Form I-693 Report of Medical Examination and Vaccination Record

DRAFT - Not for production use

OMB No. 1615-0033; Expires 06/30/07

I-693, Report of Medical
Examination and Vaccination Record

Department of Homeland Security
U.S. Citizenship and Immigration Services

Instructions
NOTE: Please read these instructions carefully to properly complete this form. If you need more space to complete an
answer, use a separate sheet(s) of paper. Write your name and Alien Registration Number (A #), if you have one, at the top of
each sheet(s) and indicate the number of the item that refers to your answer.

The instructions on this form are organized as
follows:
Section I - Applicant's Instructions - Pages 1-2.

The results of your medical examination are confidential and
are used for immigration purposes only. When required to do
so by law, the civil surgeon may share your results with public
health authorities.

How Do I Find a Designated Civil Surgeon?

NOTE: If you are applying for adjustment of status at least
one year after your first admission to the United States as a
refugee or as a "K" or "V" nonimmigrant visa holder, see
Questions 1-3 in Section III, Frequently Asked Questions,
before proceeding any further.

How Do I Fill Out My Portion of Form I-693?

How Do I File Form I-693?

How Do I Submit Form I-693 to USCIS?

A separate Form I-693 is required for each applicant. There is
no filing fee for this form. Follow these steps:

What Is the Purpose of Form I-693?
How Do I File Form I-693?

Section II-Civil Surgeon's Instructions - Pages 2-4.
What Are My Responsibilities as a Civil Surgeon?
How Do I Fill Out My Portion of Form I-693?
How Do I Complete Form I-693 If I Need to Make a
Referral?
What Do I Do After the Medical Exam and Follow-Up
(If Required) Are Completed?

Section III - Frequently Asked Questions (FAQs) Pages 4 - 6
Section IV- USCIS Information - Page 6.
How Do I Get Other Forms and Related Information?
USCIS Processing Information.

Section I - Applicant's Instructions.
What Is the Purpose of Form I-693?
Generally, all applicants filing for adjustment of status to that
of a permanent resident must submit a Form I-693 completed
by a designated civil surgeon. Form I-693 is used to report to
U.S. Citizenship and Immigration Services (USCIS) results of
a medical examination. The examination is required to
establish that you are not inadmissible to the United States on
public health grounds. A list of those health grounds can be
found in section 212(a)(1) of the Immigration and Nationality
Act. The list is also available in Question 7 of Section III,
Frequently Asked Questions.

Step 1 - Carefully read all these instructions, including
Section III, Frequently Asked Questions.
Step 2 - Call a designated physician (also known as a civil
surgeon) to make an appointment.
Step 3 - Fill out Part I of the form. Do not sign the form.
Step 4 - Attend your medical exam appointment and all
follow-up exams, as may be required. Sign Form
I-693 in front of the civil surgeon.
Step 5 - Submit Form I-693 in the sealed envelope to USCIS
according to the instructions on the Form I-485,
Application to Register Permanent Residence or
Adjust Status. USCIS will return the form to you
and/or request another Form I-693 if it is not in an
envelope or if the envelope has been opened or
altered.

Notice.
USCIS wants to make sure that you receive a correct decision
on your application for the requested immigration benefit. To
do this, we may ask for more evidence, interview you or the
civil surgeon performing the medical exam, or conduct an
inquiry. If either party gives false documents,
misrepresents facts or otherwise engages in fraud,
appropriate action will be taken. This means that USCIS
will not only deny the benefit application, you may also lose
current and future immigration benefits and the physician's
civil surgeon designation will be revoked. In addition, all
parties may face criminal and/or civil prosecution leading to
fines and/or imprisonment.
Form I-693 (Rev. 03/06/07)N

NOTE: The civil surgeon will ask you to verify your
identity. Take a Government issued photo I.D. to your
appointment. (Example: your valid unexpired passport or
driver's license.) For applicants under 14 years, USCIS will
accept other proof of identity that shows name, date and place
of birth, parents' full names and any other identifying
information about the applicant. Acceptable documents
include birth certificates (with translations if necessary) or
affidavits. Also take any vaccination records you may have to
the appointment.

