Medical Examination For Immigrant Or Refugee Applicant Page 3
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8U.S. Department of State
OMB APPROVEDS No. 1405-0113
CHEST X-RAY AND CLASSIFICATION WORKSHEET
EXPIRATION DATE: 09-30-2010
ESTIMATED BURDEN: 10 MINUTES
For Use with DS-2053
Complete Sections 1 through 5, As Applicable
(See Page 2 - Back of Form)
Name
(Last, First, MI.)
Age
Passport Number
(mm-dd-yyyy)
Alien (Case) Number
Birth Date
1. Chest X-Ray
(Mark All that Apply)
TB Signs or Symptoms
History of Tuberculosis (TB) Disease
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 if Symptomatic)
(Need Smears)
Infiltrate or Consolidation
Follow-Up Needed
Discrete Fibrotic Scar or Linear Opacity
Musculoskeletal
Discrete Nodule(s) without Calcification
Any Cavitary Lesion
Discrete Fibrotic Scar with Volume Loss
Cardiac
Nodule with Poorly Defined Margins
or Retraction
(Such as Tuberculoma)
Pulmonary
Discrete Nodule(s) with Volume Loss or
Pleural Effusion
Retraction
Other
Other (Such as Bronchiectasis)
Hilar/Mediastinal Adenopathy
No Follow-Up Needed for
Linear, Interstitial Markings
Pleural thickening, diaphragmatic tenting,
blunting costophrenic angle, solitary calcified
Other
(Such as Miliary Findings)
nodule or granuloma or minor
Remarks
musculoskeletal or cardiac finding
3. Sputum Smears
X-Ray Suggests INACTIVE TB, this is a Class B2/TB
No, Applicant has No Signs or Symptoms of TB and :
OTHER X-Ray Findings Suggest Follow-Up Needed after Arrival, this is B Other
OTHER X-Ray Findings Suggest No Follow-Up Needed, this is No Class
X-Ray Normal, this is No Class
Yes, Applicant has
(Mark All that Apply) :
and Smear Results are:
Dates Obtained
(mm-dd-yyyy)
Positive
Negative
Signs or Symptoms of TB Present, See Section 1
X-Ray Suggests ACTIVE TB, See Section 2
Sputum Smear Results and X-Ray
Three Smear Results NEGATIVE and
At least One Smear Result POSITIVE and
X-Ray Normal with
Signs of Symptoms Resolved, this is
No Class
Any Chest X-Ray Finding, this is Class
Signs or Symptoms Suggest Follow-Up Needed after Arrival, this is B Other
(Normal or Abnormal findings)
X-Ray Suggests ACTIVE or INACTIVE TB, this is Class B1/TB
OTHER X-Ray Findings Suggest Follow-Up Needed After Arrival, this is Class B
4.
Class B Other, Follow-Up
No Class
Class A/TB
Class B1/TB
Class B2/TB
5.
Follow-Up
Needed
After
TB Condition
No
Yes
If Yes, for
Not 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
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