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Instructions to Panel Physicians for Completing the U.S. Department of State Medical Examination for Immigrant or Refugee Applicant (DS-2053)
Please note: this page provides instructions for completing specific Department of State forms. The forms are not available on this website. Additional information about the forms is provided by the U.S. Department of State.
The information concerning the laboratory testing of applicants younger than 15 years of age was updated 4/02. See Technical Instructions and Updates for a summary of the changes.
This form is required for immigration. It is the summary of the three worksheets, plus it contains the results of the required laboratory tests for any applicant (immigrant and refugee) older than 14 years of age.
Complete Sections 1 Through 3 on the DS-2053.
The panel physician or a member of the physician's professional staff must complete the top section. This includes the applicant's:
- Name (LAST NAME ALL IN CAPITAL LETTERS, first name, and middle name).
- Birth date giving month, day, and year.
- Sex, either male (M) or female (F).
- Place of birth, city and country.
- Present country of residence.
- Prior country of residence. For refugees, this may be their country of birth or another second country of asylum. For immigrants, it may not apply (no prior country of residence exists).
- U.S. consul or embassy, city and country.
- Passport number.
- Alien number, or case number if a refugee, whichever is available.
- Date of prior examination (if any). If the applicant has had a prior examination by a panel physician and that examination has expired; enter the date of the prior examination.
- Date the examination expires, which is 6 months from the day of the examination (which may be different from the date laboratory tests are obtained or chest X-ray is taken) if a Class A or other tuberculosis (B1 or B2) condition is found or 12 months from the day of the examination if not Class A or other tuberculosis condition is found. Arrangements may be made with the Consular Section of the U.S. Embassy for it to complete the examination expiration date.
- Place of examination, city and country.
- Name of the panel physician, last name and then first name.
- Name of radiology facility or service. The director's of the radiology facility or the person reading the X-ray signature is not required. The panel physician is responsible for the results of any X-ray reading. If desired, the panel physician can ask for a signature from the radiology facility or radiologist. This can be placed in SECTION (2)—Chest X-ray Findings, under the Remarks row on DS-3024.
- Name of screening facility or site where the panel physician works (such as St. Joseph Clinic).
- Name of the laboratories, first HIV laboratory name, then syphilis laboratory name, and finally TB microscopy laboratory name (where the sputum smear microscopy is performed), each name is separated by a "/". The laboratory (syphilis or HIV) director's or the person performing the test signature is not required. The panel physician is responsible for the results of any laboratory testing. If desired, the panel physician can ask for a signature from the laboratory for the syphilis and HIV results. This can be placed in SECTION (2)—Laboratory Findings, under the Notes column of each test on DS-2053.
Attach a current signed photograph of the applicant that has been verified by the panel physician or a member of the physician's professional staff by comparing it with the applicant and his or her photograph in an official document such as a passport or letter from the International Organization for Migration.
SECTION (1)—Classification
Under Classification, the panel physician must check all the boxes that apply. If no defect, disease, or disability is found during the past medical history, the physical examination, or routine laboratory testing, check the box next to "No apparent defect, disease, or disability."
If a Class A condition is found, check the box next to "Class A Conditions." Next check the box next to the condition(s) that is Class A. If active, infectious tuberculosis (TB) was identified, make sure that the CHEST X-RAY AND CLASSIFICATION WORKSHEET (DS-3024) is completely filled out.
If a Class B condition is found, check the box next to "Class B Conditions." Next check the box next to the condition(s) that is Class B. A Class B condition is being defined as a condition that will require follow-up care (medication or other treatment) for the well being of the individual. Past conditions that have no impact on an individual's current or future health and well being need not be noted. If active, noninfectious TB (B1) or inactive TB (B2) was identified, make sure that the CHEST X-RAY AND CLASSIFICATION WORKSHEET (DS-3024) is completely filled out. If it is a condition not listed, check the box next to "Other" and give details on the condition. Make sure that the MEDICAL HISTORY AND PHYSICAL EXAMINATION WORKSHEET (DS-3026) is also completed.
SECTION (2)—Laboratory Findings
In this section, the panel physician must complete all lines and check all boxes that apply. These routine tests are necessary for all applicants older than 14 years of age or for applicants younger than 15 years of age, if there are reasons to believe possible infections exist (such as the parents are known to have HIV or syphilis infection).
For Syphilis
If the test is not performed, check "Not done."
If the test is performed,
- List the "Screening" test name used followed by the "Confirmatory" test name if the screening test is positive or reactive.
- Give the "Date(s)" (month, day, and year) that each test is run.
- Check the box corresponding to the correct result(s) of the test(s).
- Give the "Titer" of the reaction, if possible for the screening test that is reactive. Having the initial titer is beneficial for assessing if overseas treatment was sufficient (repeat titers will be performed after 3 to 6 months).
- Include any additional "Notes" for the resettling health department.
- Check the "Yes" box for type of treatment given, for confirmed positive results.
- Check the box to the left, if benzathine penicillin is given. If benzathine penicillin is not given, check the box to the left of "Other" and write the therapy and dose given.
- Give the Dates of the treatment(s) (month, day, and year).
For HIV
If the test is not performed, check "Not done."
If the test is performed,
- List the screening test name and brand, followed by Secondary screening name and brand (if the first screening test is positive or indeterminate), and finally the Confirmatory test name and brand if the second screening test is positive or indeterminate.
- Give the "Date(s)" (month, day, and year) that each test is run.
- Check the box corresponding to the correct result(s) of the test(s), either "Negative," "Positive," or "Indeterminate."
- Include any additional "Notes" for the resettling health department, such as whether the applicant is symptomatic or if he or she has AIDS (acquired immunodeficiency syndrome).
SECTION (3)—Immunization
This section refers to the VACCINATION DOCUMENTATION WORKSHEET (DS-3025) and corresponds to the SECTION 2. Results of that form. The results from that worksheet need to be transcribed here as a summary of the vaccination assessment and administration.
However, if a separate institution does the vaccination by prior agreement with the U.S. Embassy or Consulate, the panel physician can write, "see DS-3025—Vaccination Documentation Worksheet" and it will be the responsibility of the Consular Section to verify that the vaccines have been given.
Again, remember to give the applicant a personal copy of the VACCINATION DOCUMENTATION WORKSHEET (DS-3025).
The applicant and panel physician must sign this form, and put the date that the form is completed. The consular officer at the U.S. consul or embassy will check the signatures periodically as a fraud prevention measure.
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