Form Ds 2053 – Fill Out and Use This PDF

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

Date Exam Expires (6 months from examination date, if Class A or TB condition exists, otherwise 12 months) (mm-dd-yyyy)

Exam Place (City/Country)			/				Panel Physician
Radiology Services							Screening Site (name)
Lab (name for HIV/syphilis/TB)					/			/

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

No apparent defect, disease, or disability (see Worksheets DS-3024, DS-3025 and DS-3026) Class A Conditions (From Past Medical History and Physical Examination Worksheets)

Class B Conditions (From Past Medical History and Physical Examination 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 (3 doses for penicillin)

Yes

Benzathine penicillin, 2.4 MU IM

No

Other (therapy, dose):E

	DS-2053	(Formerly OF-157)	Page 1 of 2
	09-2007

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

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)

(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
	(i.e., mg/day)	(mm-dd-yyyy)	(mm-dd-yyyy)

Isonaizid (INH)

Rifampin

Pyrazinamide

Ethambutol

Streptomycin

Other, specify

Applicant's weight (kg)

Remarks

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

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 data, providing the information required, and reviewing the final collection. Persons are not required to provide this information in the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520.

We ask for information on this form, in the case of applicants for immigrant visas, to determine medical eligibility under INA Sections 212(a) and 221(d), and, in the case of refugees, as required under INA Section 412(b)(4) and (5). If an immigrant visa is issued or refugee status granted, you will convey this form to U.S. Department of Homeland Security (DHS) for disclosure to the Centers for Disease Control and Prevention and to the U.S. Public Health Service. Failure to provide this information may delay or prevent the processing of your case. If an immigrant visa is not issued or refugee status is not granted, this form will be treated as confidential under INA Section 222(f).

DS-2053

Page 2 of 2

U.S. Department of State

	CHEST X-RAY AND CLASSIFICATION WORKSHEET		OMB APPROVEDS No. 1405-0113
			EXPIRATION DATE: 09-30-2010
	For Use with DS-2053	Complete Sections 1 through 5, As Applicable	ESTIMATED BURDEN: 10 MINUTES
			(See Page 2 - Back of Form)
	Name (Last, First, MI.)			Age

1. Chest X-Ray (Mark All that Apply)
History of Tuberculosis (TB) Disease	TB Signs or Symptoms
Contact with Person with TB	Adult (With or Without Any of the Other)
(If child does not have any of the above, stop here.)
2. Chest X-Ray Findings	Date Chest X-Ray Taken (mm-dd-yyyy)

Normal Findings

Abnormal Findings (Indicate findings and interpretation, by checking all that apply, and any other in the table below.)

Can Suggest ACTIVE TB

Can Suggest INACTIVE TB

OTHER X-Ray Findings

(Need Smears)

(Need Smears if Symptomatic)

Infiltrate or Consolidation

Discrete Fibrotic Scar or Linear Opacity

Follow-Up Needed

Any Cavitary Lesion

Discrete Nodule(s) without Calcification

Musculoskeletal

Nodule with Poorly Defined Margins

Discrete Fibrotic Scar with Volume Loss

Cardiac

or Retraction

(Such as Tuberculoma)

Pulmonary

Pleural Effusion

Discrete Nodule(s) with Volume Loss or

Retraction

Other

Hilar/Mediastinal Adenopathy

Other (Such as Bronchiectasis)

No Follow-Up Needed for

Linear, Interstitial Markings

Pleural thickening, diaphragmatic tenting,

Other (Such as Miliary Findings)

blunting costophrenic angle, solitary calcified

nodule or granuloma or minor

Remarks

musculoskeletal or cardiac finding

3. Sputum Smears

Yes, Applicant has (Mark All that Apply) :	and Smear Results are:
	Positive	Negative	Dates Obtained (mm-dd-yyyy)
Signs or Symptoms of TB Present, See Section 1
X-Ray Suggests ACTIVE TB, See Section 2

5. Follow-Up Needed After

No

Yes

If Yes, for

Not TB Condition

TB Condition

(If yes, specify condition below and on DS-2053; include additional tests, and therapy used with start and stop dates and any changes.)

Remarks

	DS-3024	Page 1 of 2
	09-2007

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES

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 data, providing the information required, and reviewing the final collection. Persons are not required to provide this information in the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: the U.S. Department of State (A/ISS/DIR) Washington, DC 20520.

