Medical Examination for Immigrant or Refugee Applicant

Forms and Documents

Document Name	Status
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant Form	Modified
Canadian Forms Supplemental justification statement (1-09).doc Justification for No Material/Nonsubstantive Change	2009-01-22
Justification for change (DS-3025) 1-30-08.doc Supplementary Document	2008-01-30
Revised Supporting Statement 1405-0113.doc Supporting Statement A	2009-03-19
Legal Authorities.doc Supplementary Document	2007-07-02

IC Document Collections

IC ID	Document Title	Status
38745	Medical Examination for Immigrant or Refugee Applicant Form	Modified

ICR Details

OMB Control No: 1405-0113	ICR Reference No: 200901-1405-001
Status: Historical Inactive	Previous ICR Reference No: 200801-1405-004
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Examination for Immigrant or Refugee Applicant
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 04/02/2009
	Date Received in OIRA: 01/26/2009
Terms of Clearance: Agency to resubmit package as an ICR Change (substantive) in order to input the annual cost to the federal government of refugee medical exams.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2011	03/31/2011	03/31/2011
Responses	630,000	0	630,000
Time Burden (Hours)	630,000	0	630,000
Cost Burden (Dollars)	283,500,000	0	283,500,000

---

Abstract: Form DS-2053, DS-3024, DS-3025 and DS-3026 are completed by panel physicians for refugees and aliens seeking immigrant visas to the U.S. The collection records medical information necessary to determine whether refugees or immigrant visa applicants have medical conditions affecting the public health and requiring treatment. As per OMB agreement, Canadian versions of the forms have been developed only for use in Canada. These forms do not have asny identifying US government information to meet the requested legal concerns of the Canadian goverment and Canadian insurers.

---

Authorizing Statute(s): US Code: 8 USC 1101 Name of Law: Immigration and Nationality Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 46	03/09/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 121	06/25/2007
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical Examination for Immigrant or Refugee Applicant	DS-2053, DS-3024, DS-3025, DS-3026, DS-3025, Canada Main Medical Form, Canada Medical Worksheet One, Canada Medical Worksheet Two, Canada Medical Worksheet Three	Vaccination Documentation Worksheet ,   Medical Examination for Immigrant or Refugee Applicant ,   Chest X-ray and Classification, Medical Worksheet One ,   Vaccination Documentation, Medical Worksheet Two ,   Medical History and Physical Examination, Medical Worksheet Three ,   Medical Examination for Immigrant or Refugee Applicant ,   Chest X-Ray and Classification Worksheet ,   Vaccination Documentation Worksheet ,   Medical History and Physical Examination Worksheet

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/26/2009

---