Fillable Ds-3025 Form - Vaccination Documentation Worksheet (Page 2 of 2) in pdf

4. Contraindication to vaccination

If a vaccination was contraindicated, mark which contraindication were present (mark all that apply)

Pregnant

Immune compromised

History of severe allergic reaction to vaccine or vaccine component

Other severe reaction to vaccine

Current moderate to severe illness

Other, specify:

5. Remarks

6. Panel Physician Initials

Date (mm-dd-yyyy)

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for

searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and

reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control

number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them

to: PRA_BurdenComments@state.gov

CONFIDENTIALITY STATEMENT

AUTHORITIES The information asked for on this form is requested pursuant to Section 212(a) and 221(d) and as required by

Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State and of

diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United

States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the

immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary

of State, be made available to a court provided the court certifies that the information contained in such records is needed in a case

pending before the court.

PURPOSE The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and

eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may

be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or

prevent the processing of your case.

ROUTINE USES If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the

Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so

indicate, the Social Security Administration will use the information to issue a social security number. The information provided may

also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts

within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws.

More information on the Routine Uses for this collection can be found in the System of Records Notice State-24, Medical Records.

DS-3025

Page 2 of 2

Ds-3025 Form - Vaccination Documentation Worksheet Page 2