Table of Changes Form

Table of Changes-Form

Form N-648

April 16, 2010

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1	ATTENTION: ALL parts of this form (except for the "APPLICANT ATTESTATION" below) must be completed by a licensed medical doctor, licensed doctor of osteopathy, or licensed clinical psychologist. (See instructions)	ALL parts of this form, except the “APPLICANT ATTESTATION” and “INTERPRETER’S CERTIFICATION”, must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must conduct an in-person examination of the applicant. (See instructions for Form N-648 for additional information which is also located in the “Forms” section at www.uscis.gov.)
Page 1, Part I. Biographical Information	Part I. Biographical Information (Type or print clearly in black ink)	[Place section below “Reminder About Eligibility Requirements” and “Completing and Certifying This Form”] Part I. APPLICANT INFORMATION Type or print clearly in blue or black ink.
	Information About the Applicant (Patient). I certify that I have examined:	I certify that I have examined:
	Applicant Last Name *** Address *** Telephone Number E-Mail Address Date of Birth ***	Last Name *** Address (Street Number and Name) *** Telephone Number [place “( )” within text box for area code] Email Address (If any) Date of Birth (mm/dd/yyy) ***
Page 1, Part I., Biographical Information	Information About The Medical Professional *** City, State, Zip Code [text box] ***	[Place section below “Part I. APPLICANT INFORMATION”) II. MEDICAL PROFESSIONAL INFORMATION Type or print clearly in blue or black ink. If you need more space to complete an answer, use a separate sheet of paper. Write the applicant's name and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. You must sign and date each continuation sheet. You must answer and complete each question since USCIS will not accept an incomplete Form N-648. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant. NOTE: Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S. territories of Guam, Puerto Rico, and the Virgin Islands) are authorized to certify the form. While staff of the medical practice associated with the medical professional certifying the form may assist in its completion, the medical professional is responsible for the accuracy of the form's content. *** City [text box] State or Province [text box] Zip or Postal Code [text box] ***
Page 1, Reminder about Eligibility Requirements	Reminder about Eligibility Requirements This form is intended for applicants for U.S. citizenship who seek an exception to the English and civics testing requirements for naturalization "because of physical or developmental disability or mental impairment." In general, applicants for naturalization are required to learn and demonstrate knowledge of the English language, including an ability to read, write, and speak words in ordinary usage in the English language, as well as demonstrate knowledge and understanding of the fundamentals of the history, principles, and form of government of the United States (civics).	[Place above “Part I. APPLICANT INFORMATION”] Reminder about Eligibility Requirements This form is intended for an applicant who seeks an exception to the English and civics requirements due to a physical or developmental disability or mental impairment that has lasted, or is expected to last, 12 months or more. An applicant who with reasonable accommodations provided under the Rehabilitation Act of 1973 can satisfy the English and civics requirements does not need to submit this form. Reasonable accommodations include, but are not limited to, sign language interpreters, extended time for testing, and off-site testing.
Page 1, Definition of Disability or Impairment	Definition of Disability or Impairment The disability or impairment rendering the individual incapable of meeting the testing requirements must be long-term; result from anatomical, physiological, or psychological abnormalities (which can be supported by medically acceptable techniques); and result in functioning so impaired as to render an individual completely unable to learn and demonstrate the required knowledge. This definition of disability may be different from definitions used by the U.S. Social Security Administration and U.S. Department of Veterans Affairs or used in worker's compensation claims; however, such disability determinations may be considered as evidence.	DELETE THIS SECTION
Page, 1, Preparation of the Certification	Preparation of the Certification All questions must be answered fully and accurately, using common terminology that a person without medical training can understand, with no abbreviations. Copies of relevant medical reports/records may be attached to support the claim indicated. However, a supplemental report is not acceptable as a substitute for any of the responses. USCIS recommends that the certifying medical professional complete the fillable electronic Form N-648 provided on the USCIS Web site ("Immigration Forms" link www.uscis.gov). If typed or completed manually, print legibly in black ink. If you need more space, attach additional pages, indicating item, applicant's name, and your signature on each. (See instructions for further details).	[Place after “Reminder about Eligibility Requirements” and above “Part I. APPLICANT INFORMATION”] Completing and Certifying This Form All questions or items must be answered fully and accurately. Responses should utilize common terminology, without abbreviations, that a person without medical training can understand. U.S. Citizenship and Immigration Services (USCIS) recommends that the certifying medical professional use the electronic Form N-648 located in the "FORMS" section at www.uscis.gov. If the medical professional completes the form by hand, then responses must be legible and appear in blue or black ink.
