug, alcohol, inhalant, etc.) abuse or treatment for
such abuse; PTSD or/TBI?
37. Medications - Blood modifiers?
38. Medications - Antineoplastics (oncologic or
nononcologic use)?
39. Medications – Immunosuppressants?
40. Medications - Biologic Response Modifiers
(immunomodulators)?
41. Medications – Psychiatric or sleeping aides?
42. Medications – Anticonvulsants?
43. Medications – Pain medications, Opioids,
opioid combination drugs?
DS-6570 Page 2 of 2
Patient Printed Name
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 recommendations for reducing it, please send them to Office of Quality Improvement, U.S. Department of
State, M/MED/QI, SA-01, Washington DC 20522-0102; medqi@state.gov.
Patient Signature Date
click to sign
signature
click to edit
dd mmm yyyy
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