CDC Technical Instructions

CDC IMMIGRATION REQUIREMENTS:
Technical Instructions for
Physical or Mental Disorders with Associated
Harmful Behaviors and
Substance-Related Disorders
June 1, 2010

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Table of Contents

Preface ................................................................................................................................................................. 3
Role of the Civil Surgeon ................................................................................................................................. 4
Key Concepts ..................................................................................................................................................... 5
Mental Health Examination ............................................................................................................................. 8
Mental Health Screening Results ................................................................................................................... 18
Waivers .............................................................................................................................................................. 20
Mental Health and Substance Abuse/Addiction Classifications and Descriptions ............................... 21
Documentation ................................................................................................................................................ 23
APPENDIX A GLOSSARY OF ABBREVIATIONS ......................................................................................... 24
APPENDIX B USEFUL RESOURCES ............................................................................................................ 25
APPENDIX C CONTROLLED SUBSTANCES ............................................................................................... 26
APPENDIX D SUMMARY OF MENTAL HEALTH EXAMINATION............................................................ 34
Index .................................................................................................................................................................. 35

Figures
Figure 1. For Applicant With Medical History of a Physical or Mental Disorder, Next Determine:
Figure 2. Identifying and Classifying Applicants With Possible Substance Dependence or Abuse

Tables
Table 1. Indications for Laboratory Drug Screening
Table 2. Sustained, Full Remission During the Most Recent 12 Months Before Reexamination
Table 3. Factors Affecting the Applicant’s Likelihood of Maintaining Remission of a Mental
Disorder or Having a Disorder Under Control
Table 4. Referring Applicant to a Specialist Consultant

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Preface
Medical screening for physical and mental disorders with associated harmful behaviors and substancerelated disorders among persons applying for adjustment of status to permanent resident and other
persons required by law to have a medical examination, hereafter referred to as applicants, is an
essential component of the immigration-related medical evaluation. Because these conditions are
challenging to diagnose and treat, these technical instructions provide a method for recording findings
from the medical examination and additional guidance for the civil surgeon in classifying applicants.
The new technical instructions use uniform criteria and diagnosis consistent with current medical
knowledge and classification connected with legal definitions.
•

The required examination includes evaluation of physical and mental disorders with
associated harmful behaviors and substance-related disorders. Inadmissibility based on a
physical or mental disorder is limited to applicants with associated harmful behavior or
potentially harmful behavior.

The Immigration and Nationality Act (INA) provides three grounds of inadmissibility related to
substance addiction or abuse, or physical or mental disorders that affect behavior. They are • Current physical or mental disorder with associated harmful behavior.
• Past physical or mental disorder with associated harmful behavior if the harmful behavior is
likely to recur or to lead to other harmful behavior in the future.
• Drug (substance) abuse or addiction (medically called dependence). Dependence on or abuse
of any of the substances listed in Section 202 of the Controlled Substances Act (Appendix C).
(The term addiction corresponds with the medical term dependence).
The instructions in this document supersede all previous Technical Instructions, Updates to the
Technical Instructions, memoranda and letters to civil surgeons relating to substance abuse or addiction
and mental or physical disorders with associated harmful behavior (whether past or present). These new
instructions are to be followed when determining whether an applicant is afflicted with physical and
mental disorders with associated harmful behaviors and substance-related disorders among all
applicants.
For any questions about these Technical Instructions, please contact the Immigrant, Refugee, and
Migrant Health Branch of the Division of Global Migration and Quarantine (DGMQ), Centers for
Disease Control and Prevention (CDC), at [email protected] or 404-498-1600. These Technical
Instructions and other information pertinent to them and the medical examination for applicants for
U.S. immigration can be found online at
http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civilsurgeons.html.

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Role of the Civil Surgeon
The purpose of the immigration examination is to identify health-related conditions
that render an applicant inadmissible, and also to identify and inform the applicant of
conditions possibly needing follow-up care.

As part of the medical evaluation and physical examination of the applicant, the civil surgeon will carry
out or obtain a mental health evaluation • To identify and diagnose any physical or mental disorder (including alcohol-related disorders).
• To identify any harmful behavior associated with a disorder.
• To identify the use of drugs, other than those required for medical reasons, and diagnose any
substance-related disorder.
• To determine the remission status of any disorder previously diagnosed.
• To determine the likelihood of recurrence of harmful behaviors associated with a physical or mental
disorder.
For most applicants, the civil surgeon’s examination will require only one appointment. However, for
some applicants multiple appointments or specialist consultations may be required to make an accurate
diagnosis of whether the applicant is afflicted with a Class A or Class B condition as it relates to
physical or mental disorders with associated harmful behavior or substance abuse and addiction
(dependence).

