Ds-1622p Pre-employment Medical History And Examination For Forei

*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 04-30-2012
ESTIMATED BURDEN: 1 HOUR

U.S. Department of State
Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

PRE-EMPLOYMENT MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE
FOR CHILDREN 11 YEARS AND UNDER
PRIVACY ACT NOTICE: This information is requested pursuant to the Foreign Service Act of 1980, as amended ( 22 U.S.C. 4084, 3901 and 3984).
The primary purpose for soliciting this information is to make appropriate assignments abroad. Unless otherwise protected by 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 administration purposes. It may also be disclosed pursuant to court order. The information requested is voluntary however failure to
provide this information may result in denial of a medical clearance and affect your Foreign Service Eligibility.
Date (mm-dd-yyyy)

I. To Be Filled Out By Sponsor Or Parent (Complete all sections, type or in ink.)
1. Name of Examinee (Last, First, MI.)

3. Date of Birth (mm-dd-yyyy)

2. Full Name of Employee/Applicant/Sponsor

5. Agency of Employee/Applicant/Sponsor

4. Sex
Male

Female

State

Foreign Agricultural
Service

USAID

6. eMED Number if known (Employee/Applicant/Sponsor)
Board of Broadcasting
Governors

Foreign Commercial Service
7. Place of Birth
State
Country
City
9. Mailing Address
(Medical Clearance Abstract will be mailed to listed address)

8. Post of Assignment and Dates of Departure/Arrival
a. Proposed Post
EDA

(mm-dd-yyyy)

b. Present Post
EDD
(mm-dd-yyyy)
Telephone Number
(where you can be
reached for the next
90 days)
E-mail Address
(where you can be
reached for the
next 90 days)
11. Purpose of Examination

c. Last 3 Posts

10. Name of Your Health Insurance Plan

Pre-Employment
To the Doctor: 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 member's 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 services.
DS-1622P *Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required
for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required,
xx-2011
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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

Page 1 of 4

II. Have You Ever Had:
Yes

Name of Examinee

No

Yes
1. Frequent or severe headaches?
2. Dizzy spells, fainting, or seizures?
3. Any neurological disorder?
4. Chronic eye trouble or vision problems?
Date of last eye exam (mm-dd-yyyy)
5. Tooth or gum problems?
6. Ear, nose, or throat problems, including
hearing difficulties, hoarseness, or allergies?
7. Cough, wheezing, shortness of breath or
asthma?
8. Heart murmur or heart problems?
9. Rheumatic fever?
10. Esophagus, stomach, intestinal, rectal, liver,
or gallbladder problems?
11. A change in urinary habits, urinary tract
infection, bedwetting or stones, blood or
protein in urine?
12. Diabetes; thyroid or other hormonal/
metabolic disease?

No
13. Rheumatologic problems; tendon, joint or
back pain/injury; bone deformity or fracture?
14. Malaria or other tropical disease?
15. Any hair, nail or skin problems or disorders?
16. History of positive TB skin test or clinical tuberculosis/
TB exposure or BCG vaccination?
17. Anemia or blood transfusion?
18. Recent gain or loss of 10 lbs or more?
19. Frequent crying spells, trouble sleeping,
sadness, withdrawal, fears, or worries?
20. Difficulty in relaxing or calming down;
feelings of confusion?
21. Low academic functioning or learning
disability or disorders?
22. Behavioral or discipline problems at home or school?
23. Have you ever been referred to or received
mental health treatment?
24. Other?

III. List Current Medications (Include prescription, over the counter, vitamins, and herbals)

IV. Hospitalizations/Operations/Medical Evacuation (Include all medical and psychiatric illnesses)
Illness or Operation
Name of Hospital

Date (mm-dd-yyyy)

Drug Or Other Allergies

City and State

Is there anything else you would like to mention about your child's health or well being? Parent should explain "yes" answers to questions 1-24.

