DS-3030 Chest X-Ray and Classification Worksheet (2007 TI)

U.S. Department of State

CHEST X-RAY AND CLASSIFICATION WORKSHEET
For use with TB TI 2007 and the DS-2054
Name (Last, First, MI)
Birth Date (mm-dd-yyyy)

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)

Age

Passport Number

Alien (Case) Number
Test for TB infection:

1. Chest X-Ray Indication (Mark all that apply)
Age > 15 years

TST > 10 mm

Signs or symptoms of tuberculosis

IGRA Positive

HIV infection

Contact: TST > 5 mm

2. Chest X-Ray Findings

Date Chest X-Ray Taken (mm-dd-yyyy)

Normal Findings
Abnormal Findings (Indicate category and finding, checking all that apply in the table below.)
Can Suggest Tuberculosis (Need Smears and Cultures)

Other X-Ray Findings

Infiltrate or consolidation

Discrete linear opacity (fibrotic scar)

Any cavitary lesion

Discrete nodule(s) without calcification

Musculoskeletal

Nodule or mass with poorly defined margins
(such as tuberculoma)

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

Cardiac

Pleural effusion*

Other (such as bronchiectasis)

Pulmonary, non-TB (e.g., emphysema)

Follow-up needed (Mark as Class B Other)

Hilar/mediastinal adenopathy with or without
atelectasis
Other (such as miliary findings)

Other
No follow-up needed for pleural thickening,
diaphragmatic tenting, calcified pulmonary
nodule(s), calcified lymph node(s),
calcified lymph node(s) 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

Radiologist's Signature

Date Interpreted (mm-dd-yyyy)

3. Sputum Smears and Cultures
No, not indicated - Applicant has no signs or symptoms of TB, no known HIV infection, and:
:
X-ray Normal or 'Other X-Ray Findings' checked above and test for TB infection negative (if performed): this is No Class
X-ray Normal or 'Other X-Ray Findings' checked above and test for TB infection positive (if performed): this is Class B2 TB, LTBI
Yes, are indicated - Applicant has (Mark all that apply):
Signs or symptoms of TB
Chest X-ray suggests TB
HIV infection
Sputum Smear Results
Date Specimen Obtained (mm-dd-yyyy)

Sputum Culture Results
Positive

Negative

Date Specimen Obtained (mm-dd-yyyy)

Positive

Negative

NTM*

Contaminated

* Nontuberculous Mycobacteria
Positive Smear or Culture Result, or Clinical Judgment: this is a Class A TB
Negative Smear and Culture Results and:
Chest X-Ray suggests TB: Class B1 TB, Pulmonary
HIV infection with normal X-ray and no signs and symptoms of TB: No Class for TB
TURN PAGE OVER TO FINISH DS-3030 FORM
DS-3030
xx-2011

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4. Classifications (Mark all that apply and also provide complete information on the DS-2054)
No Class

Class B2 TB, LTBI Evaluation

Class A TB

Class B3 TB, Contact Evaluation

Class B1 TB, Pulmonary

Class B Other

Class B1, TB, Extrapulmonary
5. Remarks

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 State 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-3030

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