-- A # - This is your alien registration file number. If you
are not sure if you have one, look at any letters or
notices you have received from the Department of
Homeland Security (DHS). Look for a number that
begins with a letter "A" and is followed by 8 or 9
numbers. (example: A 000 000 000). If you do not
have one or if you cannot remember what it is, leave
this space blank.

How Do I Find a Designated Civil Surgeon in
the Area Where I Live?

-- Certification - Do not sign here until the civil surgeon
tells you to do so.

To find a designated civil surgeon in your area, you can call
the USCIS National Customer Service Center (NCSC) at
1-800-375-5283 and follow the instructions in the automated
menu. Service is available in English and Spanish. A list of
the designated civil surgeons in your area can also be
generated by going to the Civil Surgeon page from the USCIS
website at www.uscis.gov and clicking on the Civil Surgeon
Locator link.

How Do I Fill Out My Portion of
Form I-693?
Use black ink only. Type or print clearly. If an item does not
apply to you, write "N/A" unless the specific instruction states
otherwise.
You should fill out only Part 1. The civil surgeon and any
other doctors, clinics or health departments receiving a
referral are required to complete Parts 2 through 6.
Part 1 - Information about you - Fill this part out before
your medical exam appointment.
-- Family name (Last Name) - Use your legal name. If
you have two last names, include both and use a
hyphen (-) between the names, if appropriate.
-- Home address - Give your physical street address.
This must include a street number and name or a rural
route number. Do not put a post office box (P.O. Box)
number here.
-- Date of birth - Use eight numbers to show your date
of birth (example: May 1, 1979, should be written
05/01/1979).
-- Country of birth - Give the name of the country
where you were born.

-- U.S. Social Security # - If you do not have a U.S.
Social Security number, leave this blank.

How Do I Submit Form I-693 to USCIS?
The civil surgeon is required to give you the completed
Form I-693 in a sealed envelope. Do not accept the form
from the civil surgeon if it is not in a sealed envelope.
USCIS will return the form to you if it is not in an
envelope or if the envelope has been opened or altered.
Adjustment of status applicants: If you are applying for
adjustment of status, submit Form I-693 according to the
instructions on Form I-485, Application to Register for
Permanent Residence or Adjust Status.
Other applicants: Follow the instructions on or included
with the application form or the instructions given to you
by the office requesting the medical exam.

Section II - Civil Surgeon's Instructions.
What Are My Responsibilities as
a Designated Civil Surgeon?
Truthfully and Accurately Report the Results. You are
responsible for reporting the results of the medical exam
and all laboratory reports on the Form I-693 where
indicated, and for signing the civil surgeon's certification
provided on the form. In this regard, you must take
reasonable steps to ensure that the person appearing for the
medical exam is the same person applying for the
requested immigration benefit. All applicants must present
a valid governement issued photo identification. The law
imposes severe penalties for knowingly and willfully
falsifying or concealing a material fact or using any false
documents in connection with this medical exam.

