Medical Examination For Immigrant Or Refugee Applicant Page 5
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8U.S. Department of State
OMB No. 1405-0113
EXPIRATION DATE: 09/30/2010
VACCINATION DOCUMENTATION WORKSHEET
ESTIMATED BURDEN: 20 minutes
(See Page 2 - Back of Form)
For Use with DS-2053
To Be Completed by Panel Physician Only
Name (Last, First, MI.)
Exam Date (mm-dd-yyyy)
REQUIRED FOR U.S. IMMIGRANT VISA APPLICANTS
NOT REQUIRED FOR REFUGEE APPLICANTS
Passport Number
Alien
Number
Birth Date (mm-dd-yyyy)
(Case)
NOTE FOR PANEL PHYSICIANS:
For refugee applicants, please complete only if reliable
vaccination documents are available.
1. Immunization Record
Completed Series
Vaccine History Transferred From a Written Record
Blanket Waiver(s) To Be Requested If Vaccination Not
Vaccine Given
(
if Completed,
(List Chronologically from Left to Right)
Medically Appropriate, Check Suitable Box(es) Below
by
Write "VH" if Varicella
Date Received
Date Received
Date Received
Date Received
Panel Physician
History, or write Date
Not Age
Insufficient Time
Contra-
Not Routinely
Not Fall
Vaccine
(mm-dd-yyyy)
of Lab Test if Immune)
(Flu) Season
(mm-dd-yyyy)
(mm-dd-yyyy)
(mm-dd-yyyy)
(mm-dd-yyyy)
Appropriate
Interval
indicated
Available
DT/DTP/DTaP
Td
(OPV/IPV)
Polio
Measles (or MR
or MMR)
Mumps
(or MMR)
Rubella (or MR
or MMR)
Rotavirus
Hib
(Haemophilus
Type B)
Influenzae
Hepatitis A
Hepatitis B
Meningococcal
Human
papillomavirus
Varicella
Pneumococcal
Influenza
2. Results
Vaccine History Incomplete
Applicant may be eligible for blanket waiver(s) because
3. Panel Physician (Name)
vaccination(s) not medically appropriate (as Indicated Above).
Panel Physician (Signature)
Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met (Documented Above).
Date (mm-dd-yyyy)
Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested.
DS-3025
Page 1 of 2
Give Copy to Applicant
09-2007
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