Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 38745 under ICR 201709-1405-003 · OMB 1405-0113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0113 can be found here:

Documents and Forms

Document Name Document Type
Form DS-3030 Medical Examination for Immigrant or Refugee Applicant Form and Instruction
DS-3025 Vaccination Documentation Worksheet ds3025 - DRAFT - 10-23-2017 - flat.pdf Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet ds3026 - DRAFT - 10-23-2017 - flat.pdf Form and Instruction
DS-2054 Medical Examination for Immigrant or Refugee Applicant ds2054 - DRAFT - 10-23-2017 - flat.pdf Form and Instruction
DS-3030 Tuberculosis Worksheet ds3030 - DRAFT.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Examination for Immigrant or Refugee Applicant	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	DS-3030	Tuberculosis Worksheet	ds3030 - DRAFT.pdf	No	Fillable Printable
Form and Instruction	DS-3025	Vaccination Documentation Worksheet	ds3025 - DRAFT - 10-23-2017 - flat.pdf	No	Fillable Printable
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	ds3026 - DRAFT - 10-23-2017 - flat.pdf	No	Fillable Printable
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant	ds2054 - DRAFT - 10-23-2017 - flat.pdf	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN Visa Records, State-39	FR Citation: 60 FR 148

Number of Respondents: 828,728	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	828,728	168,728	660,000
Annual IC Time Burden (Hours)	828,728	168,728	660,000
Annual IC Cost Burden (Dollars)	372,725,100	82,475,100	290,250,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.