Ds 1843 Form PDF Details

The DS-1843 form plays a crucial role in the Department of State Medical Program, serving as the primary document for documenting the medical history and physical examination for individuals aged 12 and older who are eligible to participate in activities abroad under the Department of State's auspices. This detailed form is guided by the Foreign Service Act of 1980, highlighting its legal foundation for collecting personal health information. Its aim is to aid in the determination of medical clearance, ensuring that individuals are fit to undertake assignments outside the United States. The collection of such personal data, while voluntary, is imperative for the clearance process, with refusal potentially leading to the inability to obtain necessary medical approval. Moreover, the form touches upon the importance of privacy and legal implications, referencing laws like the Genetic Information Nondiscrimination Act of 2008 (GINA) to protect individuals' genetic information. It also outlines the expected time commitment necessary for completion, thereby underlining the balance between comprehensive health data collection and respect for individuals’ time and privacy. Furthermore, the DS-1843 form serves as a testament to the intersection of healthcare, privacy, and legal considerations in the context of international assignments, marking its significance in the operational framework of the U.S. Department of State.

QuestionAnswer
Form NameDs 1843 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshow to ds 1843, medical ds 1843 form, aca form 1843, 1843 form download

Form Preview Example

MEDICAL HISTORY AND EXAMINATION
FOR INDIVIDUALS AGE 12 AND OLDER
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited from this form will assist in making a medical clearance decision for individuals eligible to participate in the Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order. More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain the requisite medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT: Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and /or recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of state, Washington, DC 20522
I. DEMOGRAPHIC INFORMATIONDATE OF EXAM (mm-dd-yyyy)
TO BE FILLED OUT BY EXAMINEE (OR PARENT)
U.S. Department of State
Bureau of Medical Services, Room L101, SA-1, Washington, DC 20522-0102

*OMB APPROVAL NO. 1405-0068 EXPIRATION DATE: 10-31-2023

ESTIMATED BURDEN: 1 HOUR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Name of Examinee (Last, First, MI)

 

 

 

 

 

 

 

 

2. If Eligible Family Member, Name of Employee/Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Date of Birth (mm-dd-yyyy)

4. MED ID (if available)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Place of Birth

 

 

 

 

 

 

 

 

 

 

 

7. Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant

 

 

 

 

Employee

 

 

 

New Family Member

 

 

 

 

State

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Spouse, Newborn, Adoption)

City

 

 

 

 

 

 

 

 

Dependent Child

 

 

 

 

Spouse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Agency of Employee/Applicant/Sponsor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

USAID

FCS

FAS

U.S. Agency for Global Media

 

DoD Civilian

DoD Contractor

 

Non-Foreign Service Agency

 

 

 

 

 

 

 

 

 

 

 

Contracting Company

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Health Insurance Plan

 

 

 

 

 

 

 

 

 

 

 

10. Purpose of Exam

 

11. Employment Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-Employment Exam

 

 

 

 

Civil Service

 

 

 

LES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In-Service Exam

 

 

 

 

Contractor

 

 

 

LNA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PSC Contractor

 

 

 

Fellow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separation Exam

 

 

 

 

FS Officer

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. E-mail Address of examinee or parent of child < 18 y/o

 

 

 

 

 

 

REA-WAE

 

 

 

 

FS Specialist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Where You can be Reached for the Next 90 days)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Employment Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary:

 

 

 

 

 

 

 

 

 

 

 

 

TDY (Regional hub or CONUS based)

 

 

 

 

 

 

 

 

 

Alternate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Iraq - List Post

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Afghanistan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Telephone Number of examinee or parent of child < 18 y/o

 

 

 

 

 

Other ESCAPE Post(s) If yes, list

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Where You can be Reached for the Next 90 days)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Post of Assignment and Estimated Dates of Arrival / Departure

Primary:

 

 

 

 

 

 

 

 

 

 

 

a. Proposed Post

 

 

 

 

 

 

 

 

 

 

 

 

 

EDA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm-dd-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Present Post

 

 

 

 

 

 

 

 

 

 

 

 

 

EDD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(mm-dd-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

DS-1843

Page 1 of 4

06-2020

 

Name of Examinee

II. MEDICAL HISTORY

DOB

ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA.

