DS-2054 Medical Examination for Immigrant or Refugee Applicant -

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 2007 and the DS-3030
Name (Last, First, MI.)

Photo

,

,

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 of Medical Exam (Date of TB physical exam or date of lab report of final TB culture results, if cultures performed) (mm-dd-yyyy)
Date Exam Expires (3 months if Class A TB, or Class B1 TB, otherwise 6 months) (mm-dd-yyyy)
Exam Place (City/Country)

Date (mm-dd-yyyy) of Prior Exam, if any
Panel Physician

/

Radiology Services
Lab (Name for syphilis/TB)

Screening Site

/

/

(1) Classification (Check all boxes that apply):
No apparent defect, disease, or disability (See Worksheets DS-3025, DS-3026, and DS-3030)
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

Chancroid, untreated
Gonorrhea, untreated
Granuloma inguinale, untreated

*amphetamines, cannabis, cocaine, hallucinogens, inhalants,
opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Lymphogranuloma venereum, untreated

Class B Conditions (From Past Medical History and Physical Examination Worksheets)
Syphilis (with residual defect), treated within the last year

Hansen's disease, treated multibacillary

Other sexually transmitted infections, treated within last year

Treatment:

Current pregnancy, number of weeks pregnant

Hansen's disease, paucibacillary

Partial

Completed

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

Class B1 TB, Pulmonary
No treatment
Completed treatment (Check all that apply and attach all laboratory and DOT documents)
By panel physician

By non-panel physician

Initial smear positive

Initial culture positive

Pre-treatment culture and DST results performed/available

Pre-treatment culture and/or DST results not performed/available

Class B1 TB, Extrapulmonary

Anatomic Site of Disease

No treatment
Current treatment
Completed treatment

Class B2 TB, LTBI Evaluation
Test for TB infection positive:

TST

mm;

IGRA positive

Result

TST or IGRA Conversion

No LTBI treatment
Current LTBI treatment (Indicate medications in Part 4 of DS-2054 form)
Completed LTBI treatment (Indicate medications in Part 4 of DS-2054 form)
DS-2054
xx-xxxx

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Class B Tuberculosis - Continued
Class B3 TB, Contact Evaluation
TST

mm

IGRA negative

IGRA positive

IGRA Result

No preventive treatment
Current preventive treatment (Indicate medications in Part 4 of DS-2054 form)
Completed preventive treatment (Indicate medications in Part 4 of DS-2054 form)
Source Case:

Name
Alien Number
Relationship to Contact
Date Contact Ended (mm-dd-yyyy)

Type of Source Case TB (Mark only one and ATTACH DST RESULTS)
Pansusceptible TB
MDR TB (resistant to at least INH and rifampin)
Drug-resistant TB other than MDR TB
Culture negative
Culture results not available
Class B Other (specify or give details on checked conditions from worksheets)

(2) Laboratory Findings (check all boxes that apply):
Syphilis:

Not done
Test Name

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

Negative

Positive

Titer 1

Notes

Screening
Confirmatory
Treated
Yes

If treated, therapy:
Benzathine penicillin, 2.4 MU IM

No

Other (therapy, dose):

Date(s) treatment given (mm-dd-yyyy) (3 doses for penicillin)

(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.
Vaccine history complete
Incomplete vaccine history, no waiver requested

Vaccine history incomplete, requesting waiver (indicate type below)
Blanket waiver

Individual waiver

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

Applicant Signature

DS-2054

Panel Physician Signature

Date (mm-dd-yyyy)

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(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")

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

Medication

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.
DS-2054

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