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Key Concepts
A harmful behavior is defined as an action associated with a mental or physical
disorder that is or has caused • Serious psychological or physical injury to the applicant or to others (e.g., a
suicide attempt or pedophilia)
• A serious threat to health or safety (e.g., driving while intoxicated or verbally
threatening to kill someone)
• Major property damage.

An applicant who has exhibited harmful behavior not associated with a specific mental
or physical disorder is not considered inadmissible under health-related grounds, but
may be inadmissible under criminal grounds as determined by DHS/USCIS.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of
substance dependence is used in this examination to determine “addiction.”

Alcohol dependence or abuse alone is not considered a Class A condition. It is
considered the same as any other mental disorder, and requires associated harmful
behavior to be classified as a medically inadmissible condition.

Physical Disorder
A physical disorder is a clinically diagnosed medical condition where the focus of attention is physical
manifestations. Only physical conditions that are included in the current version of the World Health
Organization’s Manual of the International Classification of Diseases (ICD) will be considered for the purpose
of this examination.
Mental Disorder
Mental disorders are health conditions that are characterized by alterations in thinking, mood, or
behavior (or some combination thereof). The current version of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is an authoritative source on the
classification of mental disorders and should be considered for the purpose of this examination.
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“V” Coded Condition
“V” coded conditions listed in the DSM are not diagnoses, but are used in clinical practice settings
when the focus of clinical attention is on a behavior that is not due to a mental disorder. Because these
“V” conditions are not mental disorders, they cannot be used in determining if a person has an
inadmissible (Class A) health-related condition, regardless of whether there is an associated harmful
behavior. However, behaviors associated with “V” coded conditions might require treatment.
Harmful Behavior
The civil surgeon is to identify any harmful behavior that is associated with an applicant’s physical or
mental disorder.
Only harmful behavior that is associated with a physical or mental disorder is relevant for the
classification of U.S. medical eligibility; neither harmful behavior by itself nor the physical or mental
disorder by itself makes an applicant medically inadmissible. People can have multiple harmful
behaviors that are not associated with a physical or mental disorder. Repetitive antisocial activities and
harmful acts may warrant evaluation for personality disorders according to DSM criteria, and eventually
provide a basis for the conclusion of inadmissibility. Because of the complexity of this issue, the civil
surgeon might feel that a more specialized psychiatric examination is indicated. (Table 4)
Substance-Related Disorders
Diagnoses of substance-related disorders are to be made in accordance with existing medical standards
as determined by the current edition of the DSM. In general, the DSM criteria for substance
dependence, either on alcohol or other psychoactive substances are characterized by compulsive longterm use of the substance despite significant substance-related physical, psychological, social,
occupational, or behavioral problems. Tolerance and withdrawal are often associated with substance
dependence.
Substance abuse is characterized by a pattern of recurrent substance use despite adverse consequences
and impairment. To establish any substance-related diagnosis, the examining physician must document
the pattern of use and behavioral, physical, and psychological effects associated with the use or
cessation of use of that substance.
For the purpose of classification, an applicant is determined to be Class A for substance dependence
(drug addiction) or repetitively abusing substances (drug abuse), if he or she meets current DSM
diagnostic criteria for substance dependence or abuse with any of the specific substances listed in
Schedules I through V of Section 202 of the Controlled Substances Act (see Appendix C).
For other substances, including alcohol, not listed in Schedules I through V of Section 202 of the
Controlled Substance Act, the same diagnosis criteria apply for dependence and abuse as are found in
the current DSM, however, a determination regarding associated harmful behavior must also be made
to determine the classification for an applicant.

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Substances used for clinical care in medical practice are not prohibited and do not represent substance
abuse. Prescription drugs taken in accordance with a prescription do not amount to abuse but abuse of
prescription drugs could be an inadmissible condition.

Class A and Class B Medical Conditions
Class A medical conditions are inadmissible conditions and include an applicant who is determined to
have •

A current physical or mental disorder with associated harmful behavior

•

A past physical or mental disorder with associated harmful behavior if the harmful behavior
is likely to recur or to lead to other harmful behavior in the future

•

Drug (substance) abuse or addiction (dependence)

Class B medical conditions are not inadmissible medical conditions and include any applicant who is
determined to have a physical or mental abnormality, disease, or disability serious in degree or nature
amounting to a substantial departure from well-being.

