Form DS-3057 Medical Clearance Update

U.S Department of State
Bureau of Medical Services, M/MED, Washington, DC 20520 - 0102

MEDICAL CLEARANCE UPDATE

OMB APPROVAL NO. 1405-0131
EXPIRATION DATE: XX/XX/XXXX
ESTIMATED BURDEN: 30 MINUTES*

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, 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 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, not providing requested information may result in the failure of the individual to obtain the requisite
medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT: 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 recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522

INSTRUCTIONS: Assigned overseas: please seek assistance from the US Embassy Health Unit medical staff.
Assigned domestically: complete page 1 demographic information fields 1 – 13, complete questions on page 2 and sign.

TO BE FILLED OUT BY PATIENT (OR PARENT / GUARDIAN )

Date: (mm-dd-yyyy)

1.

Name of Patient: (Last, First, MI)

2.

3.

MED ID Number: (if available)

4.

6.

Place of Birth:

City_______________ State _______________ Country____________
8. Name of Your Health Insurance Plan:

If Eligible Family Member, Name of Employee

⧠ Male
⧠ Female
7. Status: ⧠ Employee ⧠ Spouse ⧠ Domestic Partner
⧠ Dependent Child
Date of Birth (mm-dd-yyyy) |
|

5. Sex

9a. Agency

⧠ State
⧠ USAID

Bureau/Office of assignment ___________
⧠ Other Agency _____________________

10. Mailing Address:
_____________________________________________
_____________________________________________
_____________________________________________

9b. Type of Employment

11.

12. Post of Assignment
a. Proposed Post ________________ EDA____________________
b. Present Post ________________ EDD____________________
c. Last 3 Posts ________________________________________
________________________________________
________________________________________

⧠ Foreign Service
⧠ WAE
⧠ LNA

Telephone number: (where you can be reached for the next 90 days)
(for patient or dependent > 18 years of age):

13. Email Address (where you can be reached for the next 90 days):
(for patient or dependent > 18 years of age):

⧠ Civil Service
⧠ PSC or other Contractor
⧠ Other______________

THIS SPACE RESERVED FOR OFFICIAL USE BY U.S. Department of STATE MEDICAL STAFF ONLY
Department of State / US Embassy Medical Professional Comments (attach additional sheets if needed)

MED USE ONLY
⧠ Recommend World Wide Available – Class 1 Medical Clearance
⧠ Recommend Post Specific – Class 2 Medical Clearance
⧠ Recommend Full Physical Examination for Medical Clearance Determination
__________________________________________________
Signature of FS Regional Medical Officer / FS Medical Provider

____________________________________
Printed Name

______________________
Date

To the individual and/or health care provider completing the medical history review /exam: 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 members’ 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-3057
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11- 20XX_

Page 2 INSTRUCTIONS: Please answer each of the following questions in the space provided, attach additional pages if
necessary. If you have questions, please discuss the form with the Health Unit medical staff or Foreign Service Medical
Specialist, or contact the Medical Clearances Division at [email protected]. Please scan the completed and signed
form and email in PDF format to [email protected]. Please include all supplemental pages/ medical reports / test results in
English with your submission. If it is not possible to scan, please fax the form to Medical Records FAX: 703-875-4850.
Please note: MED Clearances may request additional information in order to make a Clearance determination.
I. CURRENT MEDICATIONS:
1.

Please list your current prescription and over the counter medications and dosage. Attach additional pages as needed.

_______________________________________

___________________________________________

___________________________________________

_______________________________________

___________________________________________

___________________________________________

II. MEDICAL HISTORY UPDATE:

For YES answers, please provide a brief explanation, and use additional pages as needed.

2. Since your last medical clearance was issued, have you been diagnosed with a new medical or mental health condition?

⧠ Yes ⧠ No
3. Since your last medical clearance was issued, have you been hospitalized or medically evacuated?

⧠ Yes ⧠ No

III. If your current medical clearance is Post Specific – Class 2, or Domestic Assignment Only – Class 5:
 For MEDICAL Class 2 or Class 5 Clearance status: Please submit a written update from your medical provider(s) to include
current medical treatment plan and follow up recommendations.
 For MENTAL HEALTH or Drug/Alcohol Class 2 or Class 5 Clearance status: Please submit a Treatment Provider Information
form (TPI) (obtain from your Health Unit or the Medical Clearances Division) to be completed by your treating provider(s).
4. Since your last medical clearance, have there been any changes in your medical / mental health or drug/alcohol condition?

⧠ Yes ⧠ No

If YES, please explain below, and use additional pages as needed.

IV. For Pregnant Women: If you are pregnant and currently assigned / considering assignment to La Paz, please be advised
that the current recommendation is for pregnant women to leave La Paz as soon as possible after confirmed pregnancy.
Extreme altitude (over 10,000 ft.) in La Paz can have a negative effect on the fetus. Please contact
[email protected] with questions on this, or any other travel warnings regarding pregnancy (e.g. Zika virus).
V. For Children:
5. Has your child been referred for any special educational services, accommodations or modifications?

⧠ Yes ⧠ No

If YES, please explain below and have your child’s teacher or service provider complete a School Report of Progress and submit with this form.

6. Do you anticipate any special educational needs or requirements for your child now or in the future?
If YES, please explain below, and use additional pages as needed.

⧠ Yes ⧠ No

To all Employees and family members: The Bureau of Medical Services strongly encourages you to see your
medical provider to review age-appropriate preventive health screening guidelines/testing.
_____________________________________________________________________________________________________
Signature of Patient/Parent/Guardian

____________________________________
Date:

Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal
offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the United
States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission or
falsification or fraudulent statement of material information.
DS – 3057

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