DS-3030 Chest X-Ray and Classification Worksheet (2007 TI)

U.S. Department of State

CHEST X-RAY AND CLASSIFICATION WORKSHEET

For use with TB TI 2007 and the DS-2054
Name (Last, First, MI.)
Birth Date(mm-dd-yyyy)

Complete Sections 1 through 5, As Applicable

OMB No. 1405-0113
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 10 MINUTES
(See Page 2 - Back of Form)

Age

Passport Number

Alien (Case) Number

1. Chest X-Ray Indication (Mark all that apply)
Age > 15 years

Test for TB infection:

Signs or symptoms of tuberculosis

TST>10 mm; Result

HIV infection

IGRA Positive; Result

(If child does not have any of the above, stop here.)
2. Chest X-Ray Findings
Normal Findings

mm; Date (mm-dd-yyyy)
Date (mm-dd-yyyy)

Date Chest X-Ray Taken (mm-dd-yyyy)

Abnormal Findings (Indicate category and finding, checking all that apply in the table below.)
Can Suggest Tuberculosis (Need Smears and Cultures)

Other X-Ray Findings

Infiltrate or consolidation

Discrete linear opacity (fibrotic scar)

Any cavitary lesion

Discrete nodule(s) without calcification

Musculoskeletal

Nodule or mass with poorly defined margins
(such as tuberculoma)

Discrete linear opacity (fibrotic scar)
with volume loss or retraction

Cardiac

Pleural effusion*

Other (such as bronchiectasis)

Pulmonary, non-TB (e.g., emphysema)

Follow-up needed (Mark as Class B Other)

Hilar/mediastinal adenopathy with or without
atelectasis
Other (such as miliary findings)

Other
No follow-up needed for pleural thickening,
diaphragmatic tenting, calcified pulmonary
nodule(s), calcified lymph node(s),
calcified lymph node(s) with calcified
pulmonary nodule(s), or minor
musculoskeletal findings.

* If unclear whether pleural fluid or
thickening, perform lateral or decubitus
chest radiograph, or targeted ultrasound.

Remarks

Radiologist's Signature

Date Interpreted (mm-dd-yyyy)

3. Sputum Smears and Cultures
No, not indicated - Applicant has no signs or symptoms of TB, no HIV infection, and:
:
X-ray Normal and test for TB infection negative (if performed): this is No Class
X-ray Normal and test for TB infection positive (if performed): this is Class B2 TB, LTBI Evaluation
Yes, are indicated - Applicant has (Mark all that apply):
Signs or symptoms of TB
Chest X-ray suggests TB
HIV infection
Sputum Smear Results

Sputum Culture Results

Date Obtained (mm-dd-yyyy) Positive Negative

Date Obtained (mm-dd-yyyy) Positive Negative NTM* Contaminated

* Nontuberculous Mycobacteria
Positive Smear or Culture Result; this is a Class A TB
Negative Smear and Culture Results and:
Chest X-Ray suggests TB or signs and symptoms of TB: Class B1 TB, Pulmonary
HIV infection with normal X-ray and no signs and symptoms of TB: No Class for TB (but must mark on DS-2054 as Class A for HIV)
TURN PAGE OVER TO FINISH DS-3030 FORM
DS-3030
xx-xxxx

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4. Classifications (Mark all that apply and also provide complete information on the DS-2054)
No Class

Class B1, TB, Extrapulmonary

Class A TB

Class B2 TB, LTBI Evaluation

Class A TB with waiver

Class B3 TB, Contact Evaluation

Class B1 TB, Pulmonary

Class B Other

5. Remarks

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Public reporting burden for this collection of information is estimated to average 10 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-3030

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