DS-3025 Vaccination Documentation Worksheet

U.S. Department of State

VACCINATION DOCUMENTATION WORKSHEET
For Use with DS-2053 or DS-2054

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 documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them
to: A/ISS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202

CONFIDENTIALITY STATEMENT:
AUTHORITIES: The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by
Section 222 of the Immigration and Nationality Act.

Section 222(f) provides that the records of the Department of States and of

diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United
States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the
immigration, nationality, and other laws of the United States. Certified copies of such records may be made available to a court
provided the court certifies that the information contained in such records is needed in a case pending before the court.
PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and
eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may
be denied a U.S. immigrant visa.

Although furnishing this information is voluntary, failure to provide this information may delay or

prevent the processing of your case.
ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the
Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so
indicate, the Social Security Administration will use the information to issue a social security number. The information provided may
also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and
courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S.
laws.
DS-3025

Page 2 of 2