DS-5518-E Online Medical Examination

User Interface
Design Presentation
CEAC Medical OMB
Submission
Part 1

March 17, 2011

Bureau of Consular Affairs
Consular Systems and Technology

Welcome Page: Not Signed In
Displayed for all users when first accessing the CEAC Medical website.

CEAC Medical OMB Package

1

Sign In Page
Displayed for all users.

CEAC Medical OMB Package

2

Welcome Page: Signed In
Displayed for all users after signing in.

• The user can select the Change Password link if he/she needs to change the password
associated with his/her login.

CEAC Medical OMB Package

3

Select Applicant Page
Displayed for all users.

•
•
•
•
•

Immigrant Visa
Refugee
K or Other Non-Immigrant Visas
Follow-to-Join
Special Immigrant Visas from Afghanistan or Iraq

• The user selects his/her location from the ‘Physician Location’ drop-down.
• The user selects the type of applicant from the ‘Applicant Type’ drop-down.

CEAC Medical OMB Package

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Select Applicant Page: Immigrant Visa
Displayed if ‘Applicant Type’ is ‘Immigrant Visa’.

• The user fills in NVC Case Number or the Passport/Travel Document Number.
• The user fills in the Applicant’s Surname and Year of Birth.
• The user clicks ‘Submit’ to retrieve a list of applicants that fits the search criteria.

CEAC Medical OMB Package

5

Select Applicant Page: Refugee Applicant
Displayed if ‘Applicant Type’ is ‘Refugee Applicant’.

• Begins With…
• Exact Match…

• The user enters ‘Passport Number’ or ‘Travel Document Number’.
• The user selects ‘Begins with’ or ‘Exact match’ from the drop-down and enters the
applicant’s full or partial ‘Surname’ and ‘Given Name’.
• The user enters ‘Year of Birth’.
• The user clicks ‘Submit’. If an applicant who matches the search criteria is found, he/she
is displayed. If not, the user can select the ‘Create New Refugee’ link.

CEAC Medical OMB Package

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Refugee Personal Information Page
Displayed if the user clicks the ‘Create New Refugee’ link on the Select Applicant page.

• The user enters as many of the fields as are known and clicks ‘Save’.

CEAC Medical OMB Package

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Select Applicant Page: K And Other Non-Immigrant
Visas
Displayed if ‘Applicant Type’ is ‘K and Other Non-Immigrant Visas’.

• The user enters ‘Petition Number’.
• The user enters at least two of the following fields: ‘Passport Number’, ‘Surname’, or ‘Year
of Birth’.
• The user clicks ‘Submit’. If an applicant who matches the search criteria is found, he/she
is displayed.

CEAC Medical OMB Package

8

Select Applicant Page: Follow-to-Joins
Displayed if ‘Applicant Type’ is ‘Follow-to-Join’.

• The user enters ‘NVC Case Number’ or ‘Passport/Travel Document Number’.
• The user enters ‘Surname’ and ‘Year of Birth’.
• The user clicks ‘Submit’. If an applicant who matches the search criteria is found, he/she
is displayed.

CEAC Medical OMB Package

9

Select Applicant Page: Special Immigrants from Iraq
and Afghanistan
Displayed if ‘Applicant Type’ is ‘Special Immigrant from Iraq and Afghanistan’.

• The user enters ‘NVC Case Number’ or ‘Passport /Travel Document Number’.
• The user enters ‘Surname’ and ‘Year of Birth’.
• The user clicks ‘Submit’. If an applicant who matches the search criteria is found, he/she
is displayed.

CEAC Medical OMB Package

10

Select Applicant Page: Search Results
Displayed for all users after entering search criteria and matches are found. The list of
applicants will be the same for all applicant types.

• All applicants that meet the search criteria are displayed. If there are multiple applicants
associated to one case, they are displayed as well.
• The user clicks ‘Select’ for the applicant he/she would like to work on the forms.

CEAC Medical OMB Package

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Summary Information Page: 2053e and 3024e
Displayed for users requiring the 2053e and 3024e set of forms.

• The user selects the ‘View/Edit’ link to select the form to work on. The form will be
displayed.
• The user selects the ‘Back: Select Applicant’ button if he/she would like to go back to
Select Applicant pages.

CEAC Medical OMB Package

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Summary Information Page: 2054e and 3030e
Displayed for users requiring the 2054e and 3030e set of forms.

• The user selects the ‘View/Edit’ link to select the form to work on. The form will be
displayed.
• The user selects the ‘Back: Select Applicant’ button if he/she would like to go back to
Select Applicant pages.

CEAC Medical OMB Package

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DS-2053e: Getting Started Page
Displayed for all users requiring use of the 2053e form.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

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DS-2053e: Personal Information Page
Displayed for all users requiring use of the 2053e form.

• The following fields are required: ‘Surname’, ‘Given Name’, ‘Sex’, ‘Date of Birth’, ‘City of
Birth’ or ‘Did Not Provide’, ‘Prior Country of Residence’ or ‘Does Not Apply’, ‘Passport
Number’ or ‘Does Not Apply’, ‘A Number’ or ‘Does Not Apply’, ‘Case Number’ or ‘Does Not
Apply’.
• ‘Date of Birth’ can be a partial date for refugee applicants; the full date is required for all
other applicant types.
CEAC Medical OMB Package

15

DS-2053e: Medical Exam Information Page
Displayed for all users requiring use of the 2053e form.

