Ds 1622 - Medical History And Examination For Foreign Service printable pdf download

U.S. Department of State

*OMB APPROVAL NO. 1405-0068

Office of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

EXPIRATION DATE: 04-30-2012

ESTIMATED BURDEN: 1 HOUR

MEDICAL HISTORY AND EXAMINATION FOR FOREIGN SERVICE

FOR CHILDREN 11 YEARS AND UNDER

PRIVACY ACT NOTICE: This information is requested pursuant to the Foreign Service Act of 1980, as amended (22 U.S.C. 3084, 3901 and 3984).

The primary purpose for soliciting this information is to make appropriate assignments abroad. Unless otherwise protected by 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 administration purposes. It may also be disclosed pursuant to court order. Failure to provide this information may result in denial of a

medical clearance and affect your Foreign Service eligibility.

Date (mm-dd-yyyy)

I. To Be Filled Out By Sponsor Or Parent (Complete all sections, type or in ink.)

1. Name of Examinee (Last, First, MI.)

2. Full Name of Employee/Applicant/Sponsor

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

4. Sex

5a. Agency of Employee/Applicant/Sponsor

State

Other

USAID

Male

Female

6. Social Security Number (Employee/Applicant/Sponsor)

5b. Type of Employment

Civil Service

Foreign Service

Contractor

Excursion Tour

7. Place of Birth

8. Post of Assignment and Dates of Departure/Arrival

a. Proposed Post

State

Country

City

EDA

9. Mailing Address

(mm-dd-yyyy)

(Medical Clearance Abstract will be mailed to listed address)

b. Present Post

EDD

(mm-dd-yyyy)

Telephone Number

c. Last 3 Posts

(where you can be

reached for the next

90 days)

E-mail Address

10. Name of Your Health Insurance Plan

(where you can be

reached for the

next 90 days)

11. Purpose of Examination

a. Pre-Employment

b. In-Service

c. Separation

d. New Dependent

12. Is Child Adopted?

Yes

Check and describe medical conditions of blood relatives. Include sickle cell disease, cancer, alcoholism, heart disease, high cholesterol,

kidney disease, high blood pressure, asthma, mental health problem or learning disability.

Father

Mother

Grandmother(s)

Grandfather(s)

Sister(s)

Brother(s)

Aunt(s)

Uncle(s)

DO NOT WRITE IN THE SPACE BELOW (FOR USE BY MEDICAL DIVISION ONLY)

Clearance Action

*Public reporting burden for this collection of information is estimated to average one (1) hour 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

DS-1622

estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC

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04-2009

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Ds 1622 - Medical History And Examination For Foreign Service

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