DS-3024 Chest X-Ray and Classification Worksheet (1991TI)

U.S. Department of State

CHEST X-RAY AND CLASSIFICATION WORKSHEET
For use with TB TI 1991 and the DS-2053

Complete Sections 1 through 5, As Applicable

OMB No. 1405-0113
EXPIRATION DATE: 07/31/2013
ESTIMATED BURDEN: 10 MINUTES
(See Page 2 - Back of Form)

Name (Last, First, MI.)

Age

Birth Date (mm-dd-yyyy)

Passport Number

Alien (Case) Number

1. Chest X-Ray Indication (Mark all that apply)
History of Tuberculosis (TB) Disease

TB Signs or Symptoms

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

Adult (With or without any of the other indications)
Date Chest X-Ray Taken (mm-dd-yyyy)

(Indicate category and finding, checking all that apply, in the table below.)

Can Suggest ACTIVE TB
(Need smears)
Infiltrate or consolidation

Can Suggest INACTIVE TB
(Need smears if symptomatic)

OTHER X-Ray Findings
Follow-Up Needed (Mark as "Class B
Other")

Discrete fibrotic scar or linear opacity
(fibrotic scar)

Any cavitary lesion

Discrete nodule(s) without calcification

Nodule or mass with poorly defined margins
(such as tuberculoma)
Pleural effusion*
Hilar/mediastinal adenopathy with or without
atelectasis
Other (Such as miliary findings)

Musculoskeletal

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

Cardiac

Other (Such as bronchiectasis)

Pulmonary, non-TB (e.g., emphysema)
Other
No Follow-Up Needed for
Pleural thickening, diaphragmatic tenting,
calcified pulmonary nodule(s), calcified lymph
node(s), calcified lymph nodes 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

Date Interpreted (mm-dd-yyyy)

Radiologist's Signature
3. Sputum Smears
No, Applicant has No Signs or Symptoms of TB and :

X-Ray Suggests INACTIVE TB, this is a Class B2/TB
OTHER X-Ray Findings Suggest Follow-Up Needed after Arrival, this is B Other
OTHER X-Ray Findings Suggest No Follow-Up Needed, this is No Class
X-Ray Normal, this is No Class

Yes, Applicant has (Mark all that apply) :

and Smear Results are:
Positive

Negative

Date Specimen Obtained (mm-dd-yyyy)

Signs or Symptoms of TB, See Section 1
X-Ray Suggests ACTIVE TB, See Section 2

Sputum Smear Results and X-Ray:
At least One Smear Result POSITIVE and
Any Chest X-Ray Finding (Normal or Abnormal
findings), this is Class A/TB

Three Smear Results NEGATIVE and
X-Ray Normal with
Signs or Symptoms Resolved, this is No Class
Signs or Symptoms Suggest Follow-Up Needed after Arrival, this is B Other
X-Ray Suggests ACTIVE or INACTIVE TB, this is Class B1/TB
OTHER X-Ray Findings Suggest Follow-Up Needed After Arrival, this is Class B Other

4.

No Class

Class A/TB

Class B1/TB

Class B2/TB

Class B Other

5. Follow-Up Needed After Arrival
If Yes, for
Not TB Condition
No
Yes
TB Condition
(If non-TB condition, specify condition below and on DS-2053 form; include additional tests, and therapy used with start and stop dates and any
Remarks
changes. If TB condition, enter information in Part 4 of DS-2053 form.)

DS-3024
xx-2011

Page 1 of 2

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS
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-3024

Page 2 of 2