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)
Given Name (First Name)

Family Name (Last Name)

Full Middle Name
Gender:

Apt. Number

Home Address: Street Number and Name

Male
City

State

Zip Code

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

Female

Phone Number (Include Area Code)

A-number (if any)

U.S. Social Security # (if any)

Applicant's Certification
I certify under penalty of 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 - Do not sign or date this form until instructed to do so by the civil surgeon

Date (mm/dd/yyyy)

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

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

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

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 children under 2 years of age, 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
Class A Pulmonary TB Disease

Class B1 Pulmonary TB

Class B2 Pulmonary TB

Class B1 Extra Pulmonary TB

Class B, Latent TB Infection

Class B, Other Chest
Condition (non-TB)

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. 02/15/08)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
Screening Positive

Findings:
No Class A HIV

Confirmation Negative

If Positive or Indeterminate,
Date Confirmation Run

Confirmation Positive

Screening Indeterminate
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. 02/15/08)N Page 2

Part 2. Medical examination

(Continued)

5. Vaccinations (See Technical Instructions at http://www.cdc.gov/ncidod/dq/civil.htm for list of required vaccines.)
Vaccine History Transferred From a Written Record

Date
Received
mm/dd/yyyy

Vaccine
Specify
Vaccine:

Date
Date
Received
Received
mm/dd/yyyy mm/dd/yyyy

Vaccine Given Completed Series
Date Given
by Civil
Surgeon
mm/dd/yyyy

Waiver(s) to Be Requested From USCIS

Mark an X if
Blanket
completed; write
Not
Medically
Appropriate
date of lab test if
immune or "VH" Not Age
ContraInsufficient
if varicella history Appropriate
indication Time Interval

Not Flu
Season

DT
DTP
DTaP

Specify
Vaccine:
Specify
Vaccine:

Td
Tdap
OPV
IPV

MMR (Measles
Mumps-Rubella) or if
monovalent or other
combination of the
vaccines are given,
specify vaccine(s):

Hib
Hepatitis B
Varicella
Pneumococcal
Influenza
Other Vaccine
(specify below):
Other Vaccine
(specify below):
Other Vaccine
(specify below):
Other Vaccine
(specify below):
Other Vaccine
(specify below):

Results:

Give Copy to Applicant

A-number (if any)

Applicant may be eligible for blanket waiver(s) as indicated above.
Applicant will request an individual waiver based on religious or moral convictions.
Name (Type or print your name)
Vaccine history complete for each vaccine, all requirements met.
Applicant does not meet immunization requirements.
Form I-693 (Rev. 02/15/08)N Page 3

Part 2. Medical examination

(Continued)

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.)

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.)

Form I-693 (Rev. 02/15/08)N Page 4

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 and Prevention's Technical Instructions, and all
supplemental information or updates provided to me; and that all information provided by me on this form 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.)

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

Type or Print Name

Signature

Date (mm/dd/yyyy)

Daytime Phone Number (Include Area Code)

Form I-693 (Rev. 02/15/08)N Page 5