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Mental Health Examination
Observation alone is not sufficient to assess an applicant.

Random screening for drugs is not part of the routine medical evaluation of applicants
for U. S. admission.

If the civil surgeon is unable to determine whether an applicant has a diagnosis of a
physical or mental disorder, or substance abuse or dependence for a substance listed
in Section 202 of the Controlled Substances Act, diagnosis and classification may be
deferred in order to obtain additional medical evidence.

Record DSM diagnoses for mental disorders and substance-related disorders on the
I-693 Form under Part 2, in the Remarks for Number 3 and Number 4.

The civil surgeon can recognize that an applicant with a physical or mental disorder might have an
associated harmful behavior during any point of the examination.
• While taking the medical history of a mental disorder,
• While taking history of harmful behavior, or
• While observing for current abnormal behavior during the physical examination.

Medical History
The civil surgeon should begin by asking questions about the past medical history of the applicant. To
fully investigate the applicant’s past medical history, the civil surgeon, when possible, should • Obtain other relevant records, such as police, military, school, and employment, that might provide
a history of harmful behavior associated with physical or mental disorders.
• Ask about mental disorders in the family and, when appropriate, about signs of mental problems or
odd behaviors.
• Ask about any use of drugs and medicines.
• Ask about harmful behaviors.

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Figure 1. For Applicant With Medical History of a Physical or Mental Disorder, Next Determine:
1) Does the disorder require follow-up care?

No

No
Class

a) If YES, is there associated behavior?

No

Class B

b) If YES, is the behavior harmful?

No

Class B

a) Is there current harmful behavior?

Yes

Class A

b) If NO, is there potential for harmful
behavior?

Yes

Class A

c) If NO, is there history of harmful behavior?

No

Class B

d) If YES, is the behavior likely to recur?

Yes

Class A

2) If YES associated harmful behavior, answer
each of the following:

3) If NO current harmful behavior; NO potential
for harmful behavior; or a history of harmful
behavior, but NOT likely to recur

Class B

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When a civil surgeon defers diagnosis and classification, the civil surgeon should explain to the
applicant what the civil surgeon would like to see during the next 3-6 months (in order to classify the
applicant) to show abstinence (see Figure 2). This may include but is not limited to requiring clinical
reports from health care professionals for applicants with possible substance-related disorders to
demonstrate participation in a drug treatment program. For applicants with deferred diagnosis and
classification, the civil surgeon should consider documenting in a statement signed by the applicant the
information he or she is providing to the applicant; the statement should specify what is required
during the next 3 to 6 months (see Figure 2) to show abstinence.
Psychiatric Evaluation
The civil surgeon should conduct an activities assessment and mental status examination that assesses,
at a minimum • orientation,
• mood and affect,
• speech and language,
• anxiety,
• thought processes and content, and
• behavior.
The civil surgeon may estimate the degree of cognitive impairment in dementia or mental retardation by
assessing the applicant's (1) level of knowledge, and (2) ability to carry out functions of daily living (e.g.,
learning, communication, and routine activities).
Any available reports of cognitive, development, or intelligence testing, or neuropsychological testing in
the medical record are welcome and may be included with the civil surgeon’s report. However, the civil
surgeon is not asked to routinely send applicants for additional psychological tests.
Under most circumstances, the civil surgeon or consultant will not need to provide additional
psychological or neuropsychological testing. Use of projective instruments, such as Rorschach test,
may not be useful given the added administrative burden involved. No psychological or
neuropsychological testing is a substitute for the civil surgeon’s or consultant’s history and examination
of the applicant. However, for certain cases, these tests may aid in making a diagnosis.
Laboratory Testing
Random screening for drugs is not part of the routine medical examination for applicants for U.S.
admission. The civil surgeon needs to evaluate the applicant’s history, behavior and physical
appearance when determining if drug screening should be performed.
Whole populations of applicants should not routinely be subject to random laboratory screening. The
civil surgeon should make an individual decision based on the indications for drug screening (see Table
1).

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Laboratory testing to identify underlining medical conditions that might be causing psychiatric
manifestations may be necessary before making any mental disorder diagnoses. However, specialized
laboratory testