DS-2053 Medical Examination for Immigrant or Refugee Applicant

U. S. Department of State

OMB No. 1405-0113
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 10 minutes
(See Page 2 - Back of Form)

MEDICAL EXAMINATION FOR
IMMIGRANT OR REFUGEE APPLICANT
Name (Last, First, MI.)

Photo

,

,

Birth Date (mm-dd-yyyy)

Sex:

Birthplace (City/Country)

M

F

/
Prior Country

Present Country of Residence
U.S. Consul (City/Country)
Passport Number

/
Alien (Case) Number
Date (mm-dd-yyyy) of Prior Exam, if any

Date (mm-dd-yyyy) of Medical Exam

Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy)
Exam Place (City/Country)

Panel Physician

/

Radiology Services

Screening Site (name)

Lab (name for HIV/syphilis/TB)

/

/

(1) Classification (check all boxes that apply):
No apparent defect, disease, or disability (see Worksheets DS-3024, DS-3025 and DS-3026)
Class A Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, infectious (Class A, from Chest X-Ray Worksheet)

Human immunodeficiency virus (HIV)

Syphilis, untreated

Hansen's disease, lepromatous or multibacillary

Chancroid, untreated

Addiction or abuse of specific* substance without harmful
behavior
Any physical or mental disorder (including other
substance-related disorder) with harmful behavior or history of
such behavior likely to recur

Gonorrhea, untreated
Granuloma inguinale, untreated
Lymphogranuloma venereum, untreated

*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Class B Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, noninfectious (Class B1, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

TB, inactive (Class B2, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

See Section 4 on page 2 for TB treatment details
Syphilis (with residual deficit), treated within the last year
Other sexually transmitted infections, treated within last year
Current pregnancy, number of weeks pregnant

Hansen's disease, prior treatment
Hansen's disease, tuberculoid, borderline, or paucibacillary
Sustained, full remission of addiction or abuse of specific*
substances
Any physical or mental disorder (excluding addiction or abuse of
specific* substance but including other substance-related
disorder) without harmful behavior or history of such behavior
unlikely to recur
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Other (specify or give details on checked conditions from worksheets)

(2) Laboratory Findings (check all boxes that apply):
Syphilis:
Not done
Test name

Date(s) run (mm-dd-yyyy)

Negative

Positive

Titer 1

Notes

Screening
Confirmatory
Treated
Yes

If treated, therapy:

No

Date(s) treatment given (3 doses for penicillin)

Benzathine penicillin, 2.4 MU IM
Other (therapy, dose):E

HIV:

Not done
Test name

Date(s) run (mm-dd-yyyy)

Negative

Positive

Indeterminate

Notes

Screening
Secondary
Confirmatory
DS-2053

(Formerly OF-157)

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(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.
Vaccine history incomplete, requesting waiver (indicate type below)

Vaccine history complete

Blanket waiver

Incomplete vaccine history, no waiver requested

Individual waiver

I certify that I understand the purpose of the medical examination and I authorize the required tests to be completed.

Applicant Signature

Panel Physician Signature

Date (mm-dd-yyyy)

(4) Tuberculosis Treatment Regimen
(Fill out if applicant has taken in the past, or is now taking TB medication. If drug doses or dates not
known or not available, mark "unknown".)
Check if therapy currently prescribed (if current, don't mark "End Date")

Dose/Interval
(i.e., mg/day)

Medication

Start Date
(mm-dd-yyyy)

End Date
(mm-dd-yyyy)

Isonaizid (INH)
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Other, specify

Applicant's weight (kg)
Remarks

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including time required for searching existing data sources, gathering the necessary data, providing the
information required, and reviewing the final collection. Persons are not required to provide this information in
the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden
and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520.
We ask for information on this form, in the case of applicants for immigrant visas, to determine medical eligibility
under INA Sections 212(a) and 221(d), and, in the case of refugees, as required under INA Section 412(b)(4)
and (5). If an immigrant visa is issued or refugee status granted, you will convey this form to U.S. Department of
Homeland Security (DHS) for disclosure to the Centers for Disease Control and Prevention and to the U.S.
Public Health Service. Failure to provide this information may delay or prevent the processing of your case. If an
immigrant visa is not issued or refugee status is not granted, this form will be treated as confidential under INA
Section 222(f).
DS-2053

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