Form DS-3025 at a glance
What it is: Form DS-3025 is the U.S. Department of State Vaccination Documentation Worksheet for US Vaccination Requirements: give a copy to the applicant.
Who signs: Panel Physician Signature: "I attest that I reviewed the vaccine history, ordered vaccinations, completed or supervised completion of this form, and have an agreement with the Department of State."
A filled-in Form DS-3025 example: a panel physician records two MMR doses
How to fill out Form DS-3025, box by box
Names, dates and document
Enter the Surnames, Given Names, Birth Date (mm-dd-yyyy) and Exam Date (mm-dd-yyyy).
Enter the Document Type, Document Number and Case or Alien Number.
1. Vaccination Record
In 1. Vaccination Record, list the Vaccine History Transferred From a Written Record chronologically from left to right, and provide the date as mm-dd-yyyy.
Refugees/V93 Only: Additional Vaccine Given by Panel Site; Refugee/V93 Declines.
Vaccine: Diphtheria, tetanus, pertussis (DTP, Dtap, DT, Td, Tdap, TT); Polio (OPV, IPV); Measles, mumps, rubella (MMR, Measles, Mumps, Rubella); Rotavirus (Rotateq (RV5), Rotarix (RV1)); Hib; Hepatitis A; Hepatitis B; Meningococcal (Menacwy Conjugate (specify brand in remarks)); Varicella (Varicella History Vaccine); Pneumococcal (PCV 10, PCV 13, PPSV 23); Influenza; Other.
Blanket Waiver(s) To Be Requested
If Vaccination Not Medically Appropriate, indicate the reason under Blanket Waiver(s) To Be Requested, and mark all that apply (see legend).
Blanket waiver legend: A Not age appropriate; B Insufficient time interval to complete series; C* Contraindications (C1-C6, see the Contraindications list); D Not available in-country; F Flu vaccine not available; H Known chronic hepatitis B virus infection.
Contraindications (record in blanketwaiver column): C1 Current pregnancy; C2 Immune compromised; C3 History of severe allergic reaction to vaccine or vaccine component; C4 Other severe reaction to vaccine; C5 Current moderate to severe illness; C6 Other, specify in remarks.
Physician name, signature and date
Enter the 2. Panel Physician Name (printed), the Panel Physician Signature and the Date (mm-dd-yyyy).
3. Vaccination Documentation
Under 3. Vaccination Documentation, mark one: Immigrant Visa or Parolee applicant completed vaccination requirements; K Visa applicant voluntarily completed vaccination requirements; Immigrant Visa applicant refused vaccination (Class A); Immigrant Visa applicant requested Adoptee Exemption; Immigrant Visa applicant requests Individual Waiver based on religious or moral convictions; Refugee or follow to join Asylee/Refugee (V92/93) applicant not required to meet vaccination requirements; K Visa applicant electing not to be vaccinated at this examination; Other NIV applicant not required to meet vaccination requirements.
4. Remarks and the physician's initials
Enter 4. Remarks, then the Panel Physician Initials and the Date (mm-dd-yyyy).
More rules for Form DS-3025
The U.S. Department of State uses the information provided on this form to determine an individual's eligibility for a U.S. visa.
Although furnishing this information is voluntary, individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. visa or experience processing delays.
Common questions about Form DS-3025
What is the DS 3025 form?
Form DS-3025 is the U.S. Department of State Vaccination Documentation Worksheet for US Vaccination Requirements: give a copy to the applicant. This form is to be completed by Panel Physician only.
Sources
[1] Form DS-3025 (02-2025), Vaccination Documentation Worksheet, U.S. Department of State (the Official source link on this page).
