DS-5518-E Online Medical Examination

User Interface
Design Presentation
CEAC Medical OMB
Submission
Part 3

March 17, 2011

Bureau of Consular Affairs
Consular Systems and Technology

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

1

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

2

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

3

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

4

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

5

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

6

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

7

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

8

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

9

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

10

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

11

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

12

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

13

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

14

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

15

DS-3025e: Getting Started Page
Displayed for all users.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

16

DS-3025e: Personal Information Page
Displayed for all users.

• The following fields are required: ‘Surname’, ‘Given Name’, ‘Sex’, ‘Exam Date’, ‘Date of
Birth’, ‘Passport Number’ or ‘Did Not Provide’, ‘A Number’ or ‘Did Not Provide’, ‘Case
Number’ or ‘Did Not Provide’.
• ‘Date of Birth’ can be a partial date for refugee applicants; it must be a full date for all other
applicant types.
• ‘Exam Date’ must be a full date.

CEAC Medical OMB Package

17

DS-3025e: Immunization Record Page 1
Displayed for all users. ‘Completed Series’ selected for all immunizations, no additional
fields are displayed.

• DT
• DTP
• DTap

• If a ‘Vaccination Type’ is selected, at least one vaccination date must be filled in.
• For all applicants other than refugees, all immunizations must have at least one date filled
in.
• ‘Immunization Dates’ can be partial dates.
• ‘Given by Panel Physician’ must be a full date.
CEAC Medical OMB Package

18

DS-3025e: Immunization Record Page 1
Displayed for all users. ‘Immune’ selected for all immunizations, additional fields are
displayed.

• ‘Lab Test Date’ must be a full date.
CEAC Medical OMB Package

19

DS-3025e: Immunization Record Page 1
Displayed for all users. ‘Blanket waiver(s) requested’ selected for all immunizations,
additional fields are displayed.

CEAC Medical OMB Package

20

DS-3025e: Immunization Record Page 2
Displayed for all users. ‘Completed series’ selected for all immunizations, no additional
fields are displayed.

• Td
• Tdap

• If a ‘Vaccination Type’ is selected, at least one vaccination date must be filled in.
• For all applicants other than refugees, all immunizations must have at least one date filled
in.
• ‘Immunization Dates’ can be partial dates.
• ‘Given by Panel Physician’ must be a full date.

CEAC Medical OMB Package

21

DS-3025e: Immunization Record Page 2
Displayed for all users. ‘Immune’ selected for all immunizations, additional fields are
displayed.

• ‘Lab Test Date’ must be a full date.

CEAC Medical OMB Package

22

DS-3025e: Immunization Record Page 2
Displayed for all users. ‘Blanket waiver(s) requested’ selected for all immunizations,
additional fields are displayed.

CEAC Medical OMB Package

23

DS-3025e: Immunization Record Page 3
Displayed for all users. Answered ‘Yes’ to ‘TST Completed’ and ‘Completed series’ is
selected for all immunizations, no additional fields are displayed.

• OPV
• IPV

•
•
•
•
•
•

MMR
Measles
Mumps
Rubella
Measles-Rubella
Mumps-Rubella

• If a ‘Vaccination Type’ is selected, at least one vaccination date must be filled in.
• For all applicants other than refugees, all immunizations must have at least one date filled
in.
• ‘Immunization Dates’ can be partial dates.
• ‘Given by Panel Physician’ must be a full date.
CEAC Medical OMB Package

24

DS-3025e: Immunization Record Page 3
Displayed for all users. Answered ‘No’ to ‘TST Completed’ and ‘Completed series’ is
selected for all immunizations except ‘Varicella’ where ‘Varicella history’ is selected, no
additional fields are displayed.

CEAC Medical OMB Package

25

DS-3025e: Immunization Record Page 3
Displayed for all users. ‘Immune’ selected for all immunizations, additional fields are
displayed.

• ‘Lab Test Date’ must be a full date.
CEAC Medical OMB Package

26

DS-3025e: Immunization Record Page 3
Displayed for all users. ‘Blanket waiver(s) requested’ selected for all immunizations,
additional fields are displayed.

CEAC Medical OMB Package

27

DS-3025e: Results Page
Displayed for all users.

• One of the fields must be selected.
• If ‘Vaccine history incomplete’ is selected, one of the additionally displayed fields must be
selected.

CEAC Medical OMB Package

28

DS-3025e: Signature Page
Displayed for all users. Only users logged in as a Panel Physician can sign the page.

