Medical Examination for Immigrant or Refugee Applicant

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0113 can be found here:

Documents and Forms

Document Name Document Type
Form DS-3024 Medical Examination for Immigrant or Refugee Applicant Form
DS-2053 Medical Examination for Immigrant or Refugee Applicant DS-2053.pdf Form
DS-3024 Chest X-Ray and Classification Worksheet DS-3024.pdf Form
DS-3025 Vaccination Documentation Worksheet DS-3025.pdf Form
DS-3026 Medical History and Physical Examination Worksheet DS-3026.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Examination for Immigrant or Refugee Applicant	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DS-3024	Chest X-Ray and Classification Worksheet	DS-3024.pdf	Yes	No	Paper Only
Form	DS-3025	Vaccination Documentation Worksheet	DS-3025.pdf	Yes	No	Paper Only
Form	DS-3026	Medical History and Physical Examination Worksheet	DS-3026.pdf	Yes	No	Paper Only
Form	DS-2053	Medical Examination for Immigrant or Refugee Applicant	DS-2053.pdf	Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 630,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	630,000	0	0	630,000
Annual IC Time Burden (Hours)	630,000	0	0	630,000
Annual IC Cost Burden (Dollars)	252,000,000	189,000,000	63,000,000	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.