AUTHORITIES The information is sought pursuant to Sections 212(a), 221(d), 101, and 412(b)(4) and (5) of the Immigration and Nationality Act.

PURPOSE The primary purpose for soliciting medical information is to determine whether an applicant is eligible to obtain a visa and alien registration. This form is designed to record the result of the medical examination required by INA 221(d), which determines whether an applicant has a medical condition that renders the applicant ineligible under INA Section 212(a).

ROUTINE USES The information solicited on this form may be made available to the U.S. Department of Homeland Security for disclosure to the Centers for Disease Control and Prevention and to the U.S. Public Health Service. The information provided also may be released to federal agencies for law enforcement, counter-terrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies for certain personnel and records management matters.

Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

DS-3024	Page 2 of 2

PRIVACY ACT NOTICE

AUTHORITIES: This information is sought pursuant to Section 212(a), 212(d), 101, and 412(b)(4) and (5) of the Immigration and Nationality Act.

PURPOSE: The primary purpose for soliciting medical information is to determine whether an applicant is eligible to obtain a visa and alien registration. This form is designed to record the result of the medical examination required by INA 221(d), which determines whether an applicant has a medical condition that renders the applicant ineligible under INA Section 212(a).

ROUTINE USES: The information solicited on this form may be made available to the U.S. Department of Homeland Security for disclosure to the Centers for Disease Control and Prevention and to the U.S. Public Health Service. The information provided also may be released to federal agencies for law enforcement, counter-terrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies of certain personnel and records management matters.

Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. Persons are not required to provide this information in the absence of a valid OMB approval number. Send comments on the accuracy of this estimate of burden and recommendations for reducing it to :

the U.S. Department of State (A/ISS/DIR) Washington, DC 20520-1849.

DS-3025

Page 2 of 2

U.S. Department of State		OMB No. 1405-0113
MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET		EXPIRATION DATE: 09/30/2010
		ESTIMATED BURDEN: 35 minutes
For use with DS-2053		(See Page 2 - Back of Form)
Name (Last, First, MI)	Exam Date (mm-dd-yyyy)

1.Past Medical History (indicate conditions requiring medication or other treatment after resettlement and give details in Remarks)

NOTE: The following history has been reported, has not been verified by a physician, and should not be deemed medically definitive.

No Yes

General

Ever caused SERIOUS injury to others, caused MAJOR

Illness or injury requiring hospitalization (including psychiatric)

property damage or had trouble with the law because of

Cardiology

medical condition, mental disorder, or influence of alcohol or

Angina pectoris

drugs

Obstetrics and Sexually Transmitted Diseases

Hypertension (high blood pressure)

Cardiac arrhythmia

Pregnancy

Fundal height

cm

Last menstrual period Date (mm-dd-yyyy)

Congenital heart disease

Sexually transmitted diseases, specify

Pulmonology

History of tobacco use

Endocrinology and Hematology

Current use

Yes

No

Asthma

Diabetes mellitus

Chronic obstructive pulmonary disease (emphysema)

Thyroid disease

History of tuberculosis (TB) disease

History of malaria

Treated

Other

Yes

No

Malignancy, specify

Current TB symptoms

Yes

No

Neurology and Psychiatry

Chronic renal disease

History of stroke, with current impairment

Chronic hepatitis or other chronic liver disease

Seizure disorder

Hansen's Disease

Major impairement in learning, intelligence, self care, memory, or

Tuberculoid

Borderline

Lepromatous

communication

Paucibacillary

Multibacillary

Major mental disorder (including major depression, bipolar disorder,

OR

schizophrenia, mental retardation)

Treated

Yes

No

Use of drugs other than those required for medical reasons

Visible disabilities (including loss of arms or legs),

Addiction or abuse of specific* substance (drug)

specify

*amphetamines, cannabis, cocaine, hallucinogens, inhalants,

opioids, phencyclidines, sedative-hypnotics, and anxiolytics

Other substance-related disorders (including alcohol addiciton or

abuse)

Other requiring treatment, specify

Ever taken action to end your life

2.Physical Examination (indicate findings and give details in Remarks)

		No		Yes Applicant appears to be providing unreliable or false information, specify

Height

cm

Weight

kg

Visual Acuity at 20 feet:

Uncorrected L 20/

R 20/

BP

/

(mmHg)

Heart rate

/min Respiratory rate

/min

Corrected L 20/

R 20/