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Health Verification Form

Candidates selected for a Specialist project with in-country dates of any length must complete an HVF and submit it to the cooperating agency by the due date specified in their acceptance letter. Offers to participate in the program are conditional, pending medical clearance. Selected candidates whose HVFs are not cleared will be notified and their offer to participate in the program will be rescinded.

Only candidates selected for a Specialist project with in-country dates, of any length, 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, however, the form must be completed in English by a licensed physician (MD, DO, or foreign equivalent), or nurse practitioner (NP) who is not a member of your family. Although physicians’ offices sometimes use a physician assistant or a registered nurse to help perform the examination and tests and complete the form, only a licensed physician or nurse practitioner may sign the HVF.

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.

Medical History and Clinical Examination:

  • A comprehensive medical history overview – completed by the examining provider, with your consultation – including all diagnosed physical and mental health conditions, significant or serious illnesses, operations/surgical procedures, and hospitalizations. 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.
  • Results of the clinical examination completed by the examining provider that is completing the HVF, including additional explanation for any items marked as “abnormal.”
  • A list of any medications you are currently taking and/or have taken within the past three years, and a plan for how any current medications will be obtained during your project.
  • A list of any drug or other allergies, and if applicable, how epinephrine will be obtained during your project.
  • A plan for how any required medical care for any active and/or chronic conditions, and/or how any medical devices currently being used will be provided during your project, including information regarding management of mental health conditions.

Provider’s Statement: The examining provider must state, based on the clinical examination and your medical history, if they consider you to be physically and emotionally able to travel and teach abroad in the specific project location(s) and for the duration of the in-country dates.

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.