DS-2054 Medical Examination for Immigrant or Refugee Applicant

U.S. Department of State MEDICAL EXAMINATION FOR IMMIGRANT OR REFUGEE APPLICANT For use with DS-3030 Photo OMB No. 1405-0113 EXPIRATION DATE: xx/xx/xxxx ESTIMATED BURDEN: 10 MINUTES (See Page 2 – Back of Form)

Name (Last, First, MI)

Birth Date (mm-dd-yyyy)

Sex M F

U.S. Consul (City, Country)

Passport Number

Alien (Case) Number

Birthplace (City, Country)

Present Country of Residence

Prior Country

Present Address of Residence

Present City of Residence

Present Postal Code of Residence

Intended US Address

Intended US City

Intended US State

Intended US Postal Code

E-mail Address

Date of Medical Exam (Date of physical exam or date of final TB culture results, if cultures performed) (mm-dd-yyyy)

Date Exam Expires (3 months if Class A TB, or Class B1 TB, otherwise 6 months) (mm-dd-yyyy)

Exam Place of Current Exam (City, Country)

Date of Prior Exam, if any (mm-dd-yyyy)

Panel Physician Performing Exam

Panel Site

Radiology Facility

Sputum Smear Laboratory

Sputum Culture Laboratory

Syphilis Laboratory

Drug Susceptibility Test Laboratory

DOT Facility

Applicant Category (Mark One)

Immigrant Visa Immigrant Special Immigrant (SIV) Diversity Adoptee

Refugee Refugee Visa 92

Asylee Asylee Visa 93

Non-Immigrant Visa (NIV) K-Visa Other NIV

Parolee Parolee

Classification (Check all boxes that apply) No apparent defect, disease, or disability (See Worksheets DS-3025, DS-3026, DS-3030)

Class A Conditions (See Worksheets DS-3025, DS-3026, DS-3030)

Tuberculosis disease Syphilis, untreated Chancroid, untreated Gonorrhea, untreated Granuloma inguinale, untreated Lymphogranumoma venerum, untreated

Hansen’s Disease, untreated multibacillary or paucibacillary Addiction or abuse of specific substance on the CSA Any physical or mental disorder (including other substance-related disorder) with harmful behavior or history of such behavior likely to recur Immigrant visa applicant refuses vaccinations

Class B Conditions (See Worksheets DS-3025, DS-3026, DS-3030)

Tuberculosis B1 TB, Pulmonary B1 TB, Extrapulmonary B2 TB, LTBI Evaluation B3 TB, Contact Evaluation Hansen’s Disease Multibacillary, treated Paucibacillary, treated

Syphilis, treated within last year Any physical or mental disorder (excluding addiction or abuse of specific substance on the CSA but including other substance-related disorder) without harmful behavior or history of such behavior unlikely to recur Sustained, full remission of addiction or abuse of specific substance on the CSA

Class B Other (Specify or give details from worksheets)

Immunization Documentation for Immigrant Visa Applicants (See DS-3025, mark one) US vaccination requirements Complete: Requesting Blanket Waiver US vaccination requirements NOT Complete: Requesting Individual Waiver based on religious or moral convictions Requesting Adoptee Exemption Applicant refuses vaccinations

3. Applicant I certify that I understand the purpose of the medical examination and I authorize the required tests to be completed.

Applicant signature

Date (mm/dd/yyyy)

4. Panel Physician I attest that I performed this examination and that I have an agreement with the Department of State

Panel Physician signature

Date (mm/dd/yyyy)

PAPERWORK REDUCTION ACT AND CONFIDENTIALITY STATEMENTS PAPERWORK REDUCTION ACT STATEMENT Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to PRA_BurdenComments@state.gov. CONFIDENTIALITY STATEMENT AUTHORITIES: The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court. PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case. ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws. More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.

DRAFT6

DS-2054 Page 1 of 1

08-2011

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File Created	2021-01-25