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Health Verification Form

Candidates selected for the English Language Fellow Program must complete an HVF and submit it to the cooperating agency no later than 15 business days after receipt of an acceptance letter. Offers to participate in the program are conditional, pending medical clearance. The program will contact selected candidates if the form is incomplete or additional information is required to process the review. In some cases, the program’s Medical Reviewer will request additional information, if they determine that a clearance status of “Cleared, unconditional” will be granted only if certain requirements and conditions are met, or if additional information is required to continue with their review of the HVF. Candidates whose HVFs are not cleared by the program’s Medical Reviewer with a status of “Cleared, unconditional” will be notified and their offer to participate in the program will be rescinded.

Only candidates that have been selected for a specific English Language Fellow project will complete the HVF. To complete the HVF, you will need to schedule a clinical examination with an appropriate medical provider, who must complete parts of the form in consultation with you. The examination does not have to be completed in the United States, but the examination must be provided by, and the HVF signed by, a licensed physician, doctor (MD, DO, or foreign equivalent), or nurse practitioner, who is not a member of your family.

When completing the HVF, you must provide:

Personal data:

  • The names of medical professionals and/or practices you have consulted within the last three years, including routine physical examinations. You are asked to list your primary care provider/practice, as well as any specialists.
  • Emergency contact information for two individuals who could be notified in case of emergency during your project; and contact information for your medical proxy, if applicable.

Medical History and Clinical Examination:

  • A comprehensive medical history overview – completed by the examining provider, with your consultation – including all diagnosed conditions, hospitalizations, and past medications (taken in the last three years). For any conditions or symptoms marked as “YES”, you will be asked to provide additional explanation. Your examining provider may also recommend a test to allow for further explanation of the current status of the condition and/or the prognosis or outcome. If you are at increased risk for severe illness from COVID-19, you will need to be prepared to discuss this with your examining provider, as well as any proposed safety measures. Familiarize yourself with COVID-19 related information posted by the Centers for Disease Control and Prevention (CDC).
  • Results of the clinical examination completed by the examining provider that is completing the HVF, as well as a list of any current medications and a plan for how those medications will be provided during your project. You will also need to complete a plan for how any required medical care for any active and/or chronic conditions will be provided during your project, including information regarding mental health conditions.

Provider’s Statement: The examining provider must state, based on the clinical examination and on your physical and emotional history, if they consider you to be physically and emotionally able to travel and teach abroad in the specific project location(s), and/or if they have concerns regarding your risk factors for severe illness from COVID-19.

Candidate’s Statement: You must certify that the information on the HVF is complete and accurate, as well as certify your understanding of the program’s medical clearance policies.

Laboratory Evaluation: There are no specific laboratory tests required as part of the HVF, although the program may request further testing based on your medical history. Your examining provider will be encouraged to obtain appropriate tests as indicated by your medical history and results of the clinical examination or your project location(s) (e.g., G6PD for malarial areas). For example, a diabetic patient should have a recent blood sugar determination or patients with HIV infection should obtain a CD4 count and those results should be submitted with the HVF.

Vaccinations: There are no specific vaccinations required as part of the HVF or the medical clearance process, but you should discuss the relevance of vaccinations with your examining provider, as related to your project location(s). It is solely your responsibility to determine any vaccinations and/or tests specifically required by your country(ies) of assignment.

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This is a program of the U.S. Department of State, administered by Georgetown University, Center for Intercultural Education and Development.

All decisions related to participant terms (including candidate review, selection, funding, suspension, revocation, and termination) and all criteria related thereto are made and established by the U.S. Department of State.