Form Ds 2054 PDF Details

Embarking on the journey to becoming a lawful immigrant or refugee in the United States entails a thorough process, including the submission of the DS form, an integral document facilitated by the U.S. Department of State. It serves as a comprehensive medical examination form that must be completed by immigrant or refugee applicants, aligning with the TB Technical Instructions 2007 and the DS-3030. This document meticulously records personal information such as name, date of birth, and country of birth, alongside detailed medical examination results ranging from tuberculosis (TB) classifications to various infectious diseases assessments. Within its scope, the form categorizes medical conditions into Class A and Class B, distinguishing between more serious health conditions that could signify a public health risk and less severe issues. Additionally, the form addresses treatment histories, laboratory findings, and immunization records, ensuring that applicants meet the health standards required for entry into the U.S. It emphasizes the importance of transparency and accuracy, with the estimated burden of completing the form being around 10 minutes, although the impact on the applicant's journey is far more significant. By fulfilling the requirements outlined in the DS form, applicants take a crucial step toward their goal of residing in the United States, underpinning the process with a detail-oriented approach that underscores the intersection of public health and immigration policy.

QuestionAnswer
Form NameForm Ds 2054
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesds2054 form ds 2054

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U.S. Department of State

 

 

 

 

 

 

 

OMB No. 1405-0113

 

MEDICAL EXAMINATION FOR

 

 

EXPIRATION DATE: 08/31/2014

 

 

 

ESTIMATED BURDEN: 10 minutes

IMMIGRANT OR REFUGEE APPLICANT

 

 

(See Page 2 - Back of Form)

 

 

 

 

 

 

 

 

 

 

 

 

For use with TB Technical Instructions 2007 and the DS-3030

 

 

 

 

 

 

Name (Last, First, MI.)

 

,

 

 

 

 

 

 

 

,

 

 

Birth Date (mm-dd-yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

 

M

F

Birthplace (City/Country)

 

 

 

/

 

 

 

 

 

 

 

 

Present Country of Residence

 

 

Prior Country

 

 

 

 

 

 

U.S. Consul (City/Country)

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Passport Number

 

Alien (Case) Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Medical Exam (Date of TB physical exam or date of lab report 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)

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

 

 

 

Exam Place (City/Country)

 

 

/

Panel Physician

 

 

 

 

Radiology Services

 

 

 

 

 

Screening Site

 

 

Lab (Name for syphilis/TB)

 

/

 

 

 

 

 

(1)Classification (Check all boxes that apply):

No apparent defect, disease, or disability (See Worksheets DS-3025, DS-3026, and DS-3030)

Class A Conditions (From Past Medical History and Physical Examination Worksheets)

TB, active, infectious (Class A, from Chest X-Ray Worksheet)

Syphilis, untreated

Chancroid, untreated

Gonorrhea, untreated

Granuloma inguinale, untreated

Lymphogranuloma venereum, untreated

Hansen's disease, untreated multibacillary

Addiction or abuse of specific* substance

Any physical or mental disorder (including other substance-related disorder) with harmful behavior or history of such behavior likely to recur

*amphetamines, cannabis, cocaine, hallucinogens, opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Class B Conditions (From Past Medical History and Physical Examination Worksheets)

Syphilis (with residual defect), treated within the last year

Current pregnancy, number of weeks pregnant

Any physical or mental disorder (excluding addiction or abuse of specific* substance but including other substance-related disorder) without harmful behavior or history of such behavior unlikely to recur

Hansen's disease, treated multibacillary

 

Treatment:

Partial

Completed

 

Hansen's disease, paucibacillary

 

 

Treatment:

None

Partial

Completed

Sustained, full remission of addiction or abuse of specific* substances

*amphetamines, cannabis, cocaine, hallucinogens, opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Class B1 TB, Pulmonary

No treatment

Completed treatment (Check all that apply and attach all laboratory and DOT documents)

By panel physician

Initial smear positive

Pre-treatment culture and DST results performed/available

By non-panel physician

Initial culture positive

Pre-treatment culture and/or DST results not performed/available

Class B1 TB, Extrapulmonary

Anatomic Site of Disease

No treatment

 

Current treatment

 

Completed treatment

 

Class B2 TB, LTBI Evaluation

Test for TB infection positive:

TST

 

mm;

IGRA positive

Result

No LTBI treatment

 

 

 

 

 

Current LTBI treatment (Indicate medications in Part 4 of DS-2054 form)

Completed LTBI treatment (Indicate medications in Part 4 of DS-2054 form)

TST or IGRA Conversion

DS-2054

Page 1 of 3

08-2011

 

Class B Tuberculosis - Continued

Class B3 TB, Contact Evaluation

TST

 

mm

IGRA negative

IGRA positive IGRA Result

No preventive treatment

Current preventive treatment (Indicate medications in Part 4 of DS-2054 form)

Completed preventive treatment (Indicate medications in Part 4 of DS-2054 form) Source Case: Name

Alien Number

Relationship to Contact

Date Contact Ended (mm-dd-yyyy)

Type of Source Case TB (Mark only one and ATTACH DST RESULTS)

Pansusceptible TB

MDR TB (resistant to at least INH and rifampin)

Drug-resistant TB other than MDR TB

Culture negative

Culture results not available

Class B Other (specify or give details on checked conditions from worksheets)

(2)Laboratory Findings (check all boxes that apply):

Syphilis:

Not done

 

 

 

 

Test Name

 

Date(s) Run (mm-dd-yyyy)

Negative

Positive

Titer 1

 

 

Notes

 

Screening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confirmatory

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treated

If treated, therapy:

 

 

 

Date(s) treatment given (mm-dd-yyyy) (3 doses for penicillin)

 

 

Yes

 

Benzathine penicillin, 2.4 MU IM

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

Other (therapy, dose):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Test for Cell-Mediated Immunity to TB (Required for all applicants 2 through 14 years of age; perform one type only)

TST

 

 

 

 

 

 

 

 

 

 

Date Applied (mm-dd-yyyy)

 

 

 

 

Result (mm)

IGRA

 

 

 

 

 

 

 

 

 

 

Name of IGRA Test

 

 

 

 

 

Date Drawn (mm-dd-yyyy)

 

 

Nil Value (IU/ml or number of cells)

 

 

 

TB Response (TB- nil IU/ml or number of cells*)

 

IGRA Interpretation:

Positive

Negative

 

Indeterminate, Borderline, or Equivocal

*For T-Spot, TB Response number of cells = Higher of Panel A or Panel B minus nil value

(3)Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.

Vaccine history complete

Incomplete vaccine history, no waiver requested

Vaccine history incomplete, requesting waiver (indicate type below)

Blanket waiver

 

Individual waiver

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

Applicant Signature

Panel Physician Signature

Date (mm-dd-yyyy)

DS-2054

Page 2 of 3

(4) Tuberculosis Treatment Regimen

(Fill out if applicant has taken in the past, or is now taking TB medication. If drug doses or dates not known or not available, mark "unknown".)

Check if therapy currently prescribed (if current, don't mark "End Date")

Medication

Dose/Interval

 

Start Date

 

End Date

 

 

 

 

(e.g., mg/day)

 

(mm-dd-yyyy)

 

(mm-dd-yyyy)

 

 

Isonaizid (INH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rifampin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pyrazinamide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethambutol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Streptomycin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other, specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant's pre-treatment weight (kg)

 

Date (mm-dd-yyyy)

Remarks

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: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202

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 States 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 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.

DS-2054

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