Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 278674 under ICR 202601-1405-002 · OMB 1405-0113.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
Form DS-2054 Report of Medical Examination by Panel Physician Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
Form DS-3025 Vaccination Documentation Worksheet Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
Form DS-3026 Medical History and Physical Examination Worksheet Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
Form DS-3030 Tuberculosis Worksheet Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
DS-2054 Report of Medical Examination by Panel Physician (005) Tab 4 - DS-2054 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-2054 Report of Medical Examination by Panel Physician (005) Tab 4 - DS-2054 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3025 Vaccination Documentation Worksheet (006) Tab 5 - DS-3025 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3025 Vaccination Documentation Worksheet (006) Tab 5 - DS-3025 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet (007) Tab 6 - DS-3026 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet (007) Tab 6 - DS-3026 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3030 Tuberculosis Worksheet (008) Tab 7 - DS-3030 - 30-day PRA - MED Forms - 2025.pdf	Form and Instruction
DS-3030 Tuberculosis Worksheet (008) Tab 7 - DS-3030 - 30-day PRA - MED Forms - 2025.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: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	DS-2054	No	Paper Only
Form and Instruction	DS-3025	No	Paper Only
Form and Instruction	DS-3026	No	Paper Only
Form and Instruction	DS-3030	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title: SORN Visa Records, State-39

FR Citation: 90 FR 12890

Number of Respondents: 146,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	146,000	35,588	110,412
Annual IC Time Burden (Hours)	146,000	35,588	110,412
Annual IC Cost Burden (Dollars)	65,700,000	16,014,600	49,685,400

Documents for IC

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].