DS-2053 Medical Examination for Immigrant or Refugee Applicant

Photo
			Name (Last, First, MI) , , Birth Date (mm-dd-yyyy) Sex: M F Birthplace (City/Country) / Present Country of Residence Prior Country U.S. Consul (City/Country) /
Passport Number Alien (Case) Number Date (mm-dd-yyyy) of Medical Exam Date (mm-dd-yyyy) of Prior Exam, if any Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy) Exam Place (City/Country) / Panel Physician (name) Radiology Services (name) Screening Site (name) Lab (name for syphilis/TB) /
(1) Classification (check all boxes that apply): No apparent defect, disease, or disability (see Worksheets DS-3024, DS-3025 and DS-3026)
Class A Conditions (From Past Medical History and Physical Examination Worksheets) TB, active, infectious (Class A, from Chest X-Ray Worksheet) Hansen's disease, untreated multibacillary Syphilis, untreated Addiction or abuse of specific* substance Chancroid, untreated Any physical or mental disorder (including other Gonorrhea, untreated substance-related disorder) with harmful behavior or history of such behavior likely to recur Granuloma inguinale, untreated Lymphogranuloma venereum, untreated *amphetamines, cannabis, cocaine, hallucinogens, opioids, phencyclidines, sedative-hypnotics, and anxiolytics
Class B Conditions (From Past Medical History and Physical Examination Worksheets) TB, active, noninfectious (Class B1, from Chest X-Ray Worksheet) Hansen's disease, treated multibacillary Treatment: None Partial Completed Treatment: Partial Completed Hansen's disease, paucibacillary TB, inactive (Class B2, from Chest X-Ray Worksheet) Treatment: None Partial Completed Treatment: None Partial Completed Sustained, full remission of addiction or abuse of specific* See Section 4 on page 2 for TB treatment details substances Any physical or mental disorder (excluding addiction or abuse of Syphilis (with residual deficit), treated within the last year specific* substance but including other substance-related disorder) without harmful behavior or history of such behavior unlikely to recur Current pregnancy, number of weeks pregnant *amphetamines, cannabis, cocaine, hallucinogens, opioids, phencyclidines, sedative-hypnotics, and anxiolytics Other (specify or give details on checked conditions from worksheets)
(2)	Laboratory Findings (check all boxes that apply): Syphilis: Not done
	Screening Confirmatory	Test name		Date(s) run (mm-dd-yyyy)	Negative	Positive		Titer 1	Notes
	Treated Yes No	If treated, therapy: Benzathine penicillin, 2.4 MU IM Other (therapy, dose):E					Date(s) treatment given (3 doses for penicillin)

U. S. Department of State

MEDICAL EXAMINATION FOR IMMIGRANT OR REFUGEE APPLICANT For use with TB Technical Instructions 1991 and the DS-3024

OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

ESTIMATED BURDEN: 10 minutes

(See Page 2 - Back of Form)

DS-2053

08-2011

(Formerly OF-157)

Page 1 of 2

_{(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.}

_{Vaccine history complete}

Vaccine history incomplete, requesting waiver (indicate type below)

_{Incomplete vaccine history, no waiver requested} ^{Blanket waiver Individual waiver}

_{I certify that I understand the purpose of the medical examination and I authorize the required tests to be completed.}

_{Applicant Signature Panel Physician Signature Date (mm-dd-yyyy)}

(4) Tuberculosis Treatment Regimen

(Fill out if applicant has taken in the past, or is now taking TB medication. If drug doses or dates not

known or not available, mark "unknown".)

_{Check if therapy currently prescribed (if current, don't mark "End Date")}

Medication

Isonaizid (INH) Rifampin Pyrazinamide Ethambutol

_Streptomycin

Dose/Interval

(i.e., mg/day)

Start Date

(mm-dd-yyyy)

End Date

(mm-dd-yyyy)

_{Other, specify}

_{Applicant's pre-treatment weight (kg)}

_{Date (mm-dd-yyyy)}

_Remarks

_{PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS}

PAPERWORK REDUCTION ACT STATEMENT

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: [email protected]

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 States 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, in the discretion of the Secretary of State, 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. More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.

DS-2053 ^{Page 2 of 2}