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
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GIVE COPY TO APPLICANT
Surnames

Given Names

Document Type

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

Document Number

Case or Alien 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

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

Test for
Immunity
Positive

Indicate reason
below.

Date

A, B, C*, D, F, H

Refugee/V93 Declines

Vaccine
Diphtheria, tetanus, pertussis
DTP, DTaP

Date

Date

Date

Date

Date

Date

Date

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

Mark all that apply
(see legend):

DT
Td
Tdap
TT
Polio
OPV
IPV
Measles, mumps, rubella
MMR
Measles
Mumps
Rubella
Rotavirus
RotaTeq (RV5)
Rotarix (RV1)
Hib
Hepatitis A
Hepatitis B
Meningococcal
MenACWY Conjugate
(specify brand in remarks)
Varicella
Vaccine

Varicella History

Pneumococcal
PCV 10
PCV 13
PPSV 23
Influenza
Other

Blanket waiver legend: A Not age appropriate B Insufficient time interval to complete series C* Contraindications (C1-C6, see below) D Not available in-country
F Flu vaccine not available H Known chronic hepatitis B virus infection
Contraindications (record in blanketwaiver column): C1 Current pregnancy; C2 Immune compromised; C3 Historyof severe allergic reaction to vaccine or vaccine
component; C4 Other severe reaction to vaccine; C5 Current moderate to severe illness; C6 Other, specifyin remarks

DS-3025
03-2020

Please complete Page 2

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2. Vaccination Documentation (Mark one)
Immigrant Visa or Parolee applicant completed vaccination requirements
K Visa applicant voluntarily completed voccination requirements
Immigrant Visa applicant refused 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
3. Panel Physician Name (printed)

Panel Physician signature

Date (mm-dd-yyyy)

I attest that I reviewed the vaccine history, ordered vaccinations, completed or supervised
completion of this form, and have an agreement with the Department of State.
4. Remarks

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 60 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 immigrant, nationality, and other laws of the United States. The U.S.
Department of State uses the information provided on this form primarily 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,
counter terrorism 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 cause
processing delays.
DS-3025

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