Medical Examination for Immigrant or Refugee Applicant

Forms and Documents

Document Name	Status
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant Form and Instruction	Modified
Medical Forms Legal Authorities (7-2014).docx Supplementary Document	2014-07-21
Consular Electronic Application Center (CEAC) PIA.pdf Supplementary Document	2011-08-04
SORN STATE-39 Original.pdf Supplementary Document	2011-08-04
Medical Forms Supporting Statement (7-2014).docx Supporting Statement A	2014-07-21

IC Document Collections

IC ID	Document Title	Status
38745	Medical Examination for Immigrant or Refugee Applicant Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0113	ICR Reference No: 201407-1405-004
Status: Historical Active	Previous ICR Reference No: 201105-1405-007
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: 09/11/2014
	Date Received in OIRA: 07/21/2014
Terms of Clearance: State Department will provide more information and submit a request to OMB prior to implementing an electronic version of the information collection instruments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	09/30/2014
Responses	660,000	0	630,000
Time Burden (Hours)	660,000	0	630,000
Cost Burden (Dollars)	290,250,000	0	283,500,000

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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.

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Authorizing Statute(s): US Code: 8 USC 1101 Name of Law: Immigration and Nationality Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 13730	03/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 42391	07/21/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medical Examination for Immigrant or Refugee Applicant	DS-3025, DS-2053, DS-2054, DS-3026, DS-3024, DS-3030	Vaccination Documentation Worksheet ,   Medical History and Physical Examination Worksheet ,   Medical Examination for Immigrant or Refugee Applicant ,   Medical Examination for Immigrant or Refugee Applicant ,   Chest X-Ray and Classification Worksheet ,   Tuberculosis Worksheet

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ICR Summary 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	660,000	630,000	0	0	30,000	0
Annual Time Burden (Hours)	660,000	630,000	0	0	30,000	0
Annual Cost Burden (Dollars)	290,250,000	283,500,000	0	0	6,750,000	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: Burden changes due to increase in number of respondents.

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Annual Cost to Federal Government: $9,189,360

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 07/21/2014

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