DS-3025 Vaccination Documentation Worksheet

U.S. Department of State

VACCINATION DOCUMENTATION WORKSHEET
For Use with DS-2053 or DS-2054

To Be Completed by Panel Physician Only

Name (Last, First, MI.)

Exam Date (mm-dd-yyyy)
Passport Number

Birth Date (mm-dd-yyyy)

Alien (Case) Number

NOT REQUIRED FO

NOTE FOR PANEL P
For refugee applica
vaccination docume

1. Immunization Record
Vaccine History Transferred From a Written Record
(List Chronologically from Left to Right)

Completed Series
Vaccine Given
( if Completed,
by
Date
Date
Date
Date
Panel Physician Write "VH" if Varicella
Received
Received
Received
Received
(mm-dd-yyyy) History, or write Date
of Lab Test if Immune)
(mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy)

Vaccine

REQUIRED FOR U.S

Blanket Waiver(s) To Be R
Medically Appropriate, Che
Not Age
Insufficient Time
Appropriate
Interval

Specify (check) vaccine:
DT
DTP
DTaP
Specify (check) vaccine:
Td
Tdap
Specify (check) vaccine:
Polio -OPV
IPV
Specify (check) vaccine:
MMR (Measles-MumpsRubella)
Rubella
Specify (check) vaccine:
Measles
Measles - Rubella
Specify (check) vaccine:
Mumps
Mumps - Rubella
Rotavirus
Hib
Hepatitis A
Hepatitis B
Meningococcal
Varicella
Pneumococcal
Influenza

2. Results
Vaccine History Incomplete
Applicant may be eligible for blanket waiver(s) because vaccination(s) not medically appropriate (as Indicated Above).
Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met (Documented Above).
Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested.

DS-3025
xx-xxxx

Give Copy to Applicant

3. Panel Physician (Name)

Panel Physician (Signature
Date (mm-dd-yyyy)

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including tim

searching existing data sources, gathering the necessary documentation, providing the information and/or documents

reviewing the final collection. You do not have to supply this information unless this collection displays a currently val

number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, plea
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 a
Section 222 of the Immigration and Nationality Act.

Section 222(f) provides that the records of the Department of

diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to en

States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enfo

immigration, nationality, and other laws of the United States. Certified copies of such records may be made availa

provided the court certifies that the information contained in such records is needed in a case pending before the cour

PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your cla

eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested in
be denied a U.S. immigrant visa.

Although furnishing this information is voluntary, failure to provide this information

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
Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card,

indicate, the Social Security Administration will use the information to issue a social security number. The information
also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to

courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer o
laws.
DS-3025