• The following fields are required: ‘Date of Medical Exam’, ‘Date of Prior Exam’ or ‘Does
Not Apply’, ‘Date Exam Expires’, ‘Exam Place City’, ‘Exam Place Country’, ‘Lab Name for
TB’ or ‘Does Not Apply’ (if the applicant has a TB condition listed on the 2053e, the ‘Lab
Name for TB’ field must be filled out), and ‘Lab Name for Syphilis’ or ‘Does Not Apply’.
• ‘Date of Medical Exam’ must be a full date.
• ‘Date of Prior Exam’ can be a partial date.
• ‘Date Exam Expires’ must be a full date.

CEAC Medical OMB Package

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DS-2053e: Classification Page
Displayed for all users requiring use of the 2053e form.

• One of the main classification fields must be selected (‘No apparent defect…’, ‘Class A
Condition’, or ‘Class B Condition’).

CEAC Medical OMB Package

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DS-2053e: Lab Findings Page
Displayed for all users requiring use of the 2053e form. Answered ‘Not Done’ to ‘Syphilis
Lab’, no additional fields are displayed.

• The following fields are required: ‘Done’ or ‘Not Done’.

CEAC Medical OMB Package

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DS-2053e: Lab Findings Page
Displayed for all users requiring use of the 2053e form. Answered ‘Done’ to ‘Syphilis Lab’,
the Screening Test fields are displayed.

• VDRL (Venereal Disease Reference Laboratory)
• RPR (Rapid Plasma Reagin)
• Positive
• Negative

• The following fields are required: ‘Done’ or ‘Not Done’.
• If the ‘Result’ field is ‘Positive’ , the ‘Confirmatory Test’ fields will be displayed.
• ‘Date Run’ must be a full date.

CEAC Medical OMB Package

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DS-2053e: Lab Findings Page
Displayed for all users requiring use of the 2053e form. Answered ‘Done’ to ‘Syphilis Lab’
and ‘Positive’ to ‘Screening Test Result’, the Confirmatory Test fields are displayed.

• TPHA (Treponema Pallidum Hemagglutination Assay)
• FTA-ABS (Florscent Treponemal Antibody Absorbed)
• Positive
• Negative

• The following fields are required: ‘Done’ or ‘Not Done’.
• If the ‘Result’ field is ‘Positive’ , the ‘Treatment’ fields will be displayed.
• ‘Date Run’ must be a full date.

CEAC Medical OMB Package

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DS-2053e: Lab Findings Page
Displayed for all users requiring use of the 2053e form. Answered ‘Done’ to ‘Syphilis Lab’ ,
‘Positive’ to ‘Screening Test Result’, and ‘Positive’ to ‘Confirmatory Test Result’ , the
Treatment fields are displayed. Answered ‘No’ to ‘Treatment’, no additional fields are
displayed.

• The following fields are required: ‘Done’ or ‘Not Done’.

CEAC Medical OMB Package

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DS-2053e: Lab Findings Page
Displayed for all users requiring use of the 2053e form. Answered ‘Done’ to ‘Syphilis Lab’ ,
‘Positive’ to ‘Screening Test Result’, and ‘Positive’ to ‘Confirmatory Test Result’ , the
Treatment fields are displayed. Answered ‘Yes’ to ‘Treatment’, additional fields are
displayed.

• The following fields are required: ‘Done’ or ‘Not Done’.
• ‘Date(s) treatment given’ must be full dates.

CEAC Medical OMB Package

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DS-2053e: Immunizations Page
Displayed for all users requiring use of the 2053e form.

• Completed
• Incomplete
• Incomplete, requesting waiver

• Blanket waiver
• Individual waiver

• The user must select one of the options in the ‘Vaccine History’ drop-down.
• If ‘Requesting Waiver’ is selected from ‘Vaccine History’, then one of the options in ‘Waiver
Type’ must be selected.

CEAC Medical OMB Package

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DS-2053e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2053e form.

•
•
•
•
•
•

Isonaizid (INH)
Rifampin
Pyrazinamide
Ethambutol
Streptomycin
Other (Specify)

• The following fields are required: ‘Not Applicable’ or at least one row of medications.
• If there is a medication listed, the following must be filled in:
• Medication
• ‘Currently prescribed’, ‘End Date’, or ‘Unknown’
• ‘Dose’ or ‘Unknown’
• ‘Interval’ or ‘Unknown’
• ‘Start Date’ or ‘Unknown’
• ‘Start Date’, ‘End Date’, and ‘Date’ must be full dates.

CEAC Medical OMB Package

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DS-2053e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2053e form. Answered ‘Not Applicable’, all fields
are disabled.

CEAC Medical OMB Package

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DS-2053e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2053e form. Answered ‘OTHER (SPECIFY)’ to
‘Medication’, ‘Specify other medication’ field is displayed.

CEAC Medical OMB Package

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DS-2053e: Upload Photo Page
Displayed for all users requiring use of the 2053e form.

CEAC Medical OMB Package

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DS-2053e: Upload Photo Page
Displayed for all users requiring use of the 2053e form.

CEAC Medical OMB Package

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DS-2053e: Signature Page
Displayed for all users requiring the use of the 2053e form. Only users logged in as a Panel
Physician can sign the page.

• The form cannot be signed unless the 3024, 3025, and 3026 have been signed.

CEAC Medical OMB Package

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DS-2053e: Signature Page
Displayed after the panel physician has signed the 2053e form.

CEAC Medical OMB Package

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