DS-5518-E Online Medical Examination

User Interface
Design Presentation
CEAC Medical OMB
Submission
Part 4

March 17, 2011

Bureau of Consular Affairs
Consular Systems and Technology

DS-3030e: Getting Started Page
Displayed for all users requiring use of the 3030e form.

• The user selects the ‘Continue’ button.

CEAC Medical OMB Package

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DS-3030e: Personal Information Page
Displayed for all users requiring use of the 3030e form.

• The following fields are required: ‘Surname’, ‘Given Name’, ‘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.

CEAC Medical OMB Package

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DS-3030e: Chest X-Ray Indication Page
Displayed for all users requiring use of the 3030e form. Page enabled for radiologists, readonly for panel physicians.

CEAC Medical OMB Package

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DS-3030e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3030e form. Page enabled for radiologists, readonly for panel physicians.

• Normal
• Abnormal

• The following fields are required: ‘Findings’ must be answered either ‘Normal’ or
‘Abnormal’.
• ‘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-3030e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3030e form. Answered ‘NORMAL FINDINGS’ to
‘Findings’, no additional fields are displayed. Page enabled for radiologists, read-only for
panel physicians.

CEAC Medical OMB Package

5

DS-3030e: Chest X-Ray Findings Page
Displayed for all users requiring use of the 3030e form. Answered ‘ABNORMALFINDINGS’
to ‘Findings’, additional fields are displayed. Page enabled for radiologists, read-only for
panel physicians.

CEAC Medical OMB Package

6

DS-3030e: Chest X-Ray Findings Page, Top
Displayed for all users requiring use of the 3030e form. Answered ‘ABNORMAL FINDINGS’
to ‘Findings’, additional fields are displayed. Page enabled for radiologists, read-only for
panel physicians.

CEAC Medical OMB Package

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DS-3030e: Chest X-Ray Findings Page, Bottom
Displayed for all users requiring use of the 3030e form. Answered ‘ABNORMAL FINDINGS’
to ‘Findings’, additional fields are displayed. Page enabled for radiologists, read-only for
panel physicians.

CEAC Medical OMB Package

8

DS-3030e: Sputum Smears Page
Displayed for all users requiring use of the 3030e form.

CEAC Medical OMB Package

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DS-3030e: Sputum Smears Page
Displayed for all users requiring use of the 3030e form. Answered ‘Yes, Applicant has…’ to
‘Sputum Smear Findings’, additional fields are displayed.

• Positive
• Negative

• Positive
• Negative

• If the answer to ‘Applicant has signs or symptoms’ is ‘Yes’, at least one of the ‘Applicant
has…’ choices, ‘Smear 1’, ‘Smear 2’, ‘Smear 3’, ‘Culture 1’, ‘Culture 2’, ‘Culture 3’, and a
classification must be selected. The results and dates must be selected for smears and
cultures.
• All ‘Date Specimen Obtained’ fields must be full dates.
CEAC Medical OMB Package

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DS-3030e: Sputum Smears Page
Displayed for all users requiring use of the 3030e form. Answered ‘Yes, Applicant has…’ to
‘Sputum Smear Findings’ and ‘Positive’ to ‘Sputum Smears’ or ‘Sputum Cultures’, the
‘Positive Smear or Culture, or Clinical Judgment: this is Class A TB’ field is enabled.

CEAC Medical OMB Package

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DS-3030e: Sputum Smears Page
Displayed for all users requiring use of the 3030e form. Answered ‘Yes, Applicant has…’ to
‘Sputum Smear Findings’ and ‘Negative Smear and Culture Results and…’ field additional
fields are enabled.

CEAC Medical OMB Package

12

DS-3030e: Sputum Smears Page
Displayed for all users requiring use of the 3030e form. Answered ‘No, Applicant has…’ to
‘Sputum Smear Findings’, additional fields are displayed.

• One of the classifications must be selected if the answer to ‘Applicant has signs or
symptoms’ is ‘No’.

CEAC Medical OMB Package

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DS 3030e: Classifications Page
Displayed for all users requiring use of the 3030e form.

• At least one of the classifications must be selected.

CEAC Medical OMB Package

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DS-3030e: Remarks Page
Displayed for all users requiring use of the 3030e form.

CEAC Medical OMB Package

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DS-3030e: Signature Page
Displayed for all users. 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

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DS-3030e: Signature Page
Displayed after the panel physician has signed the 3030e form.

CEAC Medical OMB Package

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Final Validation
Displayed when the user goes to the Submit tab from the top toolbar. Changes to forms are
needed before proceeding to the signature.

CEAC Medical OMB Package

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Final Validation
Displayed when the user goes to the Submit tab from the top toolbar. Changes are not
needed to the forms before proceeding to the signature.

CEAC Medical OMB Package

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Final Signature
Displayed after the final validation. Only a user logged in as a panel physician can sign.

CEAC Medical OMB Package

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Final Signature
Displayed after the panel physician has signed the final signature page.

CEAC Medical OMB Package

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Change Your Password Page

CEAC Medical OMB Package

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Change Password Complete Message Page

CEAC Medical OMB Package

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Forgot Password Page

CEAC Medical OMB Package

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Identity Confirmation Page

CEAC Medical OMB Package

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Password Sent Notification Page

CEAC Medical OMB Package

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Change Secret Question Page

CEAC Medical OMB Package

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Change Secret Question Page

• The security questions available are:
• What is the first name of your mother’s mother?
• What is the first name of your father’s father?
• What is your maternal grandmother’s maiden name?
• What name did your family used to call you when you were a child?
• In what city did you meet your spouse/significant other?
• What is the name of your favorite childhood friend?
• What street did you live on when you were 8 years old?
• What is your oldest sibling’s birthday month and year? (E.G. JANUARY 1900)
• What is the middle name of your youngest child?
• What is your oldest sibling’s middle name?
• What school did you attend when you were 11 years old?
• What was your home phone number when you were a child?
• What is your oldest cousin’s first and last name?
• What was the name of your favorite stuffed animal or toy?
• In what city or town did your mother and father meet?
• What was the last name of your favorite teacher?
• In what city does your nearest sibling live?
• What is your youngest sibling’s birthday month and year? (E.G. JANUARY 1900)
• In what city or town was your first job?
• What was the name of your first boyfriend or girlfriend?

CEAC Medical OMB Package

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Account Details Page

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Copyright Page

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Disclaimer Page

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Paperwork Reduction Act and Confidentiality
Statement Page

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