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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Medical Examination for Immigrant or Refugee Applicant
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
DS-2053
Medical Examination for Immigrant or Refugee Applicant (1991 TI)
DS-2053.pdf
Yes
No
Printable Only
Form and Instruction
DS-2054
Medical Examination for Immigrant or Refugee Applicant (2007 TI)
DS-2054.pdf
Yes
No
Printable Only
Form and Instruction
DS-3024
Chest X-Ray and Classification Worksheet (1991TI)
DS-3024.pdf
Yes
No
Printable Only
Form and Instruction
DS-3025
Vaccination Documentation Worksheet
DS-3025.pdf
Yes
No
Printable Only
Form and Instruction
DS-3026
Medical History and Physical Examination Worksheet
DS-3026.pdf
Yes
No
Printable Only
Form and Instruction
DS-3030
Chest X-Ray and Classification Worksheet (2007 TI)
DS-3030.pdf
Yes
No
Printable Only
Form and Instruction
Main Medical Form
Medical Examination for Immigrant or Refugee Applicant (Canada)
Canada MainMedForm.pdf
Yes
No
Printable Only
Form and Instruction
Medical Worksheet One
Chest X-Ray and Classification Medical Worksheet One (Canada)
Canada MedWksht1.pdf
Yes
No
Printable Only
Form and Instruction
Medical Worksheet Two
Vaccination Documentation Medical Worksheet Two (Canada)
Canada MedWksht2.pdf
Yes
No
Printable Only
Form and Instruction
Medical Worksheet Three
Medical History and Physical Examination Medical Worksheet Three (Canada)
Canada MedWksht3.pdf
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
630,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
630,000
0
0
0
0
630,000
Annual IC Time Burden (Hours)
630,000
0
0
0
0
630,000
Annual IC Cost Burden (Dollars)
283,500,000
0
0
0
0
283,500,000
Documents for IC
Title
Document
Date Uploaded
Canadian Forms Justification (4-09)
Canadian Forms Justification.doc
04/09/2009
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.