Form DS-6570 Employee Self-Certification and Ability to Perform in Em

OMB APPROVAL NO. 1405-0224

Employee Self-Certification and Ability to Perform in EXPIRES: XX/XX/20XX
ESTIMATED BURDEN: 30 MINUTES
Emergencies (ESCAPE) Posts
PRE-DEPLOYMENT PHYSICAL EXAM ACKNOWLEDGEMENT FORM
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 from this form will assist in making a medical clearance decision for individuals eligible to participate in the
Department of State Medical Program while assigned abroad." (16 FAM 100 - 200).
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.
GINA: To the individual and/or healthcare provider completing the medical history review/exam: The Genetic Information Nondiscrimination
Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title ll 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 a family member receiving assistance reproductive services.

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.
Check One:
More probably than not, individual can live/work in above conditions.
More probably than not, individual CANNOT live/work in above conditions. Reason:

Medical Provider Stamp or Print Name
Medical Provider Signature
DS-6570
10-2019

Date
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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
[email protected] or fax to 202-647-0292.
Yes / No

Yes / No
1. Any condition that prevents performing duties
described on page 1 including all physical tasks and
wearing of personal protective equipment (mask,
helmet, body armor, and chemical/biological
garments)?

18. Hypertension not controlled with medication or that
requires frequent monitoring?
19. Heart failure or history of heart failure?
20. Morbid obesity (BMI > 40)? Calculator (See below)

2. Conditions that prohibit required immunizations
(other than smallpox and anthrax per current
guidance) or medications such as anti-malarials,
chemical and biological antidotes, and other
chemoprophylactic antibiotics?

21. Active or chronic blood-born diseases
including Hepatitis B, Hepatitis C, and HIV?
22. Active tuberculosis?

3. Any condition that requires frequent clinical visits
(more than quarterly) or ancillary tests (more than
twice a year) that are not responsive to 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,
required hospitalization in the last 12 months, or still
requires daily systemic (not inhaled) steriods?
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 Traumatic Brain
Injury (TBI) or concussion?
13. Symptomatic coronary artery disease?
14. Chronic cough or coughing up blood?
15. Myocardial infarction within the past two years?
16. Coronary artery bypass graft, coronary artery
angioplasty, carotid endoarterectomy, 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?

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

23. Untreated latent tuberculosis or currently under
treatment?
24. Vision loss?
25. Refractive eye surgery in the 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. Untreated precancerous lesions?
32. Any condition that requires surgery (e.g. unrepaired
hernia) or for which surgery has been performed
and requires ongoing treatment, rehabilitation, or
additional surgery (revision or removal of
hardware)?
33. Surgery (open or laparoscopic) within the 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 - Antineoplastic (oncologic or
nononcologic?)
39. Medications - Immunosuppressants?
40. Medications - Biologic Response Modifiers
(immunomodulators)?
41. Medications - Psychiatric or sleeping aids?
42. Medications - Anticonvulsants?
43. Medications - Pain medications, opioids, or
opioid combination drugs?

Patient Printed Name
Patient Signature

Date

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; [email protected].
DS-6570

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