Fillable Medical Examination For Immigrant Or Refugee Applicant (Page 6 of 8) in pdf

Medical Examination For Immigrant Or Refugee Applicant Page 6

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PRIVACY ACT NOTICE

AUTHORITIES:

This information is sought pursuant to Section 212(a), 212(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 of 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.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average 30 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 burden and recommendations for reducing it to :

the U.S. Department of State (A/ISS/DIR) Washington, DC 20520-1849.

DS-3025

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Medical Examination For Immigrant Or Refugee Applicant Page 6

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