DS-5518-E Online Medical Examination

User Interface
Design Presentation
CEAC Medical OMB
Submission
Part 2

March 17, 2011

Bureau of Consular Affairs
Consular Systems and Technology

DS-2054e: Getting Started Page
Displayed for all users requiring use of the 2054e form.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

1

DS-2054e: Personal Information Page
Displayed for all users requiring use of the 2054e 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; it must be a full date for all other
applicant types.
CEAC Medical OMB Package

2

DS-2054e: Medical Exam Information Page
Displayed for all users requiring use of the 2054e 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 2054e, 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

3

DS-2054e: Classification Page
Displayed for all users requiring use of the 2054e form.

• One of the main classification fields must be selected (‘No apparent defect…’, ‘Class A
Condition’, or ‘Class B Condition’).
• If ‘Class B Condition’ is selected, either a field under the general ‘Class B Condition’ must
be selected, or one of the sub-B classifications must be selected.
CEAC Medical OMB Package

4

DS-2054e: Classification Page, Top
Displayed for all users requiring use of the 2054e form.

CEAC Medical OMB Package

5

DS-2054e: Classification Page, Bottom
Displayed for all users requiring use of the 2054e form.

CEAC Medical OMB Package

6

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e form.

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

CEAC Medical OMB Package

7

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e form. Answered ‘Not Done’ to ‘Syphilis’
and ‘TST’ to ‘Test for Cell-Mediated Immunity to TB’.

• The following fields are required: ‘Done’ or ‘Not Done’.
• If ‘TST’ is selected, the ‘TST Result’ and ‘Date Applied’ fields are displayed.
• ‘Date Applied’ must be a full date.

CEAC Medical OMB Package

8

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e form. Answered ‘Not Done’ to ‘Syphilis’
and ‘IGRA’ to ‘Test for Cell-Mediated Immunity to TB’.

• Positive
• Negative
• Indeterminate, Borderline, Equivocal

• The following fields are required: ‘Done’ or ‘Not Done’.
• If ‘IGRA’ is selected, the ‘Name of IGRA Test’, ‘Date drawn’, ‘Nil Value’, ‘TB Response
Interpretation’, and ‘IGRA Result’ fields are displayed.
• ‘Date drawn’ must be a full date.

CEAC Medical OMB Package

9

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e form. Answered ‘Done’ to ‘Syphilis’.

• 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

10

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e form. Answered ‘Done’ to ‘Syphilis’ 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

11

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e 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

12

DS-2054e: Laboratory Findings Page
Displayed for all users requiring use of the 2054e 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

13

DS-2054e: Immunizations Page
Displayed for all users requiring use of the 2054e 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 ‘Incomplete, requesting waiver’ is selected from ‘Vaccine History’, then one of the
options in ‘Waiver Type’ must be selected.

CEAC Medical OMB Package

14

DS-2054e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2054e 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

15

DS-2054e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2054e form. Answered ‘Not Applicable’, all fields
are disabled.

CEAC Medical OMB Package

16

DS-2054e: TB Treatment Regimen Page
Displayed for all users requiring use of the 2054e form. Answered ‘Other (specify)’ to
‘Medication’, ‘Specify other medication’ field is displayed.

CEAC Medical OMB Package

17

DS-2054e: Upload Photo Page
Displayed for all users requiring use of the 2054e form.

CEAC Medical OMB Package

18

DS-2054e: Upload Photo Page
Displayed for all users requiring use of the 2054e form.

CEAC Medical OMB Package

19

DS-2054e: Signature Page
Displayed for all users requiring the use of the 2054e form. Only users logged in as a Panel
Physician can sign the page.

• The form cannot be signed unless the 3030, 3025, and 3026 have been signed.

CEAC Medical OMB Package

20

DS-2054e: Signature Page
Displayed after the panel physician has signed the 2054e form.

CEAC Medical OMB Package

21

DS-3024e: Getting Started Page
Displayed for all users requiring use of the 3024e form.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

22

DS-3024e: Personal Information Page
Displayed for all users requiring use of the 3024e form.

• The following fields are required: ‘Surname’, ‘Given Name’, ‘Date of Birth’, ‘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; must be a full date for all other
applicant types.

CEAC Medical OMB Package

23

DS-3024e: Chest X-Ray Indication Page
Displayed for all users requiring use of the 3024e form.

• If the applicant’s age is 15 or over, the ‘Adult’ field must be selected.

CEAC Medical OMB Package

24

DS-3024e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3024e form.

