Fillable Printable Form DS-3057
Fillable Printable Form DS-3057
Form DS-3057
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)
Recommend World Wide Available - Class 1 Medical Clearance
Recommend Post Specific - - Class 2 Medical Clearance
Signature of FS Regional Medical Officer / FS Medical Provider
MED USE ONLY
Recommend Full Physical Examination for Medical Clearance Determination
Printed Name Date
8. Name of Your Health Insurance Plan
9a. Agency
State
USAID
Bureau/Office of assignment
2. If Family Member, Name of Employee
3. MED ID Number (if available)
1. Name of Patient (Last, First, MI)
12. Post of Assignment
a. Proposed Post
b. Present Post
c. Last 3 Posts
EDA
EDD
6. Place of Birth
City
Country
7. Status
Spouse
Domestic Partner
Employee
Dependent Child
State
5. Sex4. Date of Birth (mm-dd-yyyy)
9b. Type of Employment
Foreign Service
WAE
LNA
Civil Service
Other
PSC or other Contractor
10. Mailing Address
10. Telephone Number(where you can be reached for the next 90 days)
(for patients 18 years of age or older)
11. E-mail Address (Where You can be Reached for the Next 90 days)
(for patients 18 years of age or older)
Male
Female
Other Agency
TO BE FILLED OUT BY PATIENT ( OR PARENT/GUARDIAN )
Date (mm-dd-yyyy)
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.
U.S. Department of State
Office of Medical Services, M/MED, Washington, DC 20520-0102
MEDICAL CLEARANCE UPDATE
DS-3057
05-2017
Page 1 of 2
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.
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.
OMB APPROVAL NO. 1405-0131
EXPIRATION DATE 05/31/2020
ESTIMATED BURDEN: 30 MINUTES*
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
4. Since your last medical clearance, have there been any changes in your medical / mental health or drug/alcohol condition? If YES, please explain
below, and use additional pages as needed.
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).
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?
3. Since your last medical clearance was issued, have you been hospitalized or medically evacuated?
Yes No
Yes No
1. Please list your current prescription and over the counter medications and dosage. Attach additional pages as needed.
Signature of Patient/Parent/Guardian
Date (mm-dd-yyyy)
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.
II. MEDICAL HISTORY UPDATE:
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).
5. Has your 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.
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
Yes No
V. For Children
I. CURRENT MEDICATIONS:
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.
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.
DS-3057
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