Medical Examination For Immigrant Or Refugee Applicant Page 8
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83. Additional Testing Needed Prior to Approving Medical Clearance
No Yes
Physical examination or laboratory results contradict medical history
Referral prior to departure If yes, provide results
Referral prior to departure If yes, provide results
4. Follow-up Needed After Arrival
No
Yes, within 1 week
Yes, within 1 month
Yes, within 6 months
For continuing medication, list type, dose, and frequency
For continuing other treatment, specify
5. Remarks (describe any abnormal history, abnormal findings, and resulting interventions)
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
Public reporting burden for this collection of information is estimated to average 35 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.
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DS-3026
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