Please recheck all items for completeness and accuracy. DO NOT INDICATE: "Previously Answered"
The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the U.S.C. Title 18). Pre-employment applicants who
intentionally omit information that would make them ineligible for appointment, will be subject to disciplinary action, including separation for cause if
they are hired. Current employees may also be subject to disciplinary action for intentional omission of information.
Signature of Sponsor or Parent (I certify I have read and understand the above statements)
Date (mm-dd-yyyy)

V. To Be Completed By The Examiner (Read section X before proceeding.)
Significant History (Note: The Examiner MUST comment on ALL items checked "YES" in Part II.)

DS-1622P

Page 2 of 4

VI. To Be Completed By The Examiner
1. Height

Name Of Examinee
2. Weight

in. or

lb. or

cm.

kg.

percentile
5. Distant Vision (age 5 and over)
Right 20/

Corrected 20/

Left 20/

Corrected 20/

4. Blood Pressure
(age 5 and Over)

3. Pulse (must be recorded)

percentile
6. Head Circumference
(18 months and under)

7. Development Appropriate for Age

in. or
cm.

Yes
No
Attach development screen if indicated under age 4
8. Immunizations Reviewed
Yes
No
Immunizations current?

VII. Clinical Evaluation
Check each item as indicated. Check "NE" if not evaluated.

Normal Abnormal

NE

Yes

No

Notes
(Describe every abnormality in detail.
Include pertinent item number before each comment.)

1. General/Constitution
2. Skin
3. Eyes
4. Ears/Nose/Throat
5. Neck/Thyroid
6. Lungs/Thorax
7. Breasts
8. Cardiovascular
9. Abdomen
10. Male Genitalia
11. Anus/Rectum/Prostate
12. Musculoskeletal
13. Lymphatic
14. Neurological
15. Female Gynecologic
16. Miscellaneous
17. Papanicolaou done

Not done

Reason if not done

18. Attach cytology report.
Additional Comments

VIII. All of the following tests are required unless otherwise specified (No LAB required for newborns)
1. Hematology (age 1 and over) 3. Blood Lead Level
5. Tuberculin Test (5TU PPD)
6. Pre-employment Only
recommended for all ages 1 and over, including
(recommended for ages 9
(or if previously not done)
those with previous BCG)
mo. up to 6 years)
a. Blood Type
Date (mm-dd-yyyy)
%
Hematocrit
ABO
Results
4. Chest X-RAY (for new TB
mm of induration
2. Urinalysis (preemployment
skin test convertors, or when
age 1 and over, separation and
indicated).
when indicated).
Previous BCG
Yes
No
(Rh) D
Specific
u
Previous Positive
Yes
No
Gravity
(weak) D
Albumin

Date (mm-dd-yyyy)

Previous Rx completed

Yes

Sugar

Casts

Normal

Date completed (mm-dd-yyyy)

WBC
RBC

No b. G6PD

Results

New Converter (XRay required)

Yes

No

Deficient

Treatment:

Other
DS-1622P

Page 3 of 4

Name Of Examinee
IX. Assessment Or Problem List

Recommendation For Treatment/Further Study

Typed Name of Examiner

Signature

Examining Facility and Telephone Number

Address

Date (mm-dd-yyyy)

X. Instructions to the Examiner
Disposition of Records:
Parent or sponsor must sign on page 2. Medical provider must sign on page 4.
All reports must be in English and identified with the full name and date of birth of the examinee.
Do Not Submit Reports by US Mail.
Do Not Submit Reports by Professional Courier Service (e.g. FedEx or DHL).
Keep originals as a permanent record.
For U.S. Department of State Health Units and Private Health Care Providers:
The preferred method to submit the DS-1622P is to scan and send by email to: [email protected].
If it is not possible to scan, then please FAX the DS-1622P to Medical Records at Fax: 703-875-4850.
If you wish to confirm that your exam forms were received please email [email protected].

DS-1622P

Page 4 of 4