• Normal
• Abnormal

• The user must select either ‘Normal’ or ‘Abnormal’ from ‘Findings’.
• ‘Date Chest X-Ray Taken’ must be a full date.
• For the radiologist to sign, both the ‘Chest X-Ray Indication’ and ‘Chest X-Ray Findings’
pages must be completed.

CEAC Medical OMB Package

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DS-3024e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3024e form. Answered ‘Normal Findings’ to
‘Findings’, no additional fields are displayed.

CEAC Medical OMB Package

26

DS-3024e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3024e form. Answered ‘Abnormal Findings’ to
‘Findings’, additional fields are displayed.

• If ‘Abnormal’ is selected, at least one of the following must be selected as ‘Yes’: ‘Can
suggest Active TB’, ‘Can suggest Inactive TB’, or ‘Other Findings’.
• All fields in the selected area must be answered ‘Yes’ or ‘No’.
CEAC Medical OMB Package

27

DS-3024e: Chest X-Ray Findings Page, Top
Displayed for all users requiring use of the 3024e form. Answered ‘Abnormal Findings’ to
‘Findings’, additional fields are displayed.

CEAC Medical OMB Package

28

DS-3024e: Chest X-Ray Findings Page, Bottom
Displayed for all users requiring use of the 3024e form. Answered ‘Abnormal Findings’ to
‘Findings’, additional fields are displayed.

CEAC Medical OMB Package

29

DS-3024e: Sputum Smears Page
Displayed for all users requiring use of the 3024e form.

• The user must select either ‘Yes’ or ‘No’ for ‘Applicant has signs or symptoms of TB’.

CEAC Medical OMB Package

30

DS-3024e: Sputum Smears Page
Displayed for all users requiring use of the 3024e form. Answered ‘Yes, Applicant has’ to
‘Sputum Smear Findings’.

• Positive
• Negative

• If ‘Yes’ is selected to ‘Applicant has signs or symptoms of TB’, the following fields must be
filled in:
• ‘Smear 1 Result’ and ‘Date Specimen Obtained’
• ‘Smear 2 Result’ and ‘Date Specimen Obtained’ or ‘Does Not Apply’
• ‘Smear 3 Result’ and ‘Date Specimen Obtained’ or ‘Does Not Apply’
• ‘Date Specimen Obtained’ must be a full date.

CEAC Medical OMB Package

31

DS-3024e: Sputum Smears Page
Displayed for all users requiring use of the 3024e form. Answered ‘Yes, Applicant has’ to
‘Sputum Smear Findings’ and at least one of the ‘Sputum Smear Results’ is ‘Positive’, an
additional field is enabled.

• If one of the smear results is ‘Positive’, the user should select the ‘Any Chest X-Ray
Finding’ field.

CEAC Medical OMB Package

32

DS-3024e: Sputum Smears Page
Displayed for all users requiring use of the 3024e form. Answered ‘Yes, Applicant has’ to
‘Sputum Smear Findings’ and all three of the ‘Sputum Smear Results’ are ‘Negative’,
additional fields are enabled.

• If all three of the smear results are ‘Negative’, the user should select the appropriate
classification.

CEAC Medical OMB Package

33

DS-3024e: Sputum Smears Page
Displayed for all users requiring use of the 3024e form. Answered ‘No, Applicant has’ to
‘Sputum Smear Findings’, additional fields are displayed.

• If ‘No’ is selected for ‘Applicant has signs or symptoms of TB’, the user should select the
appropriate classification.

CEAC Medical OMB Package

34

DS-3024e: Classifications Page
Displayed for all users requiring use of the 3024e form.

• At least one classification must be selected.

CEAC Medical OMB Package

35

DS-3024e: Follow-Up Page
Displayed for all users requiring use of the 3024e form.

• No follow-up needed
• Needed for TB Condition
• Needed for non-TB Condition

• The user must select one of the options from the ‘Follow-up Needed After Arrival?’ dropdown.

CEAC Medical OMB Package

36

DS-3024e: Signature Page
Displayed for all users requiring the use of the 3024e form. Only users logged in as a Panel
Physician can sign the page.

• Before signing, verify that the applicant’s age is still below 15 if the adult checkbox was
not selected.
• The radiologist must sign the form before the panel physician can sign the form.

CEAC Medical OMB Package

37

DS-3024e: Signature Page
Displayed after the panel physician has signed the 3024e form.

CEAC Medical OMB Package

38