Form DS-6571 Med Eval for LES non-drivers

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

U.S. Department of State

Bureau of Medical Services

PRE-EMPLOYMENT MEDICAL EVALUATION FOR
LOCALLY EMPLOYED STAFF
Section I: Demographic and Employment Information
Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Job Title/Section

Post

Type of Evaluation:

Initial

Follow-Up

Section II: Health History
MEDICAL EVALUATION
If "Yes", describe below
Do you have any medical
restrictions related to
performing certain job duties
(i.e., have you ever been
told by a health professional
to avoid doing certain job
tasks including lifting,
standing for extended
periods of time, bending,
stooping, etc.)?
Yes

No

Are you under the care of a
medical provider for any
medical or mental health
conditions?
Yes

If "Yes", describe below

No

Do you have any additional
medical/mental health
condition(s) for which you
are not currently being
treated or seen by a health
professional?
Yes

If "Yes", describe below

No

MEDICATION
I currently do not take any prescribed, over the counter, controlled, or other medications or supplements.
(If initialed, move directly to VISION)

(Initials)
List any current
medications/drugs taken
either on a routine schedule
or as needed.
Include all prescribed
medications,
over-the-counter
medications, controlled
substances, and/or
supplements.

Medication

Dose

How Often (once a day, as
needed, etc.)

When Started
(mm-yyyy)

Comments or Additional
Information

VISION
Yes

No

Have you ever been told by a health professional that you have a visual impairment?

Yes

No

Do you wear glasses or contact lenses?

Yes

No

Have you ever had procedures to correct your vision?

Yes

No

Have you ever been told by a health professional that you have other problems related to your vision or eyes (e.g., monocular
vision, colorblindness, etc.)?

HEARING
Yes

No

Have you ever been told by a health professional that you have hearing loss?

Yes

No

Do you currently wear (or have you ever worn) hearing aids?

DS-6571
03-2024

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Name of Examinee

DOB

Section III: Physical Exam
Part I: Blood Pressure
INSTRUCTIONS: Report systolic and diastolic as numerical values.
Systolic:

Diastolic:

Part II: Vision
STANDARD: At least 20/40 acuity (Snellen) required in each eye with, or without, correction.
INSTRUCTIONS: When a tool other than the Snellen chart is used, give test results in Snellen-reference values. In recording the distance vision, use
20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet (6.096 meters) as denominator. If the
candidate wears corrective lenses and will do so while performing official duties, these should be worn while visual acuity is being tested.

NUMERICAL READINGS MUST BE PROVIDED
ACUITY

UNCORRECTED

CORRECTED

Right Eye

20/

20/

Left Eye

20/

20/

Both Eyes

20/

20/

Part III: Hearing
STANDARD: Must perceive forced whisper voice > 5 feet (1.5 meters) with or without a hearing aid.
NUMERICAL READINGS MUST BE PROVIDED
Record distance from individual at which forced whispered voice can first be heard.
Right Ear
Feet

Left Ear
Meters

Feet

Pass
Meters

Fail

Part IV: Review of Symptoms
GENERAL

VISION/EYES

HEARING

CARDIOVASCULAR

RESPIRATORY

Fever

Pain

Tinnitus

Chest Pain

Shortness of breath

Chills

Redness

Hearing Change

Palpitations

Cough

Dizziness

Vision Change

Pain with breath

Weakness
ENDOCRINE

Hemoptysis
MENTAL HEALTH

MUSCULOSKELETAL

NEUROLOGICAL

Flushing

Irritability

Joint Pain

Headache

Skin Changes

Anxiety

Back Pain

Numbness

Temperature Instability

Depression

Neck Pain

Tingling

Swelling

Mood Changes

OTHER

Weakness

If any boxes above are checked, explain below.

DS-6571

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Name of Examinee

DOB

Part V: Tuberculosis Risk Assessment
STANDARD: All candidates require a risk assessment and should have a chest x-ray (if high or moderate risk) and other testing (if low risk) as
required. All candidates MUST complete the DS-6573, TB Risk Assessment Questionnaire.

Part VI: Clinical Evaluation
Normal?

Abnormal?

If abnormal, provide details.

General (alert/oriented, general
mental status)
Cardiovascular/Heart
Respiratory System
Musculoskeletal
Other
Other

Local or HU Medical Provider Recommendation
Based on the evaluation/examination of this candidate, I recommend the following (check one of the boxes below, fill in the blanks, and select as
needed):
Medically qualified
Not medically qualified, due to:
More information needed:
Medical Provider Name

Telephone Number

Address/Post

Medical Provider Signature

HU Provider Recommendation (as needed)
Only if required, based on local provider responses and recommendation above
Health Unit Provider Recommendation (check one of the boxes below):
Concur with recommendation above
Modify recommendation as follows:
More information needed:
Medical Provider Name

Telephone Number

Address/Post

Medical Provider Signature

DS-6571

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Paperwork Reduction Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 5 CFR 339.301 and the Foreign Service Act of 1980, as amended (Title 22 U.S.C. 4084, 3901,
and 3984).
PURPOSE: The information requested on this form will be used to determine employment eligibility for a position with specific medical standards
and/or physical requirements.
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.
This information may also be made available to local Health Units. More information on the Routine Uses for the system 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 disqualification of employment.
The Genetic Information Nondiscrimination Act of 2008 (GINA)
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-6571

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