Form I-693 (Rev. 03/06/07)N Page 2

Follow HHS Guidelines. USCIS has designated you as a
civil surgeon with the understanding that you will perform
the medical exam according to U.S. Department of Health
and Human Services' regulations. These regulations
include the specific guidelines found in the Technical
Instructions for the Medical Examination of Aliens in the
United States (Technical Instructions), published by the
Centers for Disease Control and Prevention (CDC) in
Atlanta, Georgia. The Technical Instructions are available
on the CDC's website at http://www.cdc.gov/
ncidod/dq/civil.htm. CDC also posts periodic updates to
the Technical Instructions at http://www.cdc.gov/ncidod/
dq/updates.htm.
Give Pre-Test and Post-Test Counseling for HIV/AIDS.
All civil surgeons must give pre-test and post-test
counseling to any applicant who is tested for HIV. The
pre-test counseling must include an explanation of the
purpose of the test and basic information about HIV. Civil
surgeons must also provide post-test counseling to all
applicants who test HIV positive. You must provide
information to the applicant about the test results, the
prognosis, the ways the applicant can protect himself or
herself from opportunistic infections, the ways the
applicant can protect others from HIV transmission, and
about referrals for counseling and early medical
intervention. You will find specific instructions about these
pre-test and post-test requirements in CDC's Technical
Instructions.
Make Referrals and File Case Reports, as Required.
According to CDC's Technical Instructions, you are
required to:
-- Refer the applicant to the local health department if the
chest X-ray or skin test suggests TB or other
circumstances as described in CDC's Technical
Instructions. NOTE: CDC also recommends referral
to the local health department when the chest X-ray is
normal or not suggestive of TB, but the applicant has a
TST reaction of >10 mm in order to evaluate the
possible need for preventive therapy.
-- Ensure that any applicant diagnosed with syphilis is
treated with the standard treatment regimen described
in CDC's Technical Instructions.
-- Ensure that testing and therapy are given for diagnoses
of chancroid, gonorrhea, granuloma inguinale or
lymphogranuloma venereum.
-- Refer the applicant to a Hansen's disease specialist for
evaluation to confirm a suspected diagnosis of
Hansen's disease (leprosy).

-- File a case report with the appropriate public health
authorities if: (1) the applicant tests positive for HIV
infection; and/or (2) a case report is required by local
laws or regulations. You must also advise the applicant
that a case report is being filed.

How Do I Fill Out My Portion of
This Form?
The applicant fills out Part 1 of Form I-693 before the
medical exam appointment. You, the civil surgeon, are
responsible for ensuring the remaining parts are completed
and signed, as follows.
Part 2 - Medical exam. You must fill out this part and
provide the results of each component of the medical
exam relating to: communicable disease of public health
significance, vaccinations, physical or mental disorder
with associated harmful behavior, and substance or drug
abuse/substance or drug addiction. In Part 2, you must
also include the results of any lab work or other studies
required to determine whether the applicant is
inadmissible on health grounds. You must instruct
applicants who have had a tuberculin skin test (TST) to
return to your office within 48-72 hours to have the TST
read.
Part 3 - Referral to Health Department or Other
Doctor/Facility. If you refer the applicant to a local health
department or to another physician or clinic, you must also
fill out Part 3. Also see Part 5.
Part 4 - Physician or Health Department Receiving the
Referral. If you refer the applicant for further tests or
evaluation, the health care professional receiving the
referral must fill out and sign Part 4.
Part 5 - Civil Surgeon's Certification. You must sign the
certification after the initial medical exam and all referrals/
follow-up examinations (if required) have been completed.
Note: For referrals, complete the identifying information
in this part. Do not sign and date this part until the
referral/follow-up evaluation (if required) has been
completed and the applicant has been medically cleared.
Part 6 - Health Department Identifying Information.
If you are a state or local health department that is
completing the vaccination record on behalf of a refugee,
you must complete this part.

Form I-693 (Rev. 03/06/07)N Page 3

How Do I Complete Form I-693 If I
Need to Make a Referral?
Advise the applicant that the appropriate follow-up must be
obtained before medical clearance can be granted. In Part 3,
include the name, address and telephone number of the onward
physician or public health service facility that will conduct
further evaluation or provide treatment. Specify the type of
examination and additional tests or treatment the applicant
should receive. Complete the identifying information in Part
5, but do not sign or date. Make a copy of the Form I-693 for
your records and give the original form to the applicant in a
sealed envelope.