CEAC Medical OMB Package

29

DS-3025e: Signature Page
Displayed after the panel physician has signed the 3025e form.

CEAC Medical OMB Package

30

DS-3026e: Getting Started Page
Displayed for all users.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

31

DS-3026e: Personal Information Page
Displayed for all users.

• The following fields are required: ‘Surname’, ‘Given Name’, ‘Sex’, ‘Exam Date’ ‘Date of
Birth’, ‘Passport Number’ or ‘Did Not Provide’, ‘A Number’ or ‘Did Not Provide’, ‘Case
Number’ or ‘Did Not Provide’.
• ‘Date of Birth’ can be a partial date for refugee applicants; all other applicant types must
have a full date.
• ‘Exam Date’ must be a full date.

CEAC Medical OMB Package

32

DS-3026e: Medical History Page
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

• The following fields are required: ‘Yes’ or ‘No’ for every field.
• ‘Last menstrual period date’ can be a partial date.
CEAC Medical OMB Package

33

DS-3026e: Medical History Page, Top
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

CEAC Medical OMB Package

34

DS-3026e: Medical History Page, Middle
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

CEAC Medical OMB Package

35

DS-3026e: Medical History Page, Bottom
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

CEAC Medical OMB Package

36

DS-3026e: Medical History Page
Displayed for all users. Answered all questions ‘Yes’, additional fields are enabled.

• If ‘Yes’ for ‘History of Tuberculosis’, then ‘Treated’ or ‘Current TB symptoms’ must be
selected.
• If ‘Yes’ for ‘Pregnancy’, then ‘Last menstrual period date’ must be answered.
• If ‘Yes’ for ‘Hansen’s Disease’, then ‘Multibacillary’ or ‘Paucibacillary’ must be selected.
CEAC Medical OMB Package

37

DS-3026e: Medical History Page, Top
Displayed for all users. Answered all questions ‘Yes’, additional fields are enabled.

CEAC Medical OMB Package

38

DS-3026e: Medical History Page, Middle
Displayed for all users. Answered all questions ‘Yes’, additional fields are enabled.

CEAC Medical OMB Package

39

DS-3026e: Medical History Page, Bottom
Displayed for all users. Answered all questions ‘Yes’, additional fields are enabled.

CEAC Medical OMB Package

40

DS-3026e: Physical Examination Page
Displayed for all users. Answered ‘No’ to ‘Applicant appears…’, no additional fields are
enabled.

• The following fields are required: ‘Normal’, ‘Abnormal’, or ‘Not done’ must be selected.
CEAC Medical OMB Package

41

DS-3026e: Physical Examination Page
Displayed for all users. Answered ‘Yes’ to ‘Applicant appears…’, the ‘Specify’ field is
enabled.

• The following fields are required: ‘Normal’, ‘Abnormal, or ‘Not done’ must be selected.
CEAC Medical OMB Package

42

DS-3026e: Physical Examination Page, Top
Displayed for all users. Answered ‘Yes’ to ‘Applicant appears…’, the ‘Specify’ field is
enabled.

CEAC Medical OMB Package

43

DS-3026e: Physical Examination Page, Bottom
Displayed for all users.

CEAC Medical OMB Package

44

DS-3026e: Additional Testing Needed Prior to
Approving Medical Clearance Page
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

• The following fields are required: ‘Yes’ or ‘No’ for every field.

CEAC Medical OMB Package

45

DS-3026e: Additional Testing Needed Prior to
Approving Medical Clearance Page
Displayed for all users. Answered all questions ‘Yes’, the ‘Provide results’ field is enabled.

CEAC Medical OMB Package

46

DS-3026e: Follow-up Needed After Arrival Page
Displayed for all users. Answered all questions ‘No’, no additional fields are enabled.

• The following fields are required: ‘Yes’ or ‘No’ for every field.

CEAC Medical OMB Package

47

DS-3026e: Follow-up Needed After Arrival Page
Displayed for all users. Answered all questions ‘Yes’, additional fields are enabled.

• If ‘Yes’ is selected for ‘Follow-up needed after arrival’, then a time period must also be
selected. Only one time period may be selected.

CEAC Medical OMB Package

48

DS-3026e: Remarks Page
Displayed for all users.

CEAC Medical OMB Package

49

DS-3026e: Signature Page
Displayed for all users. Only users logged in as a Panel Physician can sign the page.

CEAC Medical OMB Package

50

DS-3026e: Signature Page
Displayed after the panel physician has signed the 3026e form.

CEAC Medical OMB Package

51