Page 1, Applicant (Patient) Attestation/Release of Information	Applicant (Patient) Attestation/Release of Information *** to release to U.S. Citizenship and Immigration Services (USCIS) all relevant physical and mental health information related to my medical status for the purpose of applying for an exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury, pursuant to Title 28 U.S.C. Section 1746, that the information on this form and any evidence submitted with it are all true and correct. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under 8 U.S.C. 1324c. I understand that if this form is not completely filled out or if I fail to submit any required documentation, I may not be found eligible for the requested disability exception. Has any United States or State government agency made a determination on any disability you are claiming on this form? Yes [text box] No [text box] NOTE: If you answered "Yes," you may provide information on an attached sheet. Signature of Applicant (or Applicant’s authorized representative) [text box] ***	[Place this at the end of the form] APPLICANT (PATIENT) ATTESTATION/RELEASE OF INFORMATION *** to release to U.S. Citizenship and Immigration Services all relevant physical and mental health information related to my medical status for the purpose of applying for an exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury, pursuant to Title 28, U.S.C. Section 1746, that the information I provided to the medical professional is true and correct. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under Title 8, U.S.C. 1324c. I understand that if this form is not completely filled out or if I fail to submit any required documentation, I may not be found eligible for the requested disability exception. DELETE “Has any United States or State government agency made a determination on any disability you are claiming on this form?” DELETE Yes DELETE No DELETE “NOTE: If you answered "Yes," you may provide information on an attached sheet.” Applicant or Applicant's Authorized Representative Signature [text box] ***
Page 2, Part II. Medication Information	Part II. MEDICAL INFORMATION (Type or print clearly in black ink) *** Business Address ***	Part II. MEDICAL INFORMATION Type or print clearly in blue or black ink. If you need more space to complete an answer, use a separate sheet of paper. Write the applicant's name and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. You must sign and date each continuation sheet. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant. *** Business Address (Street Number and Name) ***
	Background Information	DELETE HEADER
	1. I am currently licensed: Medical Doctor [text box] Doctor of Osteopathy [text box] Clinical Psychologist [text box]	1. Currently licensed as a (Check all that apply): Medical Doctor [text box] Doctor of Osteopathy [text box] Clinical Psychologist [text box]
	2. What is the nature of your medical practice? Family/General Practice [text box] Internal Medicine [text box] Psychiatry/Psychology [text box] Other (specify) [text box]	2. Medical practice type: [Add text box with an underline at the bottom] DELETE “Family/General Practice” DELETE “Internal Medicine” DELETE “Psychiatry/Psychology” DELETE “Other (specify)”
	3. How long have you been treating this applicant? Year(s) [text box] Months(s) [text box] or since [text box] or This is my first examination [text box]	DELETE QUESTION
	[ADD NEW LANGUAGE]	Part III. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S)
	[ADD NEW LANGUAGE]	1. Provide the clinical diagnosis, and DSM IV code (If applicable), of the applicant's disability and/or impairment(s) that form the basis for seeking an exception to the English and/or civics requirements; e.g., "DSM-IV 318.0 Down syndrome." [text box]
	[ADD NEW LANGUAGE]	2. Provide a basic description of the disability and/or impairment(s), e.g., "Down syndrome is a genetic disorder that causes lifelong intellectual disability (also referred to as mental retardation), developmental delays, and other problems." [text box]
	4. Are you the medical professional regularly treating this applicant for the claimed condition(s)? Yes [text box] (If "Yes," go to item 5.) No [text box] (If you answered "No," state from whom the applicant usually receives medical care and explain why you are completing this form.) Name of Regularly Treating Medical Professional/Clinic and Address [text box] Explanation: [text box]	[move to number 7] 5. Are you the medical professional regularly treating this applicant for the condition(s) listed in number 1? … Yes [text box] (If "Yes," indicate duration of treatment.) “Years” [text box] “Months” [text box] No [text box] (If "No," provide the name of the applicant's regularly treating medical professional on the next page and explain why you are certifying this form instead of the regularly treating medical professional.) Name of regularly treating medical professional/clinic and address. Last Name [text box] First Name [text box] Middle Name [text box] Business Address [text box] City [text box] State or Province [text box] Zip Code or Postal Code [text box] Telephone Number [text box] Explanation: [text box]
