Ds-3025 Form - Vaccination Documentation Worksheet
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2OMB No. 1405-0113
U.S. Department of State
EXPIRATION DATE: 09/30/2017
VACCINATION DOCUMENTATION WORKSHEET
Photo
ESTIMATED BURDEN: 30 minutes
(See Page 2 of 2)
To Be Completed by Panel Physician Only
For US Vaccination Requirements
GIVE COPY TO APPLICANT
Name (Last, First, MI)
Birth Date (mm-dd-yyyy) Exam Date (mm-dd-yyyy)
Blanket Waiver(s)
To Be Requested
If Vaccination Not
Medically
Passport Number
Alien (Case) Number
Appropriate.
Indicate reason
Vaccine
For Designated
Test for
1. Immunization Record
below.
Given By
Refugees Only:
Immunity
Vaccine History Transferred From a Written Record
Panel
Additional Vaccine
Mark all that apply
List Chronologically from Left to Right. Provide date as mm-dd-yyyy
Site
Given by IOM*
(see legend):
A, B, C, D, F, H
Date
Date
Date
Date
Date
Date
Date
Date
Vaccine
Diphtheria, tetanus, pertussis
DT, DTP, DTaP
Td
Tdap
Polio
OPV
IPV
Measles, mumps, rubella
MMR
Measles
Mumps
Rubella
Rotavirus
RotaTeq (RV5)
Rotarix (RV1)
Hib
Hepatitis A
Hepatitis B
Meningococcal
MCV4
Other MCV conjugate
Varicella
Vaccine
Varicella History
Pneumococcal
PCV 7
PCV 10
PCV 13
PPSV 23
Influenza
Other
2. Summary for
US vaccination requirements
US vaccination requirements NOT Complete:
Immigrant Visa
COMPLETE
Requesting Individual Waiver based on religious
Applicants
(Requesting a Blanket Waiver)
or moral convictions
Requesting Adoptee Exemption
Applicant refuses vaccinations
Panel Physician signature
Date (mm-dd-yyyy)
3. Panel Physician Name (printed)
I attest I performed this examination and have an agreement with the Department of State or
supervised completion of this form. I am the same Panel Physician that signs the DS 2054.
* Only for designated refugees in special IOM
Blanket waiver legend:
A Not age appropriate B Insufficient time interval to complete series
vaccination program
C Contraindicated D Not routinely available F Not flu season H Known chronic hepatitis B virus infection
DS-3025
Please complete Page 2
Page 1 of 2
09-2014
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