What Do I Do After the Medical Exam and
Follow-Up (If Required) Are Completed?
You and the applicant should sign your respective
certifications. After the medical exam (and any follow-up if
required) is complete write the results in Part 2 of the Form
I-693 as they relate to the specific component of the medical
exam. The applicant should sign the certification in Part 1 and
you should sign the civil surgeon's certification in Part 5. All
signatures on the form must be originals (no stamps or
facsimiles). Do not sign the form or have the applicant sign
the form until the applicant has met all health follow-up
requirements.
Give the results to the applicant. Give the completed Form
I-693 to the applicant in a sealed envelope. On the front of
the envelope write in capital letters: "DO NOT OPEN. FOR
USCIS USE ONLY." On the back of the envelope, write
your initials across the line where the flap of the envelope and
the envelope meet. Then, with clear cellophane tape, place the
tape with half on the flap of the envelope and half on the
envelope across the envelope's entire width (and across your
initials). USCIS will not accept Form I-693 if it is not in a
sealed envelope or if the envelope is altered in any way. Also,
you should keep a copy of the I-693 for your records.
Return all supporting medical documents to the applicant
and give them a copy of the vaccination record. Return all
supporting medical documents, including chest X-rays (if
obtained), directly to the applicant. In addition, give the
applicant a copy of the completed vaccination record in
Section 2. This supplement will serve as the applicant's
official vaccination record and may be retained by the
applicant for future use in establishing compliance with
vaccination requirements. (Example: school, day care,
employment, etc.)

Section III - Frequently Asked
Questions.
1. What if I am a refugee and already
had a medical exam overseas?
If you were admitted to the United States as a refugee and are
now applying for adjustment of status one year following
your first admission, you do not need to repeat the entire
medical exam you had overseas, unless a Class A medical
condition was found during that exam.
If a complete medical exam is not required, you only need to
comply with the vaccination requirements. This means you
only need to complete the vaccination section of Part 2, not
the entire Form I-693. Contact your state or local refugee
health coordinator to find out whether it may be possible for
you to have the vaccination portion of Form I-693 completed
by a state or local health department.

2. What if I am a K nonimmigrant visa holder
and already had a medical exam overseas?
If you were admitted as a:
K-1 fiancé(e) or a K-2 child of a K-1 fiancé(e), or as a
K-3 spouse of a U.S. citizen or a K-4 child of a K-3 spouse
of a U.S. citizen, and
You received a medical examination prior to admission,
then-

3. What if I am a V nonimmigrant visa holder
and already had a medical exam overseas?
If you were admitted to the United States or obtained status
while in the United States as a:
V-1 spouse of a permanent resident or awaiting a V-1 visa,
or as a
V-2 child of a V-1 spouse of a permanent resident, or as a
V-3 child of a V-2 unmarried son or daughter of a V-1
spouse of a permanent resident, and
You received a medical examination prior to admission or
obtaining V status, thenYou are not required to have another medical examination as
long as your Form I-485, Application to Register Permanent
Residence or Adjust Status, is filed within one year of your
overseas medical examination.

Form I-693 (Rev. 03/06/07)N Page 4

You will, however, be required to submit the vaccination
record with your adjustment of status application if the
vaccination record was not completed prior to admission to
the United States. A designated civil surgeon must complete
the vaccination section.

To test for:

Then:

Tuberculosis
(TB)

All applicants six months of age and older
are required to have a tuberculin skin test
(TST) given by the Mantoux technique.
(Civil surgeons may require an applicant
younger than six months to undergo a
TST if there is a history of contact with a
household member who has been
diagnosed with TB disease, or other
reason to suspect TB disease.) After the
skin test, you, the applicant, will need to
return to the civil surgeon within 48 to 72
hours to have the results read. If you have a
reaction of four millimeters or less,
generally you will not need any further tests
for TB. A chest X-ray is required when the
reaction to the TST is five millimeters or
more. The civil surgeon will explain the
medical requirements to you in more detail.

Syphilis

All applicants age 15 and older must have a
blood test for syphilis. Civil surgeons may
require applicants under age 15 to be tested
if there is reason to suspect the possibility of
infection.

HIV

All applicants age 15 or older must have a
blood test for HIV. Civil surgeons can
require applicants under age 15 to be tested
for HIV if there is reason to suspect the
possibility of infection. Civil surgeons are
required to provide pre-test counseling to all
applicants who take the HIV test. Civil
surgeons are also required to provide posttest counseling to any applicant who tests
positive for HIV.

4. May any doctor do the required medical exam?
Only a doctor who has been specially designated by USCIS as
a civil surgeon may do the medical exam. USCIS will not
accept a Form I-693 completed by a doctor who is not a
currently designated civil surgeon.

