Revised Department of State (DS) Medical Examination Forms

Frequently Asked Questions for Panel Physicians

General Questions regarding the DS Medical Examination Forms

Why did the Department of State (DS) medical forms change?

The State Department, in collaboration with CDC, revised the DS medical examination forms as part of an ongoing effort to better reflect the current Technical Instructions [PDF – 40 pages]. The changes also help to improve the collection and recording of immigrant medical examination information.

Where can I get copies of the new DS forms?

All DS forms are posted by the State Department on their internal eForms site. Only the Department of State is allowed to provide forms to panel physicians or consular sections. Thus, you should contact your local consular section to request copies of the new DS forms. CDC will not distribute copies of the DS forms to panel physicians or consular sections.

When should I begin using the new DS forms?

The new forms are effective as of October 1, 2014. All panel physicians should use the new forms on this date. If you are not using the forms yet, you should begin doing so immediately.

Do each of the DS forms now require a separate photograph?

Yes, each form will need a copy of the same photograph attached to the front. This was added as a fraud prevention measure.

About the DS 2054: Medical Examination

For section 2, which box should be checked for non-immigrant and refugee applicants?

Section 2 on the DS 2054 refers only to immigrant visa applicants. Non-immigrant and refugee applicants are exempt from vaccination requirements. Panel physicians should leave this section blank for non-immigrant or refugee applicants.

What do I do if an applicant does not know his or her future US address or does not have an email address? Can these be left blank?

Panel physicians should do their best to get as much information from the applicant as possible. If no address is given, you may leave these sections blank. If the applicant has no email address, you may leave that area blank.

Can you clarify the different applicant categories: SIV, adoptee, refugee, asylee visa 92, visa 93, parolee?

Panel physicians should work with their consular section to clarify these categories. Please note that most applicants are not in these categories.

If an applicant refuses immunization, is he or she Class A?

Yes. Immigrant visa applicants must fulfill the vaccine requirements to complete their medical examination. Therefore, if they refuse the immunizations, they are Class A. If an immigrant visa applicant objects to all vaccination based on religious or moral convictions, the applicant will have to request an individual waiver from the US Department of Homeland Security.

About the DS 3026: Medical History and Physical Examination

In Section 1, under “Pulmonology,” do the TB symptoms of fever, cough, night sweats, and weight loss relate to current symptoms or a past diagnosis of TB?

These symptoms apply to current symptoms of TB.

In Section 1, for “TB history: Treated,” should we list the start of treatment or end of treatment?

For this section, please use the date that the person was diagnosed with TB disease.

In Section 1, for “TB history: Treated,” can we include history of treatment for extrapulmonary tuberculosis?

Yes, you can include extrapulmonary TB for this item.

In Section 3, should a circumcision be listed as a minor surgery?

If the circumcision did not have any complications, there is no reason to record it as a surgery.

In Section 5, the item “Circumcision” is no longer listed under “Genitalia.” If an applicant is circumcised, should we check “normal” or “abnormal?

CDC does not consider a circumcised ma to be “abnormal.” If an applicant is circumcised, you should check “normal.” Applicants who are uncircumcised should also be checked as “normal.”

In Section 5, the not done (ND) check box has been removed. In the case that the examination was not done, which box should we check?

Each aspect of the physical examination should be performed on all applicants. Thus, forms are not considered complete if parts of the exam have not been completed and recorded on the DS forms.

Is current pregnancy still considered a Class B condition?

No, pregnancy is no longer considered a Class B condition. It is now “No Class.”

In Section 5, “Breast” has been removed. Is a breast examination required?

No, panel physicians do not need to perform a breast examination.

For women over 40 or with a history of breast disease, where do I record this?

If a woman has a history of breast disease, please note under “Other” in Section 1.

About the DS 3030: Tuberculosis Worksheet

For applicants who are 0-2 years old with a normal medical examination, how should the DS 3030 be completed? Should the radiologist or panel physician sign the form in this situation?

In this case, the panel physician should mark the “Chest X-Ray not indicated” box. The radiologist does not need to sign the form.

In Section 3 for “Chest X-Ray Findings,” should we still report minor findings, such as degenerative changes of the thoracic spine, mild dextroscoliosis, etc.? Or should we just concentrate on Class B findings?

Yes, you may still report minor findings. Please list them in the remarks section.

If an applicant is HIV positive, with no clinical signs and symptoms of TB, a normal chest x-ray, and negative sputum smears, is he or she classified as Class B1 TB, Pulmonary?

Yes, this applicant would receive a Class B1 TB, Pulmonary classification. This is a slight change from the previous form. This change will mean that all applicants who are required to provide sputum specimens for smear and culture will receive a Class B1 TB, Pulmonary classification. This will resolve ongoing confusion over having two different classifications for applicants providing sputum specimens.

If applicant had TB years ago and was successfully treated, where should I document it?

If the TB was treated by a CDC Division of Global Migration and Quarantine-approved treatment site, this should be documented in Section 7 of the DS 3030. If treated by an outside, non-approved clinic, this can be documented in the remarks section. Additional records and lab results should be attached, if available.

Regarding the DST results table in Section 7, what date should we use for “Date specimen obtained? Should we use the sputum collection date or the date of positive culture result for DST?

“Date specimen obtained” for DST results should be the actual sputum collection date.

About the DS 3025: Vaccination Worksheet

In my country, we don’t have MCV4 or another MCV conjugate. Can we use MPSV4 instead?

According to the CDC Pink Book, routine vaccination of civilians with MPSV4 is not recommended. Use of MPSV4 should be limited to persons older than 55 years of age, or when MCV4 is not available.

However, there are several reasons why a panel site should not administer MPSV4 as a routine vaccination, even when MCV4 is not available. As compared to MPSV4, MCV4

1. Confers longer protection.
2. Reduces nasal carriage more effectively.
3. Induces herd immunity.

MCV4, therefore, has many benefits that MPSV4 does not, even though the two vaccine preparations contain the same 4 antigens (A, C, Y, W-135). CDC advises that you instead indicate that MCV4 is not routinely available in country. This way, MCV4 can be given in the US without confusion.

In Section 2, the blanket waiver option is now under the heading entitled “US vaccination requirements complete.” However, on the previous version of the form, this option was listed under “Vaccination history incomplete.” Please explain this change.

When CDC revised the forms, this language was changed from “Vaccination history” to “US vaccination requirements” to better reflect the needs of the medical examination for visa purposes. Thus, an applicant requesting a blanket waiver would satisfy US vaccination requirements.

This differs from the scenarios listed under “US vaccination requirements incomplete,” in which the US vaccination requirements are not satisfied.

What box should be checked for an applicant who is not required to get vaccinations by a panel physician (such as Non-Immigrant Visa (NIV) and refugee applicants)?

In some cases, such applicants have the option of receiving vaccinations by a panel physician. However, they are not required to do so. In these cases, if an applicant is not vaccinated by the panel physician, he or she is not requesting exemption, but rather is simply choosing to receive them once he or she is in the United States. In this case, you should leave the DS 3025 blank. It may also be helpful to record that the applicant will be vaccinated in the US, but this is not required by CDC.