Form DS-3057 Medical Clearance Update

U.S. Department of State
Bureau of Medical Services, Room L101, SA-1, Washington, DC 20520-0102

MEDICAL CLEARANCE UPDATE

OMB APPROVAL NO. 1405-0131
EXPIRATION DATE XX/XX/20XX
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 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, 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: Complete all required fields, sign and date.

Date (mm-dd-yyyy)

TO BE FILLED OUT BY PATIENT (OR PARENT/GUARDIAN )
1a. Name of Patient (Last, First, MI)

1b. Chosen Name of Patient

2. If Family Member, Name of Employee

3. MED ID Number (if available)

5a. Gender Identity - Choose all
that apply

5c. Are you/the patient transgender? 5d. Sexual Orientation

5b. Sex Assigned at Birth
Male

Man

Yes
No
Gender Pronouns - Choose all that
apply

Female

Woman

Intersex

Genderqueer/Non-binary

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

Lesbian, Gay, Homosexual
Straight, Heterosexual
Bisexual

He/Him/His
She/Her/Hers
They/Them/Theirs

6. Place of Birth
State

City

7. Relationship to Employee
Employee

Country

Spouse

Dependent Child

8. Telephone Number of Examinee or Parent of Child under 18 Y/O
(Where You can be Reached for the Next 90 days)

9. E-mail Address (Where You can be Reached for the Next 90 days)

Primary

Primary

Alternate

Alternate
11. Agency

10. Name of Your Health Insurance Plan

State

USAID

USAGM (Global Media)

FAS/USDA

FSC/Trade

Other

13. Post of Assignment

12. Type of Employment (Applicable for employees only)
Foreign Service

Civil Service

REA-WAE

Personal Service Contractor

LES
a. Proposed Post

EDA

LNA

Third Party Contractor

b. Present Post

EDD

DOD CS

DOD Contractor

14. Type of Assignment
Permanent Change of Station (PCS)

Temporary Duty (TDY) Greater than 30 days

Both PCS/TDY

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
01-2023

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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].
MED Clearances may request additional information in order to make a Clearance determination.

I. CURRENT MEDICATIONS:
1. Does your medication require refrigeration?
Yes
No

2. Are you prescribed a narcotic or FDA controlled substance?
Yes
No

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

II. MEDICAL HISTORY UPDATE:
4. Since your last medical clearance was issued, have you been diagnosed with a new medical or mental health condition? If yes, explain and attach
additional documentation as necessary.
Yes

No

5. Since your last medical clearance was issued, have you been hospitalized or medically evacuated? If yes, explain and attach additional
documentation as necessary.
Yes

No

6. Since your last medical clearance, have there been any changes in your medical / mental health or drug/alcohol condition? If yes, explain and
attach additional documentation as necessary.
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).

IV. For Pregnant Women:
If you are pregnant and currently assigned/considering assignment over seas please contact [email protected] with questions on
extreme altitude or any other travel warnings regarding pregnancy.

V. The Child Listed on this form:
7. Has the child been referred for any special educational services, accommodations or modifications? 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.
Yes

No

8. Do you anticipate any special educational needs or requirements for the 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 (mm-dd-yyyy)

SUBMITTAL: Please scan and email the completed and signed form in a PDF format to Medical Records at [email protected]. You must include
all supplemental pages, medical reports, and test results in English with your submission. If it is not possible to send electronically, please fax
the form to Medical Records at 202-647-0292.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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