Medical Examination for Immigrant or Refugee Applicant

Medical Examination for Visa or Immigration Benefit

Documents and Forms

Document Name Document Type
Form DS-2054 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-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-3030 Tuberculosis Worksheet (008) Tab 7 - DS-3030 - 30-day PRA - MED Forms - 2025.pdf Form and Instruction

Information Collection (IC) Details

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 and Instruction	DS-2054	Report of Medical Examination by Panel Physician	(005) Tab 4 - DS-2054 - 30-day PRA - MED Forms - 2025.pdf	No	Paper Only
Form and Instruction	DS-3025	Vaccination Documentation Worksheet	(006) Tab 5 - DS-3025 - 30-day PRA - MED Forms - 2025.pdf	No	Paper Only
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	(007) Tab 6 - DS-3026 - 30-day PRA - MED Forms - 2025.pdf	No	Paper Only
Form and Instruction	DS-3030	Tuberculosis Worksheet	(008) Tab 7 - DS-3030 - 30-day PRA - MED Forms - 2025.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: 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 %

	Requested	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

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.