DS-3025 Vaccination Documentation Worksheet

U.S. Department of State

VACCINATION DOCUMENTATION WORKSHEET

Photo

To Be Completed by Panel Physician Only
For US Vaccination Requirements

OMB No. 1405-0113
EXPIRATION DATE: XX/XX/XXXX
ESTIMATED BURDEN: 20 minutes
(See Page 2 of 2)

GIVE COPY TO APPLICANT
Surnames

Given Names

Document Type

Birth Date (mm-dd-yyyy) Exam Date (mm-dd-yyyy)

Document Number

Vaccine
Given By
Panel
Site

1. Vaccination Record
Vaccine History Transferred From a Written Record
List Chronologically from Left to Right. Provide date as mm-dd-yyyy
Vaccine
Diphtheria, tetanus, pertussis
DTP, DTaP

Date

Date

Date

Case or Alien Number

Date

Date

For Designated
Refugees Only:
Additional Vaccine
Given by Panel Site*
Date

Test for
Immunity
Positive

Date

Date

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

DT
Td
Tdap
Polio
OPV
IPV
Measles, mumps, rubella
MMR
Measles
Mumps
Rubella
Rotavirus
RotaTeq (RV5)
Rotarix (RV1)
Hib
Hepatitis A
Hepatitis B
Meningococcal
MCV4
Other MCV conjugate
Varicella
Vaccine

Varicella History

Pneumococcal
PCV 7
PCV 10
PCV 13
PPSV 23
Influenza
Other
2. Vaccination Documentation
(Mark one)
Immigrant Visa or Parolee applicant
completed vaccination requirements
K Visa applicant voluntarily
completed vaccination requirements

Immigrant Visa applicant refuses vaccination (Class A)
Immigrant Visa applicant requested Adoptee Exemption
Immigrant Visa applicant requests Individual Waiver based on religious or moral convictions
Refugee or follow to join Asylee/Refugee (V92/93) applicant not required to meet vaccination requirements
K Visa applicant electing not to be vaccinated at this examination
Other NIV applicant not required to meet vaccination requirements

Panel Physician signature

3. Panel Physician Name (printed)

Date (mm-dd-yyyy)

I attest I performed this examination or supervised completion of this form and have an
agreement with the Department of State.
* Only for designated refugees enrolled in the
Vaccination Program for U.S.-bound Refugees
Refugee declines to receive vaccinations

DS-3025
05-2017

Blanket waiver legend: A Not age appropriate B Insufficient time interval to complete series
C Contraindicated D Not routinely available F Flu vaccine not available H Known chronic hepatitis B
virus infection

Please complete Page 2

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4. Contraindications to vaccination
If a vaccination was contraindicated, mark which contraindications were present (mark all that apply)
Current pregnancy
Immune compromised
History of severe allergic reaction to vaccine or vaccine component
Other severe reaction to vaccine
Current moderate to severe illness
Other, specify:
5. Remarks

6. Panel Physician Initials

Date (mm-dd-yyyy)

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average 20 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
INA Section 222(f) provides that visa issuance and refusal records 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. The
U.S. Department of State uses the information provided on this form to determine an individual's eligibility for a U.S. visa. Certified
copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a
case pending before the court. 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. Although furnishing this information is voluntary,
individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. visa or experience
processing delays.
DS-3025

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