Medical Examination for Immigrant or Refugee Applicant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-3030 Tuberculosis Worksheet	Form and Instruction	Unchanged	Available
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Available
Form DS-3026 Medical History and Physical Examination Worksheet	Form and Instruction	Unchanged	Available
Form DS-3025 Vaccination Documentation Worksheet	Form and Instruction	Unchanged	Available
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Repair queued
Form DS-3030 Tuberculosis Worksheet	Form	New	Available
Form DS-3026 Medical History and Physical Examination Worksheet	Form	New	Available
Form DS-3025 Vaccination Documentation	Form	New	Available
Form DS-2054 Report of Medical Examination by Panel Physician	Form	New	Available
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant	Form	New	Repair queued
(004) Tab 3 -- Legal Authorities -- 30 Day Paper Medical.docx	Supplementary Document	Uploaded 2022-07-21	Repair queued
SIGNED T3837-21 - PRA Emergency Approval for COVID-19 Vaccine.pdf	Supplementary Document	Uploaded 2021-12-20	Repair queued
Justification for Emergency Approval.docx	Supplementary Document	Uploaded 2021-12-20	Repair queued
Legal Authorities.docx	Supplementary Document	Uploaded 2021-12-20	Repair queued
(003) Tab 2 -- Supporting Statement -- 30 Day Paper Medical .docx	Supporting Statement A	Uploaded 2022-07-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Tuberculosis Worksheet
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Medical Examination for Immigrant or Refugee Applicant
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Medical History and Physical Examination Worksheet
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged	Vaccination Documentation Worksheet
38745	Medical Examination for Immigrant or Refugee Applicant	Form and Instruction	Unchanged
254779	Medical Examination for Immigrant or Refugee Applicant	Form	New	Tuberculosis Worksheet
254779	Medical Examination for Immigrant or Refugee Applicant	Form	New	Medical History and Physical Examination Worksheet
254779	Medical Examination for Immigrant or Refugee Applicant	Form	New	Vaccination Documentation
254779	Medical Examination for Immigrant or Refugee Applicant	Form	New	Report of Medical Examination by Panel Physician
254779	Medical Examination for Immigrant or Refugee Applicant	Form	New

ICR Details

OMB Control No: 1405-0113	ICR Reference No: 202207-1405-004
Status: Historical Active	Previous ICR Reference No: 202112-1405-010
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Medical Examination for Immigrant or Refugee Applicant
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/06/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/21/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2025	36 Months From Approved	12/31/2022
Responses	220,824	0	110,412
Time Burden (Hours)	110,412	0	110,412
Cost Burden (Dollars)	49,685,400	0	49,685,400

---

Abstract: Forms for this collection are completed by panel physicians for refugees and aliens seeking immigrant visas to the U.S. The collection records medical information necessary to determine whether refugees or immigrant visa applicants have medical conditions affecting the public health and requiring treatment.

---

Authorizing Statute(s): US Code: 8 USC 1101 Name of Law: Immigration and Nationality Act
   US Code: 8 USC 1201(d) Name of Law: Immigration and Nationality Act
   US Code: 8 USC 1182(a)(1) Name of Law: Immigration and Nationality Act
   US Code: 8 USC 1182 (d)(5) Name of Law: Immigration and Nationality Act
   US Code: 8 USC 1522(b)(4) Name of Law: Immigration and Nationality Act
   US Code: 8 USC 1202(f) Name of Law: Immigration and Nationality Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11698	03/31/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11781	07/20/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Medical Examination for Immigrant or Refugee Applicant	DS-2054, DS-3025, DS-3026, DS-3030	Report of Medical Examination by Panel Physician ,   Vaccination Documentation ,   Medical History and Physical Examination Worksheet ,   Tuberculosis Worksheet
Medical Examination for Immigrant or Refugee Applicant	DS-3026, DS-2054, DS-3025, DS-3030	Vaccination Documentation Worksheet ,   Medical History and Physical Examination Worksheet ,   Medical Examination for Immigrant or Refugee Applicant ,   Tuberculosis Worksheet

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	220,824	110,412	0	110,412	0	0
Annual Time Burden (Hours)	110,412	110,412	0	0	0	0
Annual Cost Burden (Dollars)	49,685,400	49,685,400	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $248,427

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/21/2022

---