DS-6561 Pre-Assignment for Overseas Duty

OMB APPROVAL NO. 1405-xxxx
EXPIRATION DATE xx/xx/2011 ESTIMATED
BURDEN: 2 HOURS*

U.S. Department of State

Non-Foreign Service Personnel and Their Family Members
Privacy Act Statements (PAS) only cover US citizens and legally permanent residents. Non-US citizens are not
covered by the Privacy Act; therefore the PAS does not extend to them. This information is requested pursuant
to the Foreign Service Act of 1980, as amended (22 USC 3084, 3901 and 3984). The primary purpose for
soliciting this information is to screen employees who are not members of any Foreign Affairs agency and their
family members for overseas duty.
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 enforcement and administration
purposes. It may also be disclosed pursuant to court order. Failure to provide this information may result in
denial of a medical clearance.
*Public reporting burden for this collection of information is estimated to average 2 hours per response,
including time required for searching existing data sources, gathering the necessary documentation, providing
information, and/or documents required, and review 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.
To Be Filled by Examinee (Complete all sections, type or in ink). Please Print Clearly
Name of Examinee (Last, First, Middle Initial)
Sex

Male

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

Female

Post of Assignment (Required)

Agency

Place of Birth

Please Check if Going To

Email Address

Baghdad

Iraq (Outside Baghdad)

Kabul

Afghanistan (Outside Kabul)

Mailing Address

Telephone Number
Name of Employee (Last, First, Middle Initial)

Social Security Number
Status of Employee
Locally Engaged Staff

3161

Civil Service

Personal Services Contractor

DoD Civilian/Contractor

Other

Status of Examinee

Employee

Spouse

Domestic Partner

WAE

Dependent Child

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-6561
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Name of Examinee
Have you had within the past 10 years:
Yes

No

Yes

No

1. Stroke, TIA, or Blackout?

18. Diabetes or thyroid disease?

2. Epilepsy or seizures?
3. Chronic eye trouble, vision problems
or glaucoma?

19. Arthritis, rheumatism, joint pain or altered
mobility?
20. Debilitating back pain or back injury?

4. Difficulty with your hearing?

21. Skin cancer?

5. Asthma?

22. A thickening or lump in breast or elsewhere?
23. Have you ever been referred to or sought
consultation or treatment from a mental
health professional? Inpatient or
Outpatient?

6. Wheezing or shortness of breath?
7. Severe headaches or migraines?
8. Chronic cough or coughing up blood?
9. Pain or pressure in your chest?
10. Heart problems, murmur, or
palpitations?
11. High blood pressure?
12. Stomach, liver or intestinal problems?
13. Jaundice or hepatitis (Which type)?
14. Untreated hernia?
15. Rectal bleeding or black, tarry stools?
16. Frequent urination or chronic urinary
tract infection?
17. Kidney trouble; stone, blood or protein in
urine?

24. Have you consumed at any one time in
the past year, more than 6 drinks for
males or 5 drinks for females?
25. Chronic Medical/Mental Health Conditions
requiring medication or routine follow-up?
Females only:
Are you pregnant?
Have you had an abnormal Pap smear
within the last year?
Children only:
Special education requirement or
learning disability?

The intentional omission of any crucial medical information is a criminal offense (Section 1001 of the USC Title
18). Respondents who intentionally omit information may be subject to disciplinary action for intentional
omission of information.
Please answer the following questions if you have been assigned to a high/threat
unaccompanied post in the last three years:
Yes No
Have you been injured or experienced a blast or explosion? If yes, explain.
Have you been exposed to any known toxic chemicals? If yes, explain.
In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month you...
Have had nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or your surroundings?
Signature of Examinee (I certify I have read and understand the above statement.)

Date

Examiner Please Comment on Significant History: Comment on all items checked Yes in the history on a
separate piece of paper.
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Name of Examinee:
Height

Weight

Pulse

Blood Pressure

BMI

Clinical Evaluation (Check each item as indicated)
Normal Abnormal Not examined

Describe abnormalities in detail

1. Skin (Not abnormalities)
2. Head, neck, thyroid
3. Ear, nose, throat
4. Lymph nodes
5. Lungs
6. Breasts
7. Heart (Record murmurs or abnormalities)
8. Abdomen (Comment on liver and spleen)
9. Genitalia (Male testes descended? Masses)
10. Anus, rectum, and prostate
11. Vascular system
12. Extremities and spine
(Note physical limitations)
13. Neurological
14. Psychiatric (Specify any signficant mood,
cognitive, or behavioral observations)
15. Pelvic/Bimanual
Comments

Hospitalizations/Major Operations (Include all medical and psychiatric illnesses)

List Current Medications and Dose

Date (mm-dd-yyyy)

Drug or Other Allergies/Reaction

1.
2.
3.
4.
5.
6.
7.
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Name of Examinee:
ALL TESTS ARE REQUIRED UNLESS OTHERWISE SPECIFIED. PLEASE ATTACH ALL LABORATORY
REPORTS, EKG, AND CHEST X-RAY REPORTS.
Hematology (All ages)(Infants Hct only)

ECG (50 years and older, or earlier if indicated)

Hct or Hgb

Date (mm-dd-yyyy)

WBC

Results

Platelets
Screening Chemistry (12 yrs + older)
Blood Sugar (Fasting)
HgbA1c when indicated

PPD (Mantoux) Required for all ages unless
previously positive
Results

Creatinine

Date (mm-dd-yyyy)

ALT
Serology (12 yrs + older)
HIV

Chest x-ray is required
if new PPD conversion or if clinically indicated
Results
Date (mm-dd-yyyy)

Assessment or Problem List

Recommendation for Treatment/Further Study/or
Follow-up

Typed Name of Examiner

Signature

Address

Telephone Number

Date

Instructions for Examiner: Sign, Scan and Email this completed exam and supporting reports to [email protected].
If you cannot scan your documents FAX to (703-875-4850).
Keep the original for your files.
DS-6561

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