DS-3025 Vaccination Documentation Worksheet

U.S. Department of State

VACCINATION DOCUMENTATION WORKSHEET
For Use with DS-2053

To Be Completed by Panel Physician Only

Name (Last, First, MI.)
Birth Date (mm-dd-yyyy)

Exam Date (mm-dd-yyyy)
Passport Number

REQUIRED FOR U.S. IMMIGRANT VISA APPLICANTS
NOT REQUIRED FOR REFUGEE APPLICANTS

Alien (Case) Number

NOTE FOR PANEL PHYSICIANS:
For refugee applicants, please complete only if reliable
vaccination documents are available.

1. Immunization Record
Vaccine History Transferred From a Written Record
(List Chronologically from Left to Right)

Vaccine Given
by
Date Received Date Received Date Received Date Received Panel Physician
(mm-dd-yyyy) (mm-dd-yyyy)
(mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy)

Vaccine

OMB No. 1405-0113
EXPIRATION DATE: xx/xx/xxxx
ESTIMATED BURDEN: 20 minutes
(See Page 2 - Back of Form)

Completed Series
( if Completed,
Write "VH" if Varicella
History, or write Date
of Lab Test if Immune)

Blanket Waiver(s) To Be Requested If Vaccination Not
Medically Appropriate, Check Suitable Box(es) Below
Not Age
Appropriate

Insufficient Time
Interval

Contraindicated

Not Routinely
Not Fall
(Flu) Season
Available

DT/DTP/DTaP
Td
Polio (OPV/IPV)
Measles (or MR
or MMR)
Mumps (or MMR)
Rubella (or MR
or MMR)
Rotavirus
Hib (Haemophilus
Influenzae Type B)
Hepatitis A
Hepatitis B
Meningococcal
Human
papillomavirus
Varicella
Pneumococcal
Influenza
2. Results
Vaccine History Incomplete
Applicant may be eligible for blanket waiver(s) because
vaccination(s) not medically appropriate (as Indicated Above).

3. Panel Physician (Name)

Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met (Documented Above).

Panel Physician (Signature)
Date (mm-dd-yyyy)

Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested.
DS-3025

Give Copy to Applicant

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PRIVACY ACT NOTICE
AUTHORITIES: This information is sought pursuant to Section 212(a), 212(d), 101, and 412(b)(4) and (5) of the Immigration and Nationality Act.
PURPOSE: The primary purpose for soliciting medical information is to determine whether an applicant is eligible to obtain a visa and alien registration. This
form is designed to record the result of the medical examination required by INA 221(d), which determines whether an applicant has a medical condition that
renders the applicant ineligible under INA Section 212(a).
ROUTINE USES: The information solicited on this form may be made available to the U.S. Department of Homeland Security for disclosure to the Centers for
Disease Control and Prevention and to the U.S. Public Health Service. The information provided also may be released to federal agencies for law enforcement,
counter-terrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies of certain personnel
and records management matters.
Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average 30 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 burden and recommendations for reducing it to :
the U.S. Department of State (A/ISS/DIR) Washington, DC 20520-1849.

DS-3025

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