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

Instructions

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
and indicate the number of the item that refers to your answer.

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
results of a medical examination to U.S. Citizenship and
Immigration Services (USCIS). 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.
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.
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 File Form I-693?
A separate Form I-693 is required for each applicant. There is
no filing fee for this form. Follow these steps:

Step 5 - Submit Form I-693 in the sealed envelope to USCIS
according to the instructions on 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.
NOTE: The civil surgeon will ask you to verify your
identity. Take a government-issued photo identification 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.

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

Step 1 - Carefully read all these instructions, including
Section III, Frequently Asked Questions.

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

Step 2 - Call a designated physician (also known as a civil
surgeon) to make an appointment.

1. 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.

Step 3 - Fill out Part 1 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.

2. 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.
A. Part 1 - Information about you - Fill this part out
before your medical exam appointment.
B. 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.
Form I-693 (Rev. 02/15/08)N

C. 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.
D. Date of birth - Use eight numbers to show your date
of birth (example: May 1, 1979, should be written
05/01/1979).
E. Place of birth - Give the name of the city/town/
village where you were born.
F. Country of birth - Give the name of the country
where you were born.
G. A-number - 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.
H. U.S. Social Security # - If you do not have a U.S.
Social Security Number, leave this blank.
I. Certification - Do not sign here until the civil surgeon
tells you to do so.

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 government-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.
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.

3.

Give Pre-Test and Post-Test Counseling for HIV/
AIDS. All civil surgeons must give pre-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 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.

4.

Make Referrals and File Case Reports, as Required.
According to CDC's Technical Instructions, you are
required to:

How Do I Submit Form I-693 to USCIS?
1.

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.

2.

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.

3.

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?

A. Refer the applicant to the local health department if
the chest X-ray suggests TB or other circumstances
are present 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
tuberculin skin test reaction of >10 mm, in order to
evaluate the possible need for preventive therapy.

1. Truthfully and Accurately Report the Results. You are
responsible for reporting the results of the medical exam
and all laboratory reports on Form I-693 where indicated,
and for signing the civil surgeon's certification provided
on the form.
Form I-693 (Rev. 02/15/08)N Page 2

B. Ensure that any applicant diagnosed with syphilis is
treated with the standard treatment regimen described
in CDC's Technical Instructions.
C. Ensure that testing and therapy are given for
diagnoses of chancroid, gonorrhea, granuloma
inguinale, or lymphogranuloma venereum.
D. Refer the applicant to a Hansen's disease specialist
for evaluation to confirm a suspected diagnosis of
Hansen's disease (leprosy).
E. File a case report with the appropriate public health
authorities if: (1) the applicant tests positive for HIV
infection; and (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.
1.

Part 2 - Medical examination - 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.

2.

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.

3.

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.

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. Complete the identifying information in this
part before referring an applicant for further tests or
evaluation. 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.

5. 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.

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
Part 2. This 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.)
Form I-693 (Rev. 02/15/08)N Page 3

Section III. Frequently Asked Questions

B. V-2 child of a V-1 spouse of a permanent resident, or
as a

1. What if I am a refugee and already had a medical
exam overseas?

C. V-3 child of a V-2 unmarried son or daughter of a V-1
spouse of a permanent resident, and

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 Part 1, Information about you,
and the vaccination section of Part 2, not 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. The State or local
health department must also complete Part 6 of the Form.

2. What if I am a K nonimmigrant visa holder and
already had a medical exam overseas?
If you were admitted as a:
A. K-1 fiancé(e) or a K-2 child of a K-1 fiancé(e), or as a
B. K-3 spouse of a U.S. citizen or a K-4 child of a K-3
spouse of a U.S. citizen, and
C. You received a medical examination prior to
admission, thena. You 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.
b. You will, however, be required to complete Part
1, Information about you, and submit the
vaccination section of Part 2 with your
adjustment of status application. A designated
civil surgeon must complete the vaccination
section and Part 5, the Civil Surgeon's
Certification.
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:

D. You received a medical examination prior to admission
or obtaining V status, thena. You 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.
b. You will, however, be required to Part 1,
Information about you, and submit the vaccination
section of Part 2 with your adjustment of status
application. A designated civil surgeon must
complete the vaccination section and Part 5, the
Civil Surgeon's Certification.
4. May any doctor perform the required medical
exam?
Only a doctor who has been specially designated by
USCIS as a civil surgeon may perform 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?
The applicant is 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.

A. V-1 spouse of a permanent resident or awaiting a V-1
visa, or as a

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

7. What are the medical grounds of inadmissibility?
The medical grounds of inadmissibility under 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 perform a general physical
exam and specific evaluations, as described below.

Communicable Diseases of
Public Health Significance
The civil surgeon is required to perform specific tests for TB,
syphilis, and human immunodeficiency virus (HIV) infection.
The medical exam also indicates an evaluation for other
sexually transmitted diseases and Hansen's Disease (leprosy).

To test for:

Then:

Tuberculosis
(TB)

All applicants two years 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 two years to undergo a TST
if there is evidence of contact with a
person known to have tuberculosis or
other reason to suspect tuberculosis.)
After the skin test, 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

HIV

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.
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.

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.

Vaccination Requirements
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.
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, Haemophilus influenzae type B,
varicella, pneumoccal, 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.
After evaluation by the civil surgeon, 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.

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

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.

Physical or Mental Disorders
Are all physical or mental disorders considered
health-related grounds of inadmissibility?
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 for 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.

Section IV. USCIS Information
How Do I 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 the 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
You may also complete Form AR-11, Alien's Change of
Address Card, on the USCIS Internet website at
www.uscis.gov.
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.

Form I-693 (Rev. 02/15/08)N Page 6

Processing Information
Initial Processing. Once the application has been accepted, it
will be checked for completeness, including submission of the
required initial evidence. If you do not completely fill out the
form or file it without the required initial evidence, you will
not establish a basis for eligibility and we may deny your
application.
Requests for More Information. We may request more
information or evidence, or we may request that you appear at
a USCIS office for an interview. Unless specifically required
that an original document be filed with an application or
petition, an ordinary legible photocopy (standard 8 1/2 x 11
letter size) may be submitted. Original documents submitted
when not required will remain a part of the record.
Decision. The decision on the Form I-693 involves a
determination of whether you have established eligibility for
the requested benefit. You will be notified of the decision in
writing.

Privacy Act Notice
We ask for the information on this form, and associated
evidence, to determine if you have established eligibility for
the immigration benefit for which you are filing. Our legal
right to ask for this information can be found in the
Immigration and Nationality Act, as amended. We may
provide this information to other government agencies.
Failure to provide this information, and any requested
evidence, may delay a final decision or result in denial of
your Form I-693.

Penalties
If you knowingly and willfully falsify or conceal a material
fact or submit a false document with this Form I-693, we will
deny the Form I-693 and may deny any other immigration
benefit.
In addition, you will face severe penalties provided by law
and may be subject to criminal prosecution.

Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
collection of information is estimated at 2 hours, 30 minutes
per response, including the time for reviewing instructions,
completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing
this burden, 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 application to this
address.

Form I-693 (Rev. 02/01/08)N Page 7