Medical Examination For Immigrant Or Refugee Applicant Page 2
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8(3) Immunizations (See Vaccination Form, check all boxes that apply) Not required for refugee applicants.
Vaccine history incomplete, requesting waiver (indicate type below)
Vaccine history complete
Blanket waiver
Individual waiver
Incomplete vaccine history, no waiver requested
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")
Dose/Interval
Medication
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).
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DS-2053
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