Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 38745 under ICR 201005-1405-004 · OMB 1405-0113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0113 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Medical Worksheet Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
DS-2053 Medical Examination for Immigrant or Refugee Applicant ( DS-2053.pdf	Form and Instruction
DS-2054 Medical Examination for Immigrant or Refugee Applicant ( DS-2054.pdf	Form and Instruction
DS-3024 Chest X-Ray and Classification Worksheet (1991TI) DS-3024.pdf	Form and Instruction
DS-3025 Vaccination Documentation Worksheet DS-3025.pdf	Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet DS-3026.pdf	Form and Instruction
DS-3030 Chest X-Ray and Classification Worksheet (2007 TI) DS-3030.pdf	Form and Instruction
Main Medical Form Medical Examination for Immigrant or Refugee Applicant ( Canada MainMedForm.pdf	Form and Instruction
Medical Worksheet Chest X-Ray and Classification Medical Worksheet One (Ca Canada MedWksht1.pdf	Form and Instruction
Medical Worksheet Vaccination Documentation Medical Worksheet Two (Canada) Canada MedWksht2.pdf	Form and Instruction
Medical Worksheet Medical History and Physical Examination Medical Workshe Canada MedWksht3.pdf	Form and Instruction
DS-2053 Medical Examination for Immigrant or Refugee-1991 TI (11 DS-2053 11-23-09.pdf	Form and Instruction
DS-2054 Medical Examination for Immigrant or Refugee Applicant - DS-2054 11-23-09.pdf	Form and Instruction
DS-3030 Chest X-Ray and Classification Worksheet - 2007 TI (11-2 DS-3030 11-23-09.pdf	Form and Instruction
Main Medical Form Medical Examination for Immigrant or Refugee Applicant ( Canada MainMedForm 11-23-09.pdf	Form and Instruction
DS-3025 Vaccination Documentation Worksheet (5-2010) DS-3025 (5-2010).pdf	Form and Instruction
Medical Worksheet Vaccination Documentation Medical Worksheet Two (Canada Canada MedWksht2 (5-2010).pdf	Form and Instruction
Canadian Forms Justification.doc Canadian Forms Justification (4-09)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medical Examination for Immigrant or Refugee Applicant

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Medical Worksheet Two	Vaccination Documentation Medical Worksheet Two (Canada)	Canada MedWksht2.pdf	Yes	No	Printable Only
Form and Instruction	Medical Worksheet Three	Medical History and Physical Examination Medical Worksheet Three (Canada)	Canada MedWksht3.pdf	Yes	No	Printable Only
Form and Instruction	DS-2053	Medical Examination for Immigrant or Refugee-1991 TI (11-2009)	DS-2053 11-23-09.pdf	Yes	No	Printable Only
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant - 2007 TI (11-2009)	DS-2054 11-23-09.pdf	Yes	No	Printable Only
Form and Instruction	DS-3030	Chest X-Ray and Classification Worksheet - 2007 TI (11-2009)	DS-3030 11-23-09.pdf	Yes	No	Printable Only
Form and Instruction	Main Medical Form	Medical Examination for Immigrant or Refugee Applicant (Canada) (11-2009)	Canada MainMedForm 11-23-09.pdf	Yes	No	Printable Only
Form and Instruction	DS-3025	Vaccination Documentation Worksheet (5-2010)	DS-3025 (5-2010).pdf	Yes	No	Printable Only
Form and Instruction	Medical Worksheet Two (5-2010)	Vaccination Documentation Medical Worksheet Two (Canada 5-2010)	Canada MedWksht2 (5-2010).pdf	Yes	No	Printable Only
Form and Instruction	DS-2053	Medical Examination for Immigrant or Refugee Applicant (1991 TI)	DS-2053.pdf	Yes	No	Printable Only
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant (2007 TI)	DS-2054.pdf	Yes	No	Printable Only
Form and Instruction	DS-3024	Chest X-Ray and Classification Worksheet (1991TI)	DS-3024.pdf	Yes	No	Printable Only
Form and Instruction	DS-3025	Vaccination Documentation Worksheet	DS-3025.pdf	Yes	No	Printable Only
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	DS-3026.pdf	Yes	No	Printable Only
Form and Instruction	DS-3030	Chest X-Ray and Classification Worksheet (2007 TI)	DS-3030.pdf	Yes	No	Printable Only
Form and Instruction	Main Medical Form	Medical Examination for Immigrant or Refugee Applicant (Canada)	Canada MainMedForm.pdf	Yes	No	Printable Only
Form and Instruction	Medical Worksheet One	Chest X-Ray and Classification Medical Worksheet One (Canada)	Canada MedWksht1.pdf	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 630,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	630,000	630,000
Annual IC Time Burden (Hours)	630,000	630,000
Annual IC Cost Burden (Dollars)	283,500,000	283,500,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Canadian Forms Justification (4-09)	Canadian Forms Justification.doc	04/09/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.