DS-2053 Medical Examination for Immigrant or Refugee-1991 TI (11

U. S. Department of State

OMB No. 1405-0113
EXPIRATION DATE: 04/30/2012
ESTIMATED BURDEN: 10 minutes
(See Page 2 - Back of Form)

MEDICAL EXAMINATION FOR
IMMIGRANT OR REFUGEE APPLICANT
For use with TB Technical Instructions 1991 and the DS-3024

Photo

Name (Last, First, MI.)

,

,

Birth Date (mm-dd-yyyy)

Sex:

Birthplace (City/Country)

M

F

/
Prior Country

Present Country of Residence
U.S. Consul (City/Country)
Passport Number

/
Alien (Case) Number
Date (mm-dd-yyyy) of Prior Exam, if any

Date (mm-dd-yyyy) of Medical Exam

Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy)
Exam Place (City/Country)

Panel Physician (name)

/

Radiology Services (name)

Screening Site (name)

Lab (name for syphilis/TB)

/

/

(1) Classification (check all boxes that apply):
No apparent defect, disease, or disability (see Worksheets DS-3024, DS-3025 and DS-3026)
Class A Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, infectious (Class A, from Chest X-Ray Worksheet)

Hansen's disease, untreated multibacillary

Syphilis, untreated

Addiction or abuse of specific* substance without harmful
behavior
Any physical or mental disorder (including other
substance-related disorder) with harmful behavior or history of
such behavior likely to recur
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Chancroid, untreated
Gonorrhea, untreated
Granuloma inguinale, untreated
Lymphogranuloma venereum, untreated

Class B Conditions (From Past Medical History and Physical Examination Worksheets)
TB, active, noninfectious (Class B1, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

TB, inactive (Class B2, from Chest X-Ray Worksheet)
Treatment:

None

Partial

Completed

See Section 4 on page 2 for TB treatment details
Syphilis (with residual deficit), treated within the last year
Other sexually transmitted infections, treated within last year
Current pregnancy, number of weeks pregnant

Hansen's disease, treated multibacillary
Partial
Completed
Treatment:
Hansen's disease, paucibacillary
None
Partial
Completed
Treatment:
Sustained, full remission of addiction or abuse of specific*
substances
Any physical or mental disorder (excluding addiction or abuse of
specific* substance but including other substance-related disorder)
without harmful behavior or history of such behavior unlikely to recur
*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Other (specify or give details on checked conditions from worksheets)

(2) Laboratory Findings (check all boxes that apply):
Not done

Syphilis:

Test name

Date(s) run (mm-dd-yyyy)

Negative

Positive

Titer 1

Notes

Screening
Confirmatory
Treated

DS-2053
xx-xxxx

If treated, therapy:

Yes

Benzathine penicillin, 2.4 MU IM

No

Other (therapy, dose):E

(Formerly OF-157)

Date(s) treatment given (3 doses for penicillin)

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(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.
Vaccine history incomplete, requesting waiver (indicate type below)

Vaccine history complete

Blanket waiver

Incomplete vaccine history, no waiver requested

Individual waiver

I certify that I understand the purpose of the medical examination and I authorize the required tests to be completed.

Applicant Signature

Panel Physician Signature

Date (mm-dd-yyyy)

(4) Tuberculosis Treatment Regimen
(Fill out if applicant has taken in the past, or is now taking TB medication. If drug doses or dates not
known or not available, mark "unknown".)
Check if therapy currently prescribed (if current, don't mark "End Date")

Medication

Dose/Interval
(i.e., mg/day)

Start Date
(mm-dd-yyyy)

End Date
(mm-dd-yyyy)

Isonaizid (INH)
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Other, specify

Applicant's pre-treatment weight (kg)

Date (mm-dd-yyyy)

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/GIS/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.
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DS-2053