Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 38745 under ICR 200801-1405-004 · OMB 1405-0113.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-2053 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
DS-3025 Vaccination Documentation Worksheet ds3025 (rev 1-08).pdf	Form

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DS-2053	Medical Examination for Immigrant or Refugee Applicant	DS-2053.pdf	Yes	No	Paper Only
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-3025	Vaccination Documentation Worksheet	ds3025 (rev 1-08).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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	630,000	0	630,000
Annual IC Time Burden (Hours)	630,000	0	630,000
Annual IC Cost Burden (Dollars)	283,500,000	31,500,000	252,000,000

Documents for IC

table that charts IC Documents
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.