Do you (or your child) have a hisory of:

(parents - please answer for children < 18 years of age)

Yes No

1. Frequent/severe headaches or migraines?

2. Fainting, dizzy episodes, or syncope?

3. Stroke, TIA or head injury?

4. Epilepsy, seizures or other neurologic disorders?

5. Eye or vision problems?

6. Ear, nose, throat problems; hearing loss, hoarseness?

7. Allergies or history of anaphylactic reaction?

8. Shortness of breath, asthma, or COPD?

9. History of abnormal chest x-ray?

10. History of positive TB skin test, IGRA, or tuberculosis?

11. Aneurysm, blood clot or pulmonary embolism?

12. High blood pressure?

13. Murmurs, palpitations, or other heart problems?

14. Are you a former or current smoker?

15. Stomach, esophageal, or other intestinal problems?

16. Jaundice, hepatitis, or other liver disease?

17. Intestinal, rectal problems or hernia?

18. Urinary or kidney problems, blood in urine?

19. Diabetes, thyroid, or other endocrine disorders?

20. Joint or back pain/injury?

Yes No

21. Rheumatologic disorder?

22. Anemia?

23. Blood transfusion?

24. Malaria, tropical or other infectious disease?

25. Any skin or nail disorder?

26. Cancer of any type?

27. Any thickening or lump in breast, testicle?

Yes No

28. Have you consumed at any one time in the past year, more than 5 alcohol drinks for males or 4 drinks for females? Explain.

IN THE PAST SEVEN (7) YEARS (for questions 29-33) (parents - please answer for children < 18 years of age)

29. Have you used marijuana, amphetamines, narcotics, cocaine, or hallucinogenic drugs?

30. Have you been in psychotherapy/counseling or been prescribed medication for depression, anxiety, mood or stress?

31. Have you felt unusually depressed, sad, blue, or had frequent crying spells which lasted more than two weeks at a time?

32. Have you had frequent or recurrent episodes of: difficulty in relaxing or calming down, panicky feelings, irritability, anger, feeling hyper, or nervousness?

33. Have you experienced any emotional or physical symptoms related to a past trauma?

Children Only:

 

 

Yes

 

 

No 34. Has your child been referred for any current or potential special educational services, accommodations,

 

 

 

 

 

 

 

or modifications (i.e.: IFSP, Early Intervention, IEP, 504 Plan)? Explain:

Women: (provide results if applicable, N/A if not applicable)

35.

Date of last PAP test?

 

 

 

 

 

 

Results:

 

36.

Date of last Mammogram?

 

 

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

37. Are you pregnant?

 

 

Yes

 

 

No Est. due date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colon Cancer Screening: (Submit results)

 

 

 

 

 

 

 

 

 

Yes

 

No

38. History of abnormal colon cancer screening?

 

 

 

 

 

 

 

 

 

 

Date

Test (colonoscopy/sigmoidoscopy/guiacFOBT):

Results:

For all applicants, employees or eligible family members:

39. Is there any other medical or mental health condition not covered in questions 1 - 38?

Yes

No

IIA. Explanations required for "Yes" answers to questions 1-39. Attach additional sheets as needed.

III.LIST OF CURRENT MEDICATIONS (Prescription, over the counter, and vitamins/supplements with dosage and frequency)

Drug Or Other Allergies

IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)

Date (mm-dd-yyyy)

 

Illness or Operation

Name of Hospital

 

City and State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

V.SIGNATURE OF EXAMINEE OR PARENT OF CHILD <18 Y/O (I certify I have read and understand the above statement.)

X

Date (mm-dd-yyyy)

DS-1843

Page 2 of 4

Name of Examinee

DOB

VI. INSTRUCTIONS FOR COMPLETION AND SUMBISSION OF FORM DS-1843

NOTICE: This history and physical are used to make a medical clearance decision based on an individual's anticipated medical requirements while living or traveling abroad. This exam does not meet the requirements of an age appropriate wellness exam.

MEDICAL EXAMINER

Medical Examiner must comment on positive history (pg. 2), abnormal physical findings (pg. 3), and provide follow-up recommendations (pg. 4).

Medical Examiner must sign on page 4.

EXAMINEE / SPONSOR / PARENT

All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.

Submit copies of all laboratory tests and additional medical reports with DS-1843.

All Lab tests and medical reports must be in English, and identified with full name and date of birth of examinee.

Keep originals as a permanent record. Do NOT submit by U.S. Mail or by courier service (e.g. FedEx or DHL).

Submit the DS-1843 and other documentation via email in PDF format to MEDMR@state.gov (preferred), or by fax to the Medical Records Department at 202-647-0292. If you wish to confirm that your exam forms were received, email MEDMR@state.gov.

VII: Medical Examiner comments on significant patient medical history and items checked "yes" on page 2/section II. Use additional pages if needed.

