Form Ds 2054 – Fill Out and Use This PDF

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)

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

*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)

Class B1 TB, Extrapulmonary	Anatomic Site of Disease
No treatment
Current treatment
Completed treatment

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	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):

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.

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)

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(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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