Form DS-3057 Medical Clearance Update

U.S. Department of State

REQUISITION FOR PUBLISHING,
REPRODUCTION, AND DISTRIBUTION SERVICES
Security Classification

Work Order Number (For GPS Use Only)

Request Date

Unclassified

Due Date

09/07/2023

SECTION 1: SERVICE CATEGORY
Service Category:

Federal Register Publication

Specify Other

SECTION 2: REQUESTOR'S INFORMATION
Requestor

E-mail Address

Monna, Jennifer

Monna, Jennifer

monnajl@state.gov

Telephone Number

Office Symbol

202-663-1657

MGT/MED

Room Number

Building

H242

SA-1

SECTION 3: JOB INFORMATION
Title of job to be reproduced or Title of Job

60- Day Notice for Proposed Information Collection: Medical Clearance Update Form DS-3057

Publication Approval Submitted:

Yes

N/A

SECTION 3A: JOB SPECIFICATIONS
Number of Pages

SECTION 3C: ELECTRONIC CONVERSION

Number of Copies

Finished Size

CD-ROM Duplication

Scan Images (TIFF)

CD-ROM Programming

Scan Test Document

Events Calendar

Web Programming

File Conversion

SECTION 3B: KIND AND COLOR OR PAPER AND INK
Cover

Other

Ink
Specify Other

Text

Ink

Specify Other

SECTION 3D: PRINTING AND BINDERY SPECIFICATIONS/DISTRIBUTION
Copy (One-Sided)

Copy (Two-Sided)

Offset Print

Fold

GBC Bind

Perfect Bind

Saddle Stitch Bind

Laminate

Tape Bind

Mount

Punch

Velo Bind

Staple

Wire-O Bind

SECTION 3E: ADDITIONAL INSTRUCTIONS

SECTION 3F: ADDITIONAL INSTRUCTIONS
Type of Job
Graphic's Estimated Hours

SECTION 4: AUTHORIZATION
Name of Authorizing Official

Phone Number

Greenlee, Rhonda

202-633-1598

Authorizing Official Signature

Appropriation

19X45190001
DS-5
07-2019

E-mail Address

RHONDA L GREENLEE

Allotment

6025

Obligation Number

602523D9100

GreenleeRL@state.gov

Digitally signed by RHONDA L
GREENLEE
Date: 2023.09.07 10:41:46 -04'00'

Organization Code

016800

Estimated Cost

Function Code

5613

$475.00

Date (mm-dd-yyyy)

Object Code

2418

Amount

$475.00