VIII: Clinical Evaluation

1. Height

in. or

cm.

2. Weight

lbs. or

kgs

3. BMI

4. Pulse

5. Blood Pressure (sitting)

If above 140/85 repeat 3 times and record.

IX. Clinical Evaluation

 

 

 

Notes

Check each item as indicated.

Normal

Abnormal

NE

(Describe every abnormality in detail.

Include pertinent item number before each comment.)

Check "NE" if not evaluated.

 

 

 

 

 

 

 

1.General/Constitution

2.Mental / Affect / Mood / (Development-children)

3.Skin

4.Eye

5.Ears/Nose/Throat

6.Neck/Thyroid

7.Lungs/Thorax

8.Breasts

9.Cardiovascular

(Record murmurs/abnormalities)

10.Abdomen

11.Male Genitalia

12.Anus/Rectum/Prostate (if indicated)

13.Musculoskeletal / Spine / Extremities (Note limitations)

14.Lymph Nodes

15.Neurologic

16.Female Gynecologic (if indicated)

DS-1843

Page 3 of 4

Name of Examinee

 

DOB

 

 

 

IX. LABORATORY ANALYSIS

COPIES OF LABORATORY REPORTS MUST BE ATTACHED

1. Required Labs (Must attach)

 

 

A. Hematology (must include: Hematocrit, Hemoglobin, White Blood Cell Count, and Platelets)

B. Chemistry (must include: Fasting Blood Sugar, Creatinine, and ALT. Hemoglobin A1c if indicated)

C. Serology (must include: HEP B Surface Antigen, HEP C Antibody, RPR/VDRL, and HIV I/II Antibody)

D. Lipid Profile (only if > 50 years of age: Total Cholesterol, LDL, HDL, and Triglycerides)

ALL TESTS ARE REQUIRED UNLESS OTHERWISE SPECIFIED. TEST RESULTS FROM PREVIOUS 12 MONTHS ARE ACCEPTABLE.

LABORATORY REPORTS MUST BE IN ENGLISH. ATTACH LABS TO THIS FORM.

2. Tuberculin Skin Test : REQUIRED (unless previously positive)

 

3. Chest X Ray (PA and lateral) - Required only if TST >

 

For baseline status as individual who will live overseas in an endemic TB area.

 

10mm, positive IGRA or clinically indicated.

 

TST Results:

 

mm of induration

Date:

 

 

Results:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IGRA Results:

 

 

 

OR

 

Date:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interferon Gamma Release Array: (may substitute for TST if > 5 y/o or

 

 

 

 

In those with previous BCG)

 

 

 

 

 

 

 

 

4. ECG (50 years or older, earlier if indicated) -

 

 

 

 

 

 

 

 

 

 

 

 

Previous active tuberculosis

 

 

Yes

 

No

Date:

 

 

SUBMIT TRACING

 

 

 

 

 

 

Results:

 

 

 

 

 

 

 

 

 

Previous positive TST or IGRA

 

 

Yes

 

No

Date:

 

 

 

 

 

 

 

 

 

 

Previous LTBI treatment

 

 

Yes

 

No

Date:

 

 

Date:

 

 

 

 

 

 

 

 

 

Hx of BcG vaccine

 

 

Yes

 

No

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPTIONAL TESTS: The following tests are not required for a medical clearance determination. The expense of performing these exams is not routinely authorized. The tests may be performed at the clinical discretion of the examiner with patient consent. If performed or previous results are available, the results may be used by the Department of State in a medical clearance determination and future clinical care of individuals covered under the Department's Medical Program.

5. Blood Type ( if not previously documented)

Type: ABO

 

 

(Rh) Dµ:

 

 

 

(weak D):

 

 

 

 

 

 

 

 

 

 

 

 

6. G6PD (If not previously documented) for malarial prophylaxis

 

Results:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. PAP/Cervical Cytology

 

 

 

 

Results:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Mammogram

 

 

 

 

Results:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Colon Cancer Screen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test (colonoscopy/sigmoidoscopy/guiac FOBT/other):

 

 

Results:

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X. Assessment or Problem List

 

 

 

XI. Recommendation for Treatment / Further Study / Consultation or

 

 

 

 

Follow - Up

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTICE: This form is not complete until all laboratory tests and results from section IX are attached and included with this DS-1843 form.

 

 

 

 

 

 

 

 

 

 

 

Typed Name of Examiner

 

 

 

Signature of Examiner

 

 

 

 

 

Date (mm-dd-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

Telephone Number

DS-1843

Page 4 of 4

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