5. How do I know whether a doctor
is a designated civil surgeon?
You can obtain a list of the designated civil surgeons by
calling the USCIS National Customer Service Center at
1-800-375-5283, visiting the Civil Surgeon page from the
USCIS website at www.uscis.gov and clicking on the Civil
Surgeon Locator link, or by visiting your local USCIS office.
NOTE: If you choose to visit your local USCIS office, you
must first get an InfoPass appointment. For information on
InfoPass, visit the USCIS website at www.uscis.gov.

6. Who pays for the medical exam?
You, the applicant, are responsible for paying all costs of the
medical exam, including the cost of any follow up tests or
treatment that may be required. Payments are made directly
to the civil surgeon or other health care facility.

7. What are the medical grounds of inadmissibility?
The medical grounds of inadmissibility under the U.S.
immigration laws are divided into four categories communicable diseases of public health significance, lack of
required vaccinations, physical or mental disorders with
harmful behavior and drug abuse/drug addiction. The civil
surgeon is required to do a general physical exam and specific
evaluations, as described below.

Communicable Diseases of
Public Health Significance.

If you are found to have a communicable disease of public
health significance, the civil surgeon will advise you how to
obtain any necessary treatment. It also may be necessary for
you to apply for a waiver of inadmissibility. USCIS will
advise you if this is necessary. To obtain more information
about this waiver, visit the USCIS website at www.uscis.gov.

The civil surgeon is required to do specific tests for TB,
syphilis, and human immunodeficiency virus (HIV) infection.

Form I-693 (Rev. 03/06/07)N Page 5

Vaccination Requirements.

Physical or Mental Disorders.

All applicants for adjustment of status must present
documents showing they have been vaccinated against a broad
range of vaccine-preventable diseases. The civil surgeon will
review your vaccination history with you to determine
whether you have all the required vaccinations. Make sure
you take your vaccination records with you to your
appointment with the civil surgeon.

Are all physical or mental disorders considered
health-related grounds of inadmissibility?

NOTE: Please do not attempt to meet the requirements before
you are evaluated by the civil surgeon, in case it is not
medically appropriate for you to have one or more of the
required vaccines.
By law, the required vaccines include: mumps, measles,
rubella, polio, tetanus and diphtheria toxoids, pertussis,
influenza, hepatitis B, and any other vaccinations
recommended by the Advisory Committee for Immunization
Practices (ACIP).
If you never received or are unable to prove you received
certain vaccines, the civil surgeon can administer them to you.
You also have the option of asking your family doctor to
administer those vaccines to you and showing the records to
the civil surgeon to note on Form I-693.
If you initially did not have documents proving you received
all the required vaccines but later submit those documents, or
if the civil surgeon certifies that it is not medically appropriate
for you to have one or more of the missing vaccine(s), USCIS
may grant you a waiver based on the civil surgeon's
certification on the vaccination supplement.
HHS has determined that a vaccine is "not medically
appropriate" if : (a) the vaccine is not recommended for your
specific age group; (b) there is a medical reason why it would
not be safe to have the vaccine (for example, allergies to eggs
and yeast; pregnancy; hypersensitivity to prior vaccines; or
other medical reasons); or (c) you are unable to complete the
entire series of a required vaccine within a reasonable amount
of time.
If you object to receiving the recommended vaccinations
because of your sincerely held religious beliefs or moral
convictions, you may apply for a waiver of these
requirements. If you hold these objections, inform the civil
surgeon that you will apply for a waiver. If the waiver
application is denied, you may be ineligible for the
immigration benefit that you are seeking. To obtain more
information about these waivers, visit the USCIS website at
www.uscis.gov.

