DS-3024 Chest X-Ray and Classification Worksheet

U.S. Department of State

CHEST X-RAY AND CLASSIFICATION WORKSHEET

^{For use with TB TI 1991 and the DS-2053} _{Complete Sections 1 through 5, As Applicable}

OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

ESTIMATED BURDEN: 10 MINUTES (See Page 2 - Back of Form)

Name (Last, First, MI.)							Age
Birth Date (mm-dd-yyyy)		Passport Number				Alien (Case) Number
1. Chest X-Ray Indication (Mark all that apply) History of Tuberculosis (TB) Disease TB Signs or Symptoms Contact with Person with TB Adult (With or without any of the other indications) (If child does not have any of the above, stop here.)
2. Chest X-Ray Findings Date Chest X-Ray Taken (mm-dd-yyyy) Normal Findings Abnormal Findings (Indicate category and finding, checking all that apply, in the table below.) Can Suggest ACTIVE TB Can Suggest INACTIVE TB OTHER X-Ray Findings (Need smears) (Need smears if symptomatic) Infiltrate or consolidation Discrete fibrotic scar or linear opacity Follow-Up Needed (Mark as "Class B (fibrotic scar) Other") Any cavitary lesion Discrete nodule(s) without calcification Nodule or mass with poorly defined margins Musculoskeletal (such as tuberculoma) Discrete linear opacity (fibrotic scar) with Cardiac Pleural effusion* volume loss or retraction Hilar/mediastinal adenopathy with or without Other (Such as bronchiectasis) Pulmonary, non-TB (e.g., emphysema) atelectasis Other Other (Such as miliary findings) No Follow-Up Needed for * If unclear whether pleural fluid or Pleural thickening, diaphragmatic tenting, thickening, perform lateral or decubitus calcified pulmonary nodule(s), calcified lymph chest radiograph, or targeted ultrasound. node(s), calcified lymph nodes with calcified pulmonary nodule(s), or minor Remarks musculoskeletal findings Radiologist's Signature Date Interpreted (mm-dd-yyyy)
3. Sputum Smears No, Applicant has No Signs or Symptoms of TB and : X-Ray Suggests INACTIVE TB, this is a Class B2/TB OTHER X-Ray Findings Suggest Follow-Up Needed after Arrival, this is B Other OTHER X-Ray Findings Suggest No Follow-Up Needed, this is No Class X-Ray Normal, this is No Class Yes, Applicant has (Mark all that apply) : and Smear Results are: Positive Negative Dates Obtained (mm-dd-yyyy) Signs or Symptoms of TB, See Section 1 X-Ray Suggests ACTIVE TB, See Section 2
Sputum Smear Results and X-Ray: At least One Smear Result POSITIVE and Any Chest X-Ray Finding (Normal or Abnormal findings), this is Class A/TB			Three Smear Results NEGATIVE and X-Ray Normal with Signs or Symptoms Resolved, this is No Class Signs or Symptoms Suggest Follow-Up Needed after Arrival, this is B Other
					X-Ray Suggests ACTIVE or INACTIVE TB, this is Class B1/TB OTHER X-Ray Findings Suggest Follow-Up Needed After Arrival, this is Class B Other
4. No Class Class A/TB Class B1/TB Class B2/TB Class B Other
5.	Follow-Up Needed After Arrival No Yes If Yes, for Not TB Condition TB Condition (If non-TB condition, specify condition below and on DS-2053 form; include additional tests, and therapy used with start and stop dates and any Remarks changes. If TB condition, enter information in Part 4 of DS-2053 form.)

DS-3024

05-2009

Page 1 of 2

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

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 State 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

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