Form DS-3025 at a glance
What it is: The U.S. Department of State's Vaccination Documentation Worksheet is For US Vaccination Requirements; the Department uses the information provided on this form to determine an individual's eligibility for a U.S. visa.
A filled-in Form DS-3025 example: a panel physician documents the vaccination record
How to fill out Form DS-3025, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Surnames, Given Names, Birth Date, Exam Date
Write the Surnames and Given Names, the Birth Date (mm-dd-yyyy), the Exam Date (mm-dd-yyyy), the Document Type, the Document Number and the Case or Alien Number.
Blanket Waiver(s) To Be Requested If Vaccination Not Medically Appropriate
Blanket Waiver(s) To Be Requested If Vaccination Not Medically Appropriate: indicate reason below.
1. Vaccination Record
Vaccination Record: Vaccine History Transferred From a Written Record; list chronologically from left to right and provide date as mm-dd-yyyy.
2. Panel Physician Name (printed) Panel Physician Signature
The Panel Physician writes the Date (mm-dd-yyyy) and the Panel Physician Name (printed), and signs on the Panel Physician Signature line.
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.
3. Vaccination Documentation (Mark one)
Mark one in 3. Vaccination Documentation: 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.
More rules for Form DS-3025
GIVE COPY TO APPLICANT: the form is To Be Completed by Panel Physician Only.
Write the Vaccine Given By Panel Site.
Refugees/V93 Only: write the Additional Vaccine Given by Panel Site.
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 below) D Not available in-country F Flu vaccine not available H Known chronic hepatitis B virus infection
Record contraindications in the 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
For Test for Immunity, mark the Positive box.
The Panel Physician writes the Remarks, the Panel Physician Initials and the Date (mm-dd-yyyy).
Please complete Page 2.
Common questions about Form DS-3025
What is the DS 3025 form?
The U.S. Department of State's Vaccination Documentation Worksheet is For US Vaccination Requirements; the Department uses the information provided on this form to determine an individual's eligibility for a U.S. visa.
Sources
[1] Form DS-3025, Photo Vaccination Documentation Worksheet, U.S. Department of State (the Official source link on this page).
