Medical Examination for Immigrant or Refugee Applicant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Medical Worksheet Vaccination Documentation Medical Worksheet Two (Canada 5-2010)	Form and Instruction	Modified	Available
Form DS-3025 Vaccination Documentation Worksheet (5-2010)	Form and Instruction	Modified	Available
Form Main Medical Form Medical Examination for Immigrant or Refugee Applicant (Canada) (11-2009)	Form and Instruction	Modified	Repair queued
Form DS-3030 Chest X-Ray and Classification Worksheet - 2007 TI (11-2009)	Form and Instruction	Modified	Available
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant - 2007 TI (11-2009)	Form and Instruction	Modified	Available
Form DS-2053 Medical Examination for Immigrant or Refugee-1991 TI (11-2009)	Form and Instruction	Modified	Available
Form Medical Worksheet Medical History and Physical Examination Medical Worksheet Three (Canada)	Form and Instruction	Modified	Repair queued
Form Medical Worksheet Chest X-Ray and Classification Medical Worksheet One (Canada)	Form and Instruction	Modified	Available
Form Main Medical Form Medical Examination for Immigrant or Refugee Applicant (Canada)	Form and Instruction	Modified	Repair queued
Form DS-3030 Chest X-Ray and Classification Worksheet (2007 TI)	Form and Instruction	Modified	Repair queued
Form DS-3026 Medical History and Physical Examination Worksheet	Form and Instruction	Modified	Available
Form DS-3025 Vaccination Documentation Worksheet	Form and Instruction	Modified	Available
Form DS-3024 Chest X-Ray and Classification Worksheet (1991TI)	Form and Instruction	Modified	Repair queued
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant (2007 TI)	Form and Instruction	Modified	Available
Form DS-2053 Medical Examination for Immigrant or Refugee Applicant (1991 TI)	Form and Instruction	Modified	Available
Form Medical Worksheet Vaccination Documentation Medical Worksheet Two (Canada)	Form and Instruction	Modified	Available
CDC-FR Notice eliminating HPV & Zoster vaccine 11-13-09.pdf	Supplementary Document	Uploaded 2010-05-10	Available
Justification for Revision (5-2010).doc	Supplementary Document	Uploaded 2010-05-10	Available
Legal Authorities (5-2010).doc	Supplementary Document	Uploaded 2010-05-10	Available
Emergency Review Justification 11-23-09.doc	Supplementary Document	Uploaded 2009-11-23	Available
Legal Authorities 11-23-09.doc	Supplementary Document	Uploaded 2009-11-23	Available
Canadian Forms Justification.doc	Supplementary Document	Uploaded 2009-04-09	Repair queued
Justification for change (DS-3025) 1-30-08.doc	Supplementary Document	Uploaded 2008-01-30	Available
Supporting Statement (5-2010).doc	Supporting Statement A	Uploaded 2010-05-10	Available
Legal Authorities.doc	Supplementary Document	Uploaded 2007-07-02	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Vaccination Documentation Medical Worksheet Two (Canada 5-2010)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Vaccination Documentation Worksheet (5-2010)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee Applicant (Canada) (11-2009)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Chest X-Ray and Classification Worksheet - 2007 TI (11-2009)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee Applicant - 2007 TI (11-2009)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee-1991 TI (11-2009)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical History and Physical Examination Medical Worksheet Three (Canada)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Chest X-Ray and Classification Medical Worksheet One (Canada)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee Applicant (Canada)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Chest X-Ray and Classification Worksheet (2007 TI)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical History and Physical Examination Worksheet
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Vaccination Documentation Worksheet
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Chest X-Ray and Classification Worksheet (1991TI)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee Applicant (2007 TI)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Medical Examination for Immigrant or Refugee Applicant (1991 TI)
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Modified	Vaccination Documentation Medical Worksheet Two (Canada)

ICR Details

OMB Control No: 1405-0113	ICR Reference No: 201005-1405-004
Status: Historical Active	Previous ICR Reference No: 200911-1405-003
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Examination for Immigrant or Refugee Applicant
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/20/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/10/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2013	36 Months From Approved	07/31/2010
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: Forms for this collection 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.

---

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:
	74 FR 223	11/20/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 89	05/10/2010
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Medical Examination for Immigrant or Refugee Applicant	DS-2054, DS-3025, DS-2053, DS-3024, Medical Worksheet Three, Main Medical Form, Medical Worksheet Two (5-2010), DS-2053, Medical Worksheet One, Medical Worksheet Two, DS-3030, DS-3026, DS-2054, DS-3030, Main Medical Form, DS-3025	Medical Examination for Immigrant or Refugee Applicant (1991 TI) ,   Medical Examination for Immigrant or Refugee Applicant (2007 TI) ,   Chest X-Ray and Classification Worksheet (1991TI) ,   Vaccination Documentation Worksheet ,   Medical History and Physical Examination Worksheet ,   Chest X-Ray and Classification Worksheet (2007 TI) ,   Medical Examination for Immigrant or Refugee Applicant (Canada) ,   Chest X-Ray and Classification Medical Worksheet One (Canada) ,   Vaccination Documentation Medical Worksheet Two (Canada) ,   Medical History and Physical Examination Medical Worksheet Three (Canada) ,   Medical Examination for Immigrant or Refugee-1991 TI (11-2009) ,   Medical Examination for Immigrant or Refugee Applicant - 2007 TI (11-2009) ,   Chest X-Ray and Classification Worksheet - 2007 TI (11-2009) ,   Medical Examination for Immigrant or Refugee Applicant (Canada) (11-2009) ,   Vaccination Documentation Worksheet (5-2010) ,   Vaccination Documentation Medical Worksheet Two (Canada 5-2010)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	630,000	630,000	0	0	0	0
Annual Time Burden (Hours)	630,000	630,000	0	0	0	0
Annual Cost Burden (Dollars)	283,500,000	283,500,000	0	0	0	0

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: $18,719,000

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]? No

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: 05/10/2010

---