DS-2054 Medical Examination for Immigrant or Refugee Applicant

U. S. Department of State

OMB No. 1405-0113
EXPIRATION DATE: XX/XX/XXXX
ESTIMATED BURDEN: 10 minutes
(See Page 2 - Back of Form)

REPORT OF MEDICAL EXAMINATION
BY PANEL PHYSICIAN
Photo

Surnames

Given Names

Birth Date (mm-dd-yyyy)

Sex

M
U.S. Consulate/Embassy

Document Type

Document Number

F

Case or Alien Number

Birthplace (City, Country)

Present Country of Residence

Prior Country of Residence

Present Address of Residence

Present City of Residence

Present Postal Code of Residence

Intended US Address

Intended US City

Intended US State

Intended US Postal Code

E-mail Address

Date of Medical Exam (Date of physical exam or date of final TB culture results, if cultures performed) (mm-dd-yyyy)

Date Exam Expires (3 months if Class A TB, or Class B1 TB, otherwise 6 months) (mm-dd-yyyy)

Exam Place of Current Exam (City, Country)

Date of Prior Exam, if any (mm-dd-yyyy)

Panel Physician Performing Exam

Panel Site

Radiology Facility

Sputum Smear Laboratory

Sputum Culture Laboratory

Syphilis Laboratory

Drug Susceptibility Test Laboratory

TB DOT Facility

Gonorrhea Laboratory

Applicant Category
(Mark One)

Immigrant Visa
Immigrant
Special Immigrant (SIV)

Refugee
Refugee

Diversity
Adoptee
1. Classification (Check all boxes that apply)

Follow to join
refugee
(Visa 93)

Asylee
Follow to join
asylee
(Visa 92)

Non-Immigrant Visa (NIV) Parolee
K-Visa
Parolee
Other NIV

No apparent defect, disease, or disability (See Worksheets DS-3025, DS-3026, DS-3030)
Class A Conditions (See Worksheets DS-3025, DS-3026, DS-3030)
Tuberculosis disease (1A1)
Syphilis, untreated (1A1)

Any physical or mental disorder (excluding addiction or abuse of specific substance
on the Controlled Substances Act but including other substance-related disorder)
with harmful behavior or history of such behavior likely to recur (1A3)

Gonorrhea, untreated (1A1)

Addiction or abuse of specific substance on the Controlled Substances Act (1A4)

Hansen's Disease, untreated multibacillary or
paucibacillary (1A1)

Immigrant visa applicant refuses vaccinations (1A2)

Class B Conditions (See Worksheets DS-3025, DS-3026, DS-3030)
Tuberculosis
B1 TB, Pulmonary
B1 TB, Extrapulmonary
B2 TB, LTBI Evaluation
B3 TB, Contact Evaluation
Syphilis, treated within last year
Gonorrhea, treated within last year
DS-2054
05-2017

Hansen's Disease
Multibacillary, treated
Paucibacillary, treated
Any physical or mental disorder (excluding addiction or abuse of specific
substance on the Controlled Substances Act but including other
substance-related disorder) without harmful behavior or history of such
behavior unlikely to recur
Sustained, full remission of addiction or abuse of specific substance on the CSA
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Class B Other (Specify or give details from worksheets)

2. Vaccination Documentation (See DS-3025, mark one)
Immigrant Visa or Parolee applicant
completed vaccination requirements

Immigrant Visa applicant refuses vaccination (Class A)

K Visa applicant voluntarily completed
vaccination requirements

Immigrant Visa applicant requests Individual Waiver based on religious or moral convictions

Immigrant Visa applicant requested Adoptee Exemption

Refugee or follow to join Asylee/Refugee (V92/93) applicant not required to meet
vaccination requirements
K-Visa applicant electing to not be vaccinated at this examination
Other NIV applicant not required to meet vaccination requirements
3. Panel Physician

Panel Physician Signature

Date (mm-dd-yyyy)

I attest that I performed this examination, have reviewed all test results,
and that the medical classification is correct in accordance with the
Centers for Disease Control and Prevention's Technical Instructions for
panel physicians. I further attest that I have a current panel physician
agreement with the Department of State. I further attest that I provided the
applicant the "applicant consent statement" and that the applicant read,
understands, and has agreed to its contents.
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
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-2054

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