Form DS-3025 Vaccination Documentation Worksheet

Medical Examination for Immigrant or Refugee Applicant

DS 3025 Paper Form (7-2014)

Medical Examination for Immigrant or Refugee Applicant

OMB: 1405-0113

Document [docx]
Download: docx | pdf


Name (Last, First, MI.)

Birth Date (mm-dd-yyyy)

Exam Date (mm-dd-yyyy)

Blanket Waiver(s) To Be Requested If Vaccination Not Medically Appropriate.

Indicate reason below.

Mark all that apply (see legend):

A, B, C D, F, H

Passport Number

Alien (Case) Number

1. Immunization Record

Vaccine History Transferred From a Written Record

List Chronologically from Left to Right. Provide date as mm-dd-yyyy

Vaccine Given by Panel Site

For Designated Refugees Only: Additional Vaccine Given by IOM*



Test for Immunity

Vaccine

Date

Date

Date

Date

Date

Date

Date

Date

Diphtheria, tetanus, pertussis

Shape1
































DT, DTP, DTaP










Shape2
































Td










Shape3
































Tdap










Polio

Shape4
































OPV











Shape5
































IPV










Measles, mumps, rubella

Shape6
































MMR











Shape7
































Measles











Shape8
































Mumps











Shape9
































Rubella











Rotavirus

Shape10
































RotaTeq (RV5)










Shape11
































Rotarix (RV1)










Hib










Hepatitis A










Hepatitis B










Meningococcal

Shape12
































MCV4











Shape13
































Other MCV conjugate










Varicella

Shape14
































Vaccine











Shape15
































Varicella history










Pneumococcal

Shape16
































PCV 7











Shape17
































PCV 10











Shape18
































PCV 13











Shape19
































PPSV 23










Influenza










Other










2. Summary for Immigrant Visa Applicants


Shape20
































US vaccination requirements COMPLETE

(Requesting a Blanket Waiver)





US vaccination requirements NOT Complete:

Shape21
































Requesting Individual Waiver based on religious or moral convictions

Shape22
































Requesting Adoptee Exemption

Shape23
































Applicant refuses vaccinations


3. Panel Physician Name (printed)

Shape24

I attest I performed this examination and have an agreement with the Department of State or supervised completion of this form. I am the same Panel Physician that signs the DS 2054.

Panel Physician signature

Date (mm/dd/yyyy)

Shape26 Shape25

Please complete Page 2

DS-3025

08-2011

* Only for designated refugees in special IOM vaccination program

Blanket waiver legend: A Not age appropriate B Insufficient time interval to complete series

C Contraindicated D Not routinely available F Not flu season H Known chronic hepatitis B virus infection

Shape29 Shape27 Shape30 Shape31 Shape32 Shape28

Page 1 of 2

DRAFT6

U.S. Department of State

VACCINATION DOCUMENTATION WORKSHEET

To Be Completed by Panel Physician Only

For US Vaccination Requirements

GIVE COPY TO APPLICANT



OMB No. 1405-0113

EXPIRATION DATE: xx/xx/xxxx

ESTIMATED BURDEN: 30 minutes

(See Page 2 of 2)




Photo



4. Contraindication to vaccination

If a vaccination was contraindicated, mark which contraindication were present (mark all that apply)

Shape33

Page 2 of 2


Shape34
































Pregnant

Shape35
































Immune compromised

Shape36
































History of severe allergic reaction to vaccine or vaccine component

Shape37 Shape38
































DS-3025

08-2011

Other severe reaction to vaccine

Shape39
































Current moderate to severe illness

Shape41 Shape40































Other, specify:

5. Remarks

Shape46 Shape45 Shape44 Shape43 Shape42


5. Panel Physician Initials

Date (mm/dd/yyyy)

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 30 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.


Shape47

DRAFT6



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy