Form DS-2054 at a glance
What it is: The U.S. Department of State Report of Medical Examination by Panel Physician.
Who signs: 4. Panel Physician: sign on the Panel Physician Signature line and enter the Date (mm-dd-yyyy).
A filled-in Form DS-2054 example: a panel physician reports an immigrant visa exam
How to fill out Form DS-2054, box by box
Surnames, Given Names, Birth Date and Sex
Enter the Surnames, Given Names and Birth Date (mm-dd-yyyy) and mark the Sex.
U.S. Consulate/Embassy, Document Type, Document Number and Case or Alien Number
Enter the U.S. Consulate/Embassy, the Document Type, Document Number and Case or Alien Number, the Birthplace (City, Country), the Present Country of Residence and the Prior Country of Residence.
Present Address of Residence and Intended US Address
On the U.S. Department of State form, enter the Present Address of Residence, the Present City of Residence and the Present Postal Code of Residence, then the "Intended US Address", "Intended US City", "Intended US State" and "Intended US Postal Code".
Country of Nationality, Phone Number and E-mail Address
Enter the Country of Nationality, the Phone Number and the E-mail Address.
Date of Medical Exam, Date Exam Expires and Exam Place
Date of Medical Exam (Date of physical exam or date of final TB culture results, if cultures performed) (mm-dd-yyyy).
Date Exam Expires (3 months if Class B0 or B1 TB, otherwise 6 months) (mm-dd-yyyy).
Exam Place of Current Exam (City, Country) and Date of Prior Exam, if any (mm-dd-yyyy).
Panel Physician Performing Exam, Panel Site and laboratories
Enter the Panel Physician Performing Exam, Panel Site, Radiology Facility, Sputum Collection Site, Sputum Smear and Culture Laboratory, Syphilis Laboratory, Gonorrhea Laboratory, TB DOT Facility and Drug Susceptibility Test Laboratory.
Applicant Category (Mark One)
Applicant Category (Mark One).
Mark one Applicant Category: Immigrant, Special Immigrant (SIV), Refugee, Parolee or Asylee.
Mark one Applicant Category: K-Visa, Other NIV, Follow to join refugee, Follow to join asylee or Adoptee.
1. Classification (Check all boxes that apply)
1. Classification (Check all boxes that apply)
Check No apparent defect, disease, or disability, and see Worksheets DS-3025, DS-3026, DS-3030.
Class A Conditions: Tuberculosis disease (1A1), Syphilis, untreated (1A1), Gonorrhea, untreated (1A1), Hansen's Disease, untreated multibacillary or paucibacillary (1A1).
Class A Conditions: Addiction or abuse of specific substance on the Controlled Substances Act (1A4), Immigrant visa applicant refuses vaccinations (1A2), or any physical or mental disorder with harmful behavior or history of such behavior likely to recur (1A3).
Class B Conditions
Class B Conditions, Tuberculosis: B0 TB, Pulmonary, B1 TB, Pulmonary, B1 TB, Extrapulmonary, B2 TB, LTBI Evaluation or B3 TB, Contact Evaluation.
Class B Conditions: Any physical or mental disorder (excluding addiction or abuse of specific substance on the Controlled Substances Act but including other substance-related disorder) without harmful behavior or history of such behavior unlikely to recur; Sustained, full remission of addiction or abuse of specific substance on the CSA; Syphilis, treated within last year.
Class B Conditions, Hansen's Disease: Multibacillary, treated or Paucibacillary, treated; also Gonorrhea, treated within last year.
Class B Other (Specify or give details from worksheets)
2. Vaccination Documentation (See DS-3025, mark one)
2. Vaccination Documentation (See DS-3025, mark one)
Vaccination Documentation, mark one: Immigrant Visa or Parolee applicant completed vaccination requirements, Immigrant Visa applicant refused vaccination (Class A) or Immigrant Visa applicant requested Adoptee Exemption.
Vaccination Documentation, mark one: K Visa applicant voluntarily completed vaccination requirements, K-Visa applicant electing to not be vaccinated at the examination or Other NIV applicant not required to meet vaccination requirements.
Vaccination Documentation, mark one: Immigrant Visa applicant requests Individual Waiver based on religious or moral convictions (Class A) or Refugee or follow to join Asylee/Refugee (V92/93) applicant not required to meet vaccination requirements.
4. Panel Physician
4. Panel Physician: sign on the Panel Physician Signature line and enter the Date (mm-dd-yyyy).
The panel physician attests: "I attest that I performed this examination, have reviewed all test results, and that the medical classification is correct in accordance with the Centers for Disease Control and Prevention's Technical Instructions for panel physicians."
The panel physician attests: "I further attest that I have a current panel physician agreement with the Department of State."
Further attested: provided the applicant the applicant consent statement, and that the applicant read, understands, and has agreed to its contents.
More rules for Form DS-2054
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.
Sources
[1] Form DS-2054, Report of Medical Examination by Panel Physician, U.S. Department of State (the Official source link on this page).