Form I-693 Report of Medical Examination and Vaccination Record

OMB No. 1615-0033; Expires 08/31/09

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

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

Class A Conditions (see 2 through 5 below)

Date of Exam

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 2 years of age and older: for 2 exceptions see pp. 11-12 of Technical Instructions at
http://www.cdc.gov/ncidod/dq/civil.htm.)
Date TST Applied

Date TST Read

Size of Reaction (mm)

Chest X-Ray - Required ONLY for TST reactions of > 5mm or if specific TST exception criteria met, or for 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 (same)

Class B1 Pulmonary TB

Class B2 Pulmonary TB

Class B, Other Chest
Condition (non-TB)
Class B, Latent TB
Infection
Remarks: (Include any signs or symptoms of TB, additional tests, and therapy given, with stop and start dates and any changes.)
Class A Pulmonary TB Disease

Class B1 Extrapulmonary TB

Form I-693 (Rev. 08/10/07)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)
Date Screening Run

Screening Negative

Positive or Indeterminate

Confirmation Positive

Screening Positive
Screening Indeterminate

Findings:
No Class A HIV

Confirmation 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. 08/10/07)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

If completed;
Date Given write date of lab
test if immune or
by Civil
"VH" if varicella
Surgeon
history
mm/dd/yyyy

Waiver(s) to Be Requested From USCIS
Blanket
Not Medically Appropriate
Not Age
Appropriate

Contra- Insufficient Time Not Flu
indication
Interval
Season

Specify (circle)
vaccine: DT or
DTP or DTaP
Specify (circle)
vaccine: Td or
Tdap
Specify (circle)
vaccine: Polio -OPV
or IPV
MMR (Measles Mumps - Rubella)
Specify (circle)
vaccine: Measles or
MR (MeaslesRubella)
Rotavirus
Hib
Hepatitis A
Hepatitis B
Meningococcal
Human
papillomavirus
Varicella
Pneumococcal
Influenza
Other vaccine
(specify):
Other vaccine
(specify):

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).

Form I-693 (Rev. 08/10/07)N Page 3

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.)

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

Form I-693 (Rev. 08/10/07)N Page 4

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. 08/10/07)N Page 5