No. The emphasis is more on the behavior associated with the
physical or mental disorder, instead of the physical or mental
disorder itself. This means that the civil surgeon must
determine that there is behavior associated with the disorder
that is harmful either to you, to others or to property. If you
have had a history of a physical or a mental disorder, there
must be associated harmful behavior that is likely to recur in
order for you to be considered inadmissible.
The civil surgeon will ask you general questions during the
medical exam to determine whether you have such a
condition. Depending on the outcome of the initial exam, the
civil surgeon may find it necessary to refer you to a specialist
for further testing.
If the civil surgeon finds that you have a physical or mental
disorder with associated harmful behavior, you may apply for
a waiver according to the terms, conditions and controls
determined necessary by USCIS in consultation with HHS.
To obtain more information about these waivers, visit the
USCIS website at www.uscis.gov.

Drug Addiction/Drug Abuse.
What are the guidelines for determining whether
someone is a drug abuser/drug addict?
The civil surgeon will review your medical history during the
medical exam and ask you questions necessary to determine
whether you are currently using or have used in the past any
drugs or other psychoactive substances. The medical
guidelines of determining drug abuse and drug addiction are
determined by HHS.
If the civil surgeon determines you have a medical condition
of drug addiction/abuse, you are not eligible to apply for a
waiver unless you are applying for adjustment of status one
year after you were admitted as a refugee, or you are applying
for adjustment of status one year after you were granted
asylum. If you are ineligible to apply for a waiver, but are
later found by the civil surgeon to be in remission from the
drug abuse or drug addiction (as determined by HHS), you
may proceed with your adjustment of status application, if
eligible.

Form I-693 (Rev. 03/06/07)N Page 6

Section IV - USCIS Information.
How to Get USCIS Forms
and Related Information.
To request USCIS forms, call our toll-free forms line at
1-800-870-3676. You may also obtain USCIS forms and
information about immigration laws and regulations, policy
and procedures by calling our National Customer Service
Center at 1-800-375-5283 or visiting USCIS internet website
at www.uscis.gov.
Address Changes. If you change your address, you must fill
out and give us a Form AR-11, Alien's Change of Address
Card. Mail the completed form to:
U.S. Citizenship and Immigration Services
Change of Address
P.O. Box 7134
London, KY 40742-7134
For commercial overnight or fast freight services only, mail
to:
U.S. Citizenship and Immigration Services
Change of Address
1084-I South Laurel Road
London, KY 40744

Reporting Burden: A person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number.
We try to create forms and instructions that are accurate, can
be easily understood and impose the least possible burden on
applicants to provide us with information.
Accordingly, the reporting burden for this collection of
information is computed as follows: (1) learning about the
form, 30 minutes; (2) making an appointment with a civil
surgeon for a medical exam, 15 minutes; (3) taking the
medical exam, 1 hour; (4) reading the results of the tuberculin
skin test (TST) (which requires a second appointment with
the civil surgeon), 30 minutes; (5) reporting the results of the
medical exam on the form, 10 minutes; and (6) submitting the
medical exam report to USCIS, 5 minutes, for an estimated
average of 2 hours, 30 minutes per response.
If you have comments about this estimate or suggestions for
simplifying this form, write to: U.S. Citizenship and
Immigration Services, Regulatory Management Division, 111
Massachusetts Avenue N.W. , 3rd Floor, Suite 3008
Washington, DC 20529, OMB No. 1615-0033.
Do not mail your completed form to this Washington, D.C.
address.

Visiting a USCIS Office in Person - InfoPass. To visit a
USCIS office in person you must first have an appointment.
InfoPass is an internet-based system that allows you to make
an appointment to talk to an Immigration Information Officer
in person. To access InfoPass, log onto the internet website at
www.uscis.gov.

Processing Information.
Privacy Act Notice: The authority for collection of the
information requested on this form is contained in 8 U.S.C.
1182, 1183A, 1184(a), 1252, 1255 and 1258. The information
collected on this form will be used to determine whether you
are inadmissible on health grounds. Failure by the civil
surgeon or by you, the applicant being examined, to provide
all of the requested information may result in the delay of the
final decision, or in denial of the requested immigration
benefit. The information contained in this form may be
provided to other government agencies (federal, state and/or
local).

