Medical Examination For Immigrant Or Refugee Applicant Page 4
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8PAPERWORK 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
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