	5. Date and location of your most recent examination(s) of the applicant: Date [text box] Location (if different from business address on Page 1; otherwise write "same as business address") [text box]	3. Date you first examined the applicant regarding the condition(s) listed in number 1. Date [text box] Location (if different from business address on Page 1; otherwise write "same as business address") [text box]
	6. How often do you examine this applicant? (Check or specify) Weekly [text box] Monthly [text box] Annually [text box] Other [text box]	DELETE QUESTION
	[ADD NEW LANGUAGE]	4. Date you last examined the applicant regarding the condition(s) listed in number 1, if different from above. Date [text box] Location (if different from business address on Page 1; otherwise write "same as business address") [text box]
Page 2, Nature and Duration of Disability or Impairment	Nature and Duration of Disability or Impairment	DELETE HEADER
	7. Has the applicant's claimed disability or impairment lasted, or do you expect it to last, 12 months or longer? Yes [text box] No [text box]	6. Has the applicant's disability and/or impairment(s) lasted, or do you expect it to last, 12 months or more? Yes [text box] (If "Yes," continue to complete this form.) No [text box] (If "No," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.")
	8. Is the particular claimed disability or impairment(s) the direct effect of the applicant's illegal use of drugs? Yes [text box] No [text box]	9. Is the applicant's disability and/or impairment(s) the result of the applicant's illegal use of drugs? Yes [text box] (If "Yes," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.") No [text box] (If "No," continue to complete this form.)
Page 3, Diagnosis of Disability or Impairment(s)	Diagnosis of Disability or Impairment(s)	DELETE HEADER
	9. (a) Provide your clinical diagnosis of the applicant's disability or impairment(s) and its origin. Describe the disability or impairment(s) in terms a person without medical training can understand (See Page 2 of the instructions for examples). NOTE: The description should include the severity of the effects of the disability or impairment.	8. What caused this applicant's medical disability and/or impairment(s) listed in number 1, if known? [text box]
	(b) What medically acceptable clinical or laboratory diagnostic techniques were used to arrive at this diagnosis, as well as the plan of treatment administered, if any? (List and provide the results and conclusions drawn from these tests.)	9. What clinical methods did you use to diagnose the applicant's medical disability and/or impairment(s) listed in number 3? [text box]
Page 4, Nexus (connection) Between Disability or Impairment and Inability to Learn/Demonstrate	Nexus (connection) Between Disability or Impairment and Inability to Learn/Demonstrate	DELETE HEADER
Page 4, Nexus (connection) Between Disability or Impairment and Inability to Learn/Demonstrate	10. In your professional opinion, based on your examination of the applicant, provide detailed information on the nexus (connection) between the disability, impairment, or combination of impairments and the applicant's inability to learn and/or demonstrate knowledge of English and/or civics (See Page 2 of the instructions for examples). NOTE: This description must address the severity of the effects of the medical condition(s) on: 1. The applicant's ability to learn and demonstrate the required knowledge; and 2. The activities of the applicant's daily life.	10. Clearly describe how the applicant's disability and/or impairment(s) affect his or her ability to demonstrate knowledge and understanding of English and/or civics. [text box]
Page 5. Professional Certified Opinion	The law requires that in order to be eligible for the disability exception, the applicant must be unable to fulfill the English and civics testing requirements for naturalization. An applicant's difficulty in fulfilling the requirements, such as illiteracy in his or her native language, is not sufficient by itself to support a finding of eligibility for the exception.	DELETE WORDING
Page 5. Professional Certified Opinion	11. English Requirement In your professional medical opinion, based on your examination of the applicant, the applicant's symptoms, previous medical records, clinical findings, or tests: (a) Does the applicant have any disability or impairment that affects his or her ability to function to such a degree that he or she is unable to learn and demonstrate an ability to speak, read, or write English? (b) If "Yes," which of the following is the applicant unable to learn and demonstrate? (Check all that apply.)	DELETE QUESTION
