Form DS-3057 Medical Clearance Update

OMB APPROVAL NO. 1405-0131
EXPIRATION DATE: xx-xx-20xx
ESTIMATED BURDEN: 30 Minutes

U.S. Department of State
Bureau of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

MEDICAL CLEARANCE UPDATE

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.

DATE (mm-dd-yyyy)
TO BE FILLED OUT BY EXAMINEE OR PARENT/GUARDIAN
1a. Legal Name of Examinee (Last, First, MI)

1b. Maiden/Other Name of Examinee (if applicable)

2. Date of Birth of Examinee (mm-dd-yyyy)

3. If Eligible Family Member, Name of Employee/Applicant

4. Place of Birth of Examinee

5. MED ID Number (if available)

6. Sex
Female

7. Examinee Status
Male

Applicant

Employee

8. Agency of Employee/Applicant/Sponsor
STATE
USAID
FCS

FAS

Dependent Child

U.S. Agency for Global Media

Other Government Agency
9. Purpose of Review

Spouse

DoD Civilian

DoD Contractor

Contracting Company

10. Employment Type

Pre-Employment

3rd Party Contractor

Fellow

LNA

REA-WAE

In-Service

CA-EFM

FS Generalist

LES

Other:

Civil Service

FS Specialist

PSC Contractor

11. Post of Assignment and Estimated Dates of Arrival / Departure
a. Proposed Post

EDA
(mm-dd-yyyy)

b. Present Post

EDD
(mm-dd-yyyy)

12. Special Assignment/ESCAPE Post(s) (if applicable)
Iraq

Yemen

Afghanistan

Syria

Libya

Peshawar

Somalia

Other:

13. Assignment Type
Temporary Duty (TDY) greater than 30 days

Permanent Change of Station (PCS)

14. Contact Information of examinee or parent of child < 18 y/o (where you can be reached for the next 90 days)
Primary Email Address:

Primary Telephone:

Alternate Email Address:

Alternate Telephone:

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.

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.
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.

DS-3057
03-2025

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Name of Examinee

DOB

I. MEDICAL HISTORY
PLEASE SCAN THE COMPLETED AND SIGNED FORM AND EMAIL IN PDF FORMAT TO MEDMR@state.gov.
Answer each of the following questions in the space provided, attach additional pages if necessary. If you have questions, please discuss with the Health Unit
staff or contact Medical Clearances at MEDClearances@state.gov.
PLEASE NOTE: Additional information may be requested via the primary email address provided on page 1.

II. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)

III. MEDICAL HISTORY UPDATE
1. Since your last medical clearance was issued, have you been diagnosed with a new medical or mental health condition or started on new
medication? If yes, explain and attach additional sheets as needed.
Yes

No

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

No

3. Have you been advised to see a specialist more than once a year for a medical/mental health condition? (Check all that apply)
Cardiologist

Hematologist/Oncologist

Ophthalmologist

Rheumatologist

Endocrinologist

Nephrologist

Psychiatrist/Mental Health Provider

Other:

Gastroenterologist

Neurologist

Pulmonologist

IV. IF EXAMINEE IS A CHILD
4. 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.
Yes

No

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

No

V. If 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 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 Medical Clearances) to be completed by your treating provider(s).
VI. SIGNATURE OF EXAMINEE/PARENT/GUARDIAN (I certify I have read and understand the expressed statements in this document.)
Date (mm-dd-yyyy)

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
Signature of FS Regional Medical Officer / FS Medical Provider

Printed Name

Date

SUBMITTAL: PLEASE SCAN THE COMPLETED AND SIGNED FORM AND EMAIL IN PDF FORMAT TO MEDMR@state.gov.
For more information on completion of forms and best practice advice on managing a medical/mental health condition while traveling or
living overseas, please visit our website at:
https://www.state.gov/bureaus-offices/under-secretary-for-management/bureau-of-medical-services/medical-clearances/.
DS-3057

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