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Instructions to Panel Physicians for Completing Vaccination Documentation Worksheet (DS-3025)
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.
Each immigrant applicant must as part of his or her health assessment have:
- Assessment of any vaccine needed—copy dates of all acceptable documented vaccinations from written records and administer needed vaccines, and
- Complete results of assessment and administration.
Complete the top section with the applicant's:
- Name (last name, first name, and middle name).
- Date of the examination giving month, day, and year.
- Birth date giving month, day, and year.
- Passport number.
- Alien number, or case number if a refugee, whichever if available.
See the 'Technical Instructions to Panel Physicians for Vaccination Requirements (revised December 2002)' [
82 KB, 12 pages] for more details. The one difference from the old Supplemental Form to OF-157 is under the column of Blanket Waivers To Be Requested If Vaccination Not Medically Appropriate, is Not Routinely Available has replaced Not Available. Each row in SECTION 1. Immunization Record of the worksheet must have at least one check mark.
SECTION 2. Results must also be completed. If the box to the left of "Vaccine history incomplete" (at least one more vaccine of any series is needed to complete the series) is checked, either the box to the left of:
- "Applicant may be eligible for blanket waiver(s) because vaccination(s) not medically appropriate" or
- "Applicant will request an individual waiver based on religious or moral conviction"
must also be checked.
If all requirements are met (the applicant is immune or has received all vaccines needed to complete a vaccine series), the box to the left of "Vaccine history complete for each vaccine, all requirements met" is checked.
If the applicant refuses to meet the vaccination requirements and no waiver is requested, such as a waiver request on religious or moral grounds, the box to the left of "Applicant does not meet vaccination requirements for one or more vaccines and no waiver is requested" is checked.
The worksheet needs to have the panel physician's name written legibly, his or her signature (or another authorized personnel's signature in addition to panel physician's signature or stamp), and the date the form was completed (usually the date the vaccines were given).
This worksheet is useful for applicants after resettlement so each applicant should have his or her personal copy provided by the panel physician, in addition to the copy that is given to the embassy or consulate. Although this worksheet is not required for any refugee, if reliable vaccination documents are available, the panel physician should also complete this document and give the refugee a copy. This worksheet is accepted for a child attending a U.S. school, so it is very helpful after resettlement.