Page 11. Professional Certified Opinion	NOTE: If you answered No to BOTH items 11(a) and (12), the applicant is ineligible for a disability exception.	DELETE WORDING
Page 5. Professional Certified Opinion	12. U.S. HISTORY AND CIVICS REQUIREMENT In your professional medical opinion, based on your examination of the applicant, the applicant's symptoms, previous medical records, clinical findings, or tests, does the applicant have any disability or impairment(s) that affects his or her ability to function to such a degree that he or she is unable to learn and demonstrate knowledge of U.S. history and civics, even in a language the applicant understands?	DELETE SECTION
	[ADD NEW LANGUAGE]	11. In your professional medical opinion, does the applicant's disability or impairment(s) prevent him or her from demonstrating the following requirements? (Check all that apply. If none applies, the applicant is not eligible for this exception) [text box] [include the following verbiage inside text box] The ability to: Read English [text box] Write English [text box] Speak English [text box] Answer questions regarding United States history and civics, even in a language the applicant understands [text box]
	[ADD NEW LANGUAGE]	12. Was an interpreter used during your examination of the applicant? Yes [text box] (If "Yes," the interpreter must complete the "Interpreter Certification" section.) No [text box] (If "Yes," the interpreter(s) must complete the "Interpreter Certification" section.)
	[ADD NEW LANGUAGE]	Additional Comments (Optional)
Page 5. Professional Certified Opinion	Sign the "Medical Professional's Certification" below.	DELETE WORDING
Page 5, Medical Professional’s Certification	I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and any evidence submitted with it are all true and correct. The applicant having consented in Part I to the release of his or her relevant medical records to U.S. Citizenship and Immigration Services, I will furnish such records, if requested by that agency. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties under Title 18, U.S.C.1546 and civil penalties under Title 8, U.S.C.1324c. Licensed Medical Professional’s Signature [text box] ***	Complete the following if an interpreter was not used during your examination of the applicant between the applicant and medical professional pertaining to the examination(s) that form the basis of this Form N-648 certification. I am fluent in English and ________, the language spoken by this patient. Therefore, an interpreter was not used during my examination(s) of this applicant. I certify that the applicant’s identity has been verified through the following United States or State government issued photographic identity document: [text box] Permanent Resident Card [text box] State ID Card Number: ____________ [text box] Other Identification(state type and ID number): ______________ I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and any evidence submitted with it are all true and correct. I will furnish relevant medical records to USCIS, if requested to do so by USCIS, based on the applicant’s consent. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties including under Title 18, U.S.C. Section 1546, civil penalties under Title 18, U.S.C. Section 274C of the Immigration and Nationality Act, and civil license suspension or revocation by the appropriate authorities. *** Licensed Medical Professional Signature [text box] ***
	[ADD NEW SECTION]	INTERPRETER’S CERTIFICATION An interpreter must complete, and certify, the section below if an interpreter translated communications between the applicant and medical professional on the day of the examination that formed the basis of this Form N-648 certification. Interpreter Information Last Name [text box] First Name [text box] Middle Name [text box] Business Address (Street Number and Name) [text box] City [text box] State or Province [text box] Zip Code or Postal Code [text box] Was a phone interpreter used? No [text] (the interpreter is required to complete the information below) Yes [text] (the interpreter is not required to complete the information below) Interpreter Certification As the interpreter, I certify that I speak English and the following language: __________. I further certify that I have accurately and completely translated all communications between the medical professional and the applicant that occurred on ____________, the date(s) of the examination(s) that form the basis of this certification. Interpreter Signature [text box] Date [text box]

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