Form I-693 (Rev. 03/06/07)N Page 7

OMB No. 1615-0033; Expires 06/30/07

I-693, Report of Medical
Examination and Vaccination Record

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in CAPITAL letters. Use black ink.

Part 1. Information about you. (The person requesting a medical examination or vaccinations must complete this part.)
Family Name (Last Name)

Given Name (First Name)

Full Middle Name

Home Address: Street Number and Name

Apt. #

Gender:
Male

State

City

Phone Number (Include Area Code)

Zip Code

(
Date of Birth (mm/dd/yyyy) Place of Birth (City/Town/Village) Country of Birth

Female

)

A # (if any)

U.S. Social Security # (if any)

Applicant's Certification - Do not sign or date this form until instructed to do so by the civil surgeon.
I certify under perjury under United States law that I am the person who is identified in Part 1 of this Form I-693, Report of Medical Examination
and Vaccination Record, and that the information in Part 1 of this Form is true to the best of my knowledge. I understand the purpose of this medical
exam and I authorize the required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided
false/altered information or documents with regard to my medical exam, I understand that any immigration benefit I derived from this medical exam
may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties.

Signature

Date (mm/dd/yyyy)

Part 2. Medical examination. (The civil surgeon completes this part.)
1. Examination.
Date of First
Examination

Date(s) of Follow-up Examination(s) if Required:
Date of Exam
Date of Exam

Date of Exam

Summary of Overall Findings:
No Class A or Class B Condition

Class A Conditions (see 2 through 5 below)

Class B Conditions (see 2 through 6 below)

2. Communicable Diseases of Public Health Significance.
A. Tuberculosis (TB)
Tuberculin Skin Test (TST) (Required for applicants 6 months of age and older)
Date TST Applied

Date TST Read

Size of Reaction (mm)

Chest X-Ray - Required ONLY for TST reactions of > 5mm or an applicant with TB symptoms or immunosuppression (e.g. HIV. )
Attach copy of X-Ray Report.
Date Chest X-Ray
Taken

Date Chest X-Ray
Read

Results
Normal
Abnormal (Describe results in remarks.)

Findings:
No Class A or Class B TB

TB, active noninfectious, Class B1

TB, latent infection, Class B

TB, active infectious, Class A

TB, inactive, Class B2

Other (non-TB) condition noted on chest x-ray
that needs follow up, Class B other

Remarks: (Include any signs or symptoms of TB, additional tests, and therapy given, with stop and start dates and any changes.)

Form I-693 (Rev. 03/06/07)N

Part 2. Medical examination.

(Continued.)

B. Syphilis.
Serologic Test for Syphilis (Required for applicants 15 years and older)
Date Screening Run
Screening Nonreactive
Screening Reactive, Titer 1:

If Reactive, Date Confirmation Run

Confirmation Nonreactive
Confirmation Reactive

Findings:
Syphilis, Class A
(untreated)

No Class A or Class
B Syphilis

Syphilis, Class B (with residual
deficit, treated in the past year)

Remarks: (Include any therapy given with doses and dates.)

C. HIV/AIDS.
Serologic Test for HIV Antibody (Required for applicants 15 years and older)
If Positive or Indeterminate, Date
Confirmation Run

Date Screening Run

Confirmation Negative

Screening Positive

Confirmation Positive

Screening Indeterminate

Findings:
No Class A HIV

Screening Negative

HIV, Class A

Remarks: (Include any signs or symptoms of HIV infection, therapy given and any counseling or referrals.)

D. Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance.
Findings:
Chancroid, Class A

Gonorrhea, Class A

Hansen's Disease (Leprosy, Infectious), Class A

Granuloma Inguinale, Class A

Lymphogranuloma Venereum, Class A

Hansen's Disease (Leprosy, Noninfectious, Class B)

Remarks: (Include any therapy given and any counseling or referrals.)

3. Physical or Mental Disorders With Associated Harmful Behavior.
Physical/Mental Disorder, With Associated Harmful Behavior, Class A
Physical/Mental Disorder, Without Associated Harmful Behavior, Class B
Remarks: (Include diagnosis, with likelihood of harmful behavior to recur, therapy given and any counseling or referrals.)

