OMB control number

Medical Examination for Visa or Immigration Benefit

OMB 1405-0113 · STATE/AFA.

OMB 1405-0113

Forms in this collection record the medical information necessary to determine whether an alien seeking entry to the United States has a medical or other condition affecting his or her eligibility for a visa or immigration benefit. Forms are completed by panel physicians on behalf of visa applicants; refugees; refugees and asylees (including “following-to-join"); and certain parolees.

The latest form for Medical Examination for Visa or Immigration Benefit expires 2029-04-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Form DS-2054 Medical Examination for Immigrant or Refugee Applicant Form
(010) Tab 9 - Consolidated Public Comments Received from 60-day FRN - MED Forms - 2025.docx Supplementary Document
(004) Tab 3 - Legal Authorities - 30-day PRA - MED Forms - 2025.docx Supplementary Document
FW COVID 19 Vaccine Update.msg Supplementary Document
DS-3025 nonsub change justification.docx Justification for No Material/Nonsubstantive Change
(004) Tab 3 -- Legal Authorities -- 30 Day Paper Medical.docx Supplementary Document
SIGNED T3837-21 - PRA Emergency Approval for COVID-19 Vaccine.pdf Supplementary Document
Justification for Emergency Approval.docx Supplementary Document
Legal Authorities.docx Supplementary Document
(003) Tab 2 - Supporting Statement - 30-day PRA - MED Forms - 2025.docx Supporting Statement A
Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Medical Examination for Immigrant or Refugee Applicant Form and Instruction
Medical Examination for Immigrant or Refugee Applicant Form

All Historical Document Collections

202601-1405-002	Revision of a currently approved collection	2026-01-08
202503-1405-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2025-03-20
202207-1405-004 Approved without change	Revision of a currently approved collection	2022-07-21
202112-1405-010 Approved with change	Revision of a currently approved collection	2021-12-20
202010-1405-004	Revision of a currently approved collection	2020-10-23
201709-1405-003 Approved without change	Revision of a currently approved collection	2017-09-15
201501-1405-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-01-05
201410-1405-004 Improperly submitted and continue	No material or nonsubstantive change to a currently approved collection	2014-10-29
201407-1405-004 Approved without change	Revision of a currently approved collection	2014-07-21
201105-1405-007 Approved without change	Revision of a currently approved collection	2011-06-07
201005-1405-004 Approved without change	Revision of a currently approved collection	2010-05-10
200911-1405-003 Approved without change	Revision of a currently approved collection	2009-11-23
200904-1405-002 Approved without change	Revision of a currently approved collection	2009-04-09
200901-1405-001 Withdrawn and continue	No material or nonsubstantive change to a currently approved collection	2009-01-26
200801-1405-004 Approved without change	Revision of a currently approved collection	2008-01-31
200707-1405-001 Approved without change	Revision of a currently approved collection	2007-07-03
200601-1405-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-01-24
200504-1405-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2005-04-27
200402-1405-002 Approved with change	Extension without change of a currently approved collection	2004-02-05
200104-1405-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2001-04-11
200004-1405-003 Approved without change	Revision of a currently approved collection	2000-04-25
199907-1405-009 Approved without change	Existing collection in use without an OMB Control Number	1999-07-09

OMB Details

Medical Examination for Immigrant or Refugee Applicant

Federal Enterprise Architecture: International Affairs and Commerce - Foreign Affairs

Form DS-3026	Medical History and Physical Examination Worksheet	Fillable Printable	Form and instruction
Form DS-3030	Tuberculosis Worksheet	Fillable Printable	Form and instruction
Form DS-3025	Vaccination Documentation Worksheet	Fillable Printable	Form and instruction
Form DS-2054	Medical Examination for Immigrant or Refugee Applicant	Fillable Printable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.