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.)

Exam Date (mm-dd-yyyy)
Passport Number

Birth Date (mm-dd-yyyy)

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
Date
Date
Date
Panel
Received
Received
Received
Received
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: 30 minutes
(See Page 2 of 2)

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

Specify (check) vaccine:
DT
DTP
DTaP
Specify (check) vaccine:
Td
Tdap
Specify (check) vaccine:
Polio -OPV
IPV
Specify (check) vaccine:
MMR (Measles-MumpsRubella)
Rubella
Specify (check) vaccine:
Measles
Measles - Rubella
Specify (check) vaccine:
Mumps
Mumps - Rubella
Rotavirus
Hib
Hepatitis A
Hepatitis B
Meningococcal
Human papillomavirus
Varicella
Zoster
Pneumococcal
Influenza

2. Results
Vaccine History Incomplete
Applicant may be eligible for blanket waiver(s) because vaccination(s) not medically appropriate (as Indicated Above).
Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met (Documented Above).

3. Panel Physician (Name)
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
XX-XXXX

Give Copy to Applicant

Page 1 of 2

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
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: Department of State (A/ISS/DIR) Washington, DC
20520-1849.

We ask for information on this form, in the case of applicants for immigrant visas, to determine medical eligibility under INA Section
212 (a) and 221 (d), and as required by INA Section 212(g)(2). If an immigrant visa is issued, you will convey this form to the INS for
disclosure to the Center for Disease Control and the US Public Health Service. Failure to provide this information may delay or
prevent the processing of your case. If an immigrant visa is not issued, this form will be treated as confidential under INA Section
222(f).

DS-3025

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