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Employee Self-Certification and Ability to Perform in 2026
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Send pre deployment physical exam via email, link, or fax. You can also download it, export it or print it out.
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information, including your name, date of birth, and ID number. Ensure accuracy as this information is crucial for your medical clearance.
- Review the pre-deployment physical exam acknowledgment section carefully. This outlines the responsibilities of both you and your medical provider regarding the evaluation process.
- In the medical provider section, ensure that your healthcare provider fills out their stamp, name, signature, and date. This validates the form.
- Proceed to answer each question on page two honestly. These questions assess any conditions that may affect your ability to perform duties in challenging environments.
- Attach any relevant medical reports that clarify your health status. This will aid in expediting the clearance process.
- Once completed, scan and email the form to MEDMR@state.gov or fax it to 202-647-0292 for submission.
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| Versions | Form popularity | Fillable & printable |
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| 2019 | 4.9 Satisfied (54 Votes) |
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Related links
Given the likelihood of staff shortages, persons without formal medical training or licensure could be used to perform most POD functions, including most client.Read more
Employee Self-Certification and Ability to Perform in Emergencies (ESCAPE) One of the medical clearance requirements is to complete this 2-page form.
The employer must give the employee at least 15 calendar days to provide the certification. If the employee fails to provide complete and sufficient medicalRead more