Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 254779 under ICR 202207-1405-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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-2054 Medical Examination for Immigrant or Refugee Applicant Form
DS-2054 Report of Medical Examination by Panel Physician (005) Tab 4 -- DS-2054.pdf Form
DS-2054 Report of Medical Examination by Panel Physician (005) Tab 4 -- DS-2054.pdf Form
DS-3025 Vaccination Documentation (006) Tab 5 -- DS-3025 DRAFT with new CS.pdf Form
DS-3025 Vaccination Documentation (006) Tab 5 -- DS-3025 DRAFT with new CS.pdf Form
DS-3026 Medical History and Physical Examination Worksheet (007) Tab 6 -- DS-3026.pdf Form
DS-3026 Medical History and Physical Examination Worksheet (007) Tab 6 -- DS-3026.pdf Form
DS-3030 Tuberculosis Worksheet (008) Tab 7 -- DS-3030.pdf Form
DS-3030 Tuberculosis Worksheet (008) Tab 7 -- DS-3030.pdf Form

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: New

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	DS-2054	Report of Medical Examination by Panel Physician	(005) Tab 4 -- DS-2054.pdf	No	Paper Only
Form	DS-3025	Vaccination Documentation	(006) Tab 5 -- DS-3025 DRAFT with new CS.pdf	No	Paper Only
Form	DS-3026	Medical History and Physical Examination Worksheet	(007) Tab 6 -- DS-3026.pdf	No	Paper Only
Form	DS-3030	Tuberculosis Worksheet	(008) Tab 7 -- DS-3030.pdf	No	Paper Only

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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	110,412	110,412
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

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.