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-3025	Vaccination Documentation Worksheet	ds3025 - DRAFT - 10-23-2017 - flat.pdf		No		Fillable Printable
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	ds3026 - DRAFT - 10-23-2017 - flat.pdf		No		Fillable Printable
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant	ds2054 - DRAFT - 10-23-2017 - flat.pdf		No		Fillable Printable
Form and Instruction	DS-3030	Tuberculosis Worksheet	ds3030 - DRAFT.pdf		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: SORN Visa Records, State-39	FR Citation: 60 FR 148

Number of Respondents: 828,728	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	828,728	0	168,728	0	0	660,000
Annual IC Time Burden (Hours)	828,728	0	168,728	0	0	660,000
Annual IC Cost Burden (Dollars)	372,725,100	0	82,475,100	0	0	290,250,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.