4. Drug Abuse/Drug Addiction.
Substance (Drug) Use, Listed in Section 202 of Controlled Substance Act, Class A
Substance (Drug) Use, Not Listed in Section 202 of Controlled Substance Act, But With Associated Harmful Behavior, Class A
Prior Substance (Drug) Use in Remission, Class B
Remarks: (Include any therapy given, rehabilitation, counseling or referrals.)

Form I-693 (Rev. 03/06/07)N Page 2

Part 2. Medical examination.

(Continued.)

5. Vaccinations.
Vaccine History Transferred From a Written Record
Date
Received
mm/dd/yyyy

Vaccine

Date
Received
mm/dd/yyyy

Date
Received
mm/dd/yyyy

Vaccine
Given

Completed Series

Waiver(s) to Be Requested From USCIS

Date Given
by Civil
Surgeon
mm/dd/yyyy

Mark an X if
completed; write
date of lab test if
immune or "VH"
if varicella history

Blanket
Not Medically Appropriate
Not Age
Appropriate

Contra- Insufficient Time Not Flu
indication
Interval
Season

DT/DTP
Td
Polio (OPV/IPV)
Measles
(or MR or MMR)
Mumps
(or MMR)
Rubella
(or MR or MMR)
Hib
Hepatitis B
Varicella
Pneumococcal
Influenza

Give Copy to Applicant

Results:

Applicant may be eligible for blanket waiver(s) as indicated above.
Applicant will request an individual waiver based on religious or moral convictions.
Vaccine history complete for each vaccine, all requirements met.
Applicant does not meet immunization requirements.

6. List other medical conditions, Class B other (e.g. hypertension, diabetes).

Part 3. Referral to health department or other doctor/facility. (To be completed by Civil Surgeon, if referral was made.)
Type or Print Name of Doctor or Health Department

Date of Referral (mm/dd/yyyy)

Address: (Street Number and Name, City, State and Zip Code)

Daytime Phone Number (Include Area Code)

(

)

Remarks: (Include name of medical condition and reasons for referral.)

Form I-693 (Rev. 03/06/07)N Page 3

Part 4. To be completed by physician or health department performing referral evaluation.
The applicant identified on this form was referred to me by the civil surgeon named in Part 5 of this form. I have provided
appropriate evaluation/treatment.
Type or Print Full Name of Evaluating Physician or Health Department

Signature

Address: (Street Number and Name, City, State and Zip Code)

Date (mm/dd/yyyy)

Name of Medical Practice or Health Department

Daytime Phone Number (Include Area Code)

(

)

Remarks: (Attach a separate sheet of paper, if needed.)

Part 5. Civil surgeon's certification.

(Do not sign form or have the applicant sign in Part 1 until all health follow-up
requirements have been met.)

I certify under penalty of perjury under United States law that: I am a civil surgeon in current status designated to examine applicants seeking certain
immigration benefits in the United States; I have a currently valid and unrestricted license to practice medicine in the state where I am performing
medical examinations; I performed this examination of the person identified in Part 1 of this Form I-693, after having made every reasonable effort
to verify that person whom I examined is the person identified in Part 1; that I performed the examination in accordance with the Centers for Disease
Control's Technical Instructions, and all supplemental information or updates provided to me; and that all information provided by me on this Form
and the accompanying vaccination supplement is true and correct to the best of my information, knowledge and belief.
Type or Print Full Name (First, Middle, Last)

Signature

Address: (Street Number and Name, City, State and Zip Code)

Date (mm/dd/yyyy)

Name of Medical Practice or Health Department

Daytime Phone Number (Include Area Code)

(
Civil Surgeon ID #

)

E-Mail Address

Part 6. Health department identifying information. (If completed by state or local health department on behalf of a
refugee, place a stamp or seal where indicated)

Type or Print Name

Signature

Date (mm/dd/yyyy)

Daytime Phone Number (Include Area Code)

(

(Place State or local health
department stamp/seal below.)

)

Form I-693 (Rev. 03/06/07) N Page 4