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U.S. DOS Form usdos-employment-ds-1622. Free download

U.S. DOS Form usdos-employment-ds-1622. Free download-2026

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The U.S. DOS Form DS-1622 is a medical history and examination form required by the U.S. Department of State for children under 11 years old seeking medical clearance for Foreign Service eligibility. It collects personal information, medical history, current medications, and details about family health conditions to assess the child's medical fitness for assignments abroad. The form emphasizes the importance of complete and accurate information due to potential consequences on Foreign Service eligibility.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section I, which requires details about the examinee, including their name, date of birth, and social security number. Ensure all fields are completed accurately.
In Section II, answer the medical history questions honestly. This section is crucial for assessing any pre-existing conditions that may affect eligibility.
Proceed to Section III to list current medications and any drug allergies. This information is vital for your health assessment.
Complete Sections IV through IX as instructed, providing detailed information about hospitalizations and any significant medical history.
Finally, review all entries for completeness and accuracy before signing at the end of the form. Your signature certifies that all information provided is true.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (193 Votes)
2017	4.3 Satisfied (126 Votes)
2002	4.3 Satisfied (422 Votes)

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How long does it take for a medical certificate?

How you can apply. If youre entitled to a certificate because of your medical condition, speak to your GP or doctor. Theyll give you an application form. Youll get a certificate in the post within 10 working days of us receiving your application.

What happens during a medical clearance?

The medical clearance is based upon the employee participating in a complete head-to-toe physical examination, a complete blood panel, a health history questionnaire, an EKG, vision test, pulmonary function test, hearing test, and a stress test for those over the age of 40 or at the discretion of the provider.

How long does a medical clearance take?

Basic Evaluations: Without tests, it may take up to 12 days. Comprehensive Clearances: If lab tests or imaging studies are required, may take several days.

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