[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-281350-105":53,"doc-detail-281350-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","medical-clearance-update-ds-3057","MEDICAL CLEARANCE UPDATE - DS-3057","","Medical clearance update form for the U.S. Department of State Medical Program. Collects examinee identity, date and place of birth, sex, eligibility family member/employer details, medical identification number, and employment review purpose. Captures agency/sponsor information, employment type, assignment post and dates, special assignments, contact information, and instructions for completing and submitting the signed form. Includes confidentiality and compliance notices such as OMB burden estimate, Privacy Act authorities and purpose, routine uses, and the prohibition on providing genetic information under GINA.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-clearance-update-ds-3057/281350/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medical-clearance-update-ds-3057/281350.png","ImageObject",442,249,{"name":88,"@type":89},"Aran","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-21","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who must complete the DS-3057 medical clearance update form?","Question",{"text":109,"@type":110},"The form is for the examinee, or a parent/guardian where applicable, to fill in required personal and medical information.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What key information fields are collected on the form?",{"text":114,"@type":110},"It collects legal name (and other/maiden name if applicable), date of birth, place of birth, sex, medical ID number (if available), examinee status, and agency/sponsor and review purpose details.",{"name":116,"@type":107,"acceptedAnswer":117},"Are applicants allowed to include genetic information?",{"text":118,"@type":110},"No. The form states that genetic information should not be provided when responding to this request for medical information, consistent with GINA.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},281350,1789565657,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","U.S. Department of State  \nBureau of Medical Services, Room L101, SA-1, Washington, DC 20522-0102 MEDICAL CLEARANCE UPDATE  \nOMB APPROVAL NO. 1405-0131 EXPIRATION DATE: 01-31-2027  \nESTIMATED BURDEN: 30 Minutes  \n\n| 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. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| TO BE FILLED OUT BY EXAMINEE OR PARENT/GUARDIAN |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | DATE (mm-dd-yyyy) |\n| 1a. Legal Name of Examinee (Last, First, MI) |  |  |  |  |  |  |  |  |  | 1b. Maiden/Other Name of Examinee (if applicable) |  |  |  |  |  |  |\n| 2. Date of Birth of Examinee (mm-dd-yyyy) |  |  |  |  |  |  |  |  |  | 3. If Eligible Family Member, Name of Employee/Applicant |  |  |  |  |  |  |\n| 4. Place of Birth of Examinee |  |  |  |  |  |  |  |  |  | 5. MED ID Number (if available) |  |  |  |  |  |  |\n| 6. Sex |  |  | Male |  | 7. Examinee Status |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  | | Applicant | |  | Employee | | Dependent Child |  | |  | Spouse |  |\n|  Female |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 8. Agency of Employee/Applicant/Sponsor\u003Cbr>\u003Cbr>STATE\u003Cbr>\u003Cbr>USAID\u003Cbr>\u003Cbr>FCS\u003Cbr>\u003Cbr>FAS\u003Cbr>\u003Cbr>U.S. Agency for Global Media\u003Cbr>\u003Cbr>DoD Civilian\u003Cbr>\u003Cbr>DoD Contractor\u003Cbr> Other Government Agency    Contracting Company   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 9. Purpose of Review  Pre-Employment  In-Service |  |  |  | 10. Employment Type\u003Cbr> 3rd Party Contractor  CA-EFM\u003Cbr> Civil Service |  |  |  | | Fellow\u003Cbr>FS Generalist\u003Cbr>FS Specialist | | LNA\u003Cbr>LES\u003Cbr>PSC Contractor | |  | REA-WAE\u003Cbr>Other:   |  |  |\n| 11. Post of Assignment and Estimated Dates of Arrival / Departure |  |  |  |  |  |  |  |  |  | 12. Special Assignment/ESCAPE Post(s) (if applicable) |  |  |  |  |  |  |\n| a. Proposed Post\u003Cbr>b. Present Post |  |  |  |  |  |  | EDA\u003Cbr> (mm-dd-yyyy) \u003Cbr>EDD\u003Cbr> (mm-dd-yyyy)  |  |  | | Iraq Afghanistan Libya\u003Cbr>Somalia | |  | Yemen\u003Cbr>Syria\u003Cbr>Peshawar\u003Cbr>Other:   |  |  |\n| 13. Assignment Type\u003Cbr> Temporary Duty (TDY) greater than 30 days  Permanent Change of Station (PCS) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 14. Contact Information of examinee or parent of child \u003C 18 y/o (where you can be reached for the next 90 days)\u003Cbr>Primary Email Address:   Primary Telephone:   Alternate Email Address:   Alternate Telephone:   |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| 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. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| PAPERWORK REDUCTION ACT S","cbCaicHOSnFksebZ","https://ap.wps.com/l/cbCaicHOSnFksebZ","pdf",101482,"English","# TO BE FILLED OUT BY EXAMINEE OR PARENT/GUARDIAN\n# Medical History","[{\"question\":\"Who must complete the DS-3057 medical clearance update form?\",\"answer\":\"The form is for the examinee, or a parent/guardian where applicable, to fill in required personal and medical information.\"},{\"question\":\"What key information fields are collected on the form?\",\"answer\":\"It collects legal name (and other/maiden name if applicable), date of birth, place of birth, sex, medical ID number (if available), examinee status, and agency/sponsor and review purpose details.\"},{\"question\":\"Are applicants allowed to include genetic information?\",\"answer\":\"No. The form states that genetic information should not be provided when responding to this request for medical information, consistent with GINA.\"}]","MEDICAL CLEARANCE UPDATE - DS-3057 | PDF"]