Medical Examination for Immigrant or Refugee Applicant

⚠️ Notice: This information collection may be referencing outdated material.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-2054 Medical Examination for Immigrant or Refugee Applicant Form and Instruction
DS-3025 Vaccination Documentation Worksheet DS-3025.pdf Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet DS-3026.pdf Form and Instruction
DS-2054 Medical Examination for Immigrant or Refugee Applicant DS-2054.pdf Form and Instruction
DS-3030 Tuberculosis Worksheet DS-3030.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-3025	Vaccination Documentation Worksheet	DS-3025.pdf	No	Fillable Printable
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	DS-3026.pdf	No	Fillable Printable
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant	DS-2054.pdf	No	Fillable Printable
Form and Instruction	DS-3030	Tuberculosis Worksheet	DS-3030.pdf	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

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

Number of Respondents: 110,412	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	110,412	-718,316	828,728
Annual IC Time Burden (Hours)	110,412	-718,316	828,728
Annual IC Cost Burden (Dollars)	49,685,400	-323,039,700	372,725,100

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.