Form I-693 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 - 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

Apt. Number

Home Address: Street Number and Name

Gender:
Male

City

State

Zip Code

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

Female

Phone # ( Include Area Code) no dashes or ()

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)

DRAFT

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

Date of Exam

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): An initial screening test, either a Tuberculin Skin Test (TST) or an Interferon Gamma Release Assay (IGRA) is required
for all applicants 2 years of age and older; for children under 2 years of age, see Technical Instructions at http://cdc.gov/
ncidod/dq/civil.htm. The civil surgeon should perform one type of initial screening test only, followed by further
evaluation, if needed (chest X-ray).

1. Tuberculin Skin Test (TST):
Not administered (TST exception applies)
Date TST Applied

Result:

Date TST Read

Negative (4mm or less of induration)

Size of Reaction (mm)

Positive (> 5mm; chest X-ray required)

2. Interferon Gamma Release Assay (IGRA) (for acceptable IGRAs consult the Technical Instructions and any
updates posted on CDC's Web site at http://www.cdc.gov/ncidod/dq/civil.htm):
Not administered (IGRA
exception applies)

Name of Test

Date Blood Sample Drawn

Form I-693 (Rev. 06/29/09)N

Part 2. Commumicable Diseases of Public Health Significance (Cont'd)
Result:

IU/ml:

Negative (including indeterminate, or borderline/
equivocal) (no chest X-ray required)

Positive (chest X-ray required)

Initial Screening Test Result and Chest X-Ray Determination:
Chest X-ray not required (medically cleared for TB for USCIS)

Chest X-ray required due to TB signs or symptoms,
or due to immunosuppression (e.g. HIV)

Chest X-ray required due to initial screening test results

Chest X-ray required due to TST or IGRA exception
(The civil surgeon must clearly specify the TST or
IGRA exception in the "Remarks" field below.)

4. Chest X-Ray: Required based on TST or IGRA result, or if specific TST or IGRA exceptions apply, or for an applicant with TB
signs or symptoms or immunosuppression (e.g., HIV). Attach a copy of X-ray report.
Date Chest X-Ray
Taken

Date Chest X-Ray
Read

Results
Normal

DRAFT

Abnormal (Describe results in remarks.)

TB Classification/Findings (check only if chest x-ray was performed):
No Class A or Class B TB

Class B1 Pulmonary TB

Class B2 Pulmonary TB

Class A Pulmonary TB Disease

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. 06/29/09)N Page 2

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:
No Class A or Class B
Syphilis

Syphilis, Class A
(untreated)

Syphilis, Class B (with residual
deficit, and 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

Confirmation Negative

If Positive or Indeterminate,
Date Confirmation Run

Confirmation Positive

Screening Indeterminate
Findings:
No Class A HIV

HIV, Class A

DRAFT

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:
No Class A/B Condition

Granuloma Inguinale, Class A

Lymphogranuloma Venereum, Class A

Chancroid, Class A

Gonorrhea, Class A

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

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

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

3. Physical or Mental Disorders With Associated Harmful Behavior
No Class A or B Physical or Mental Disorder
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
No Class A or B Drug Abuse/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. 06/29/09)N Page 3

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:

Vaccine Given Completed Series

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

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

DRAFT

Hepatitis B
Varicella
Pneumococcal
Influenza
Rotavirus

Hepatitis A

Meningococcal
Human Papillomavirus

Zoster

Give Copy to Applicant

Results:

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 of Applicant
Vaccine history complete for each vaccine, all requirements met.
Applicant does not meet immunization requirements.

Remarks: (If needed, provide any remarks; e.g., reason for contraindication)

Form I-693 (Rev. 06/29/09)N Page 4

Part 2. Medical Examination (Continued)
6. List other medical conditions, Class B other (e.g., hypertension, diabetes)

Part 3. Referral to Health Department Other Doctor/Facility (To be completed by civil surgeon, if referral was required
and made)
Type or Print Name of Doctor or Health Department Receiving Required Referral

Date of Referral (mm/dd/yyyy)

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

Daytime Phone # (Include Area Code) no dashes or ( )

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, having made every reasonable effort to verify that the person whom I evaluated/treated is the person identified in
Part 1.

DRAFT

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 # (Include Area Code) no dashes or ( )

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

Form I-693 (Rev. 06/29/09)N Page 5

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; and that all information provided by me on this form is true and correct to the best of my
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

E-Mail Address

Daytime Phone # (Include Area Code) no dashes or ( )

DRAFT

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 # (Include Area Code) no dashes or ( )

Part 7. For USCIS Use Only (Not to be completed by the civil surgeon)
212(g)(2)(B) Blanket Waiver for Vaccination Granted
Remarks (if needed):

Form I-693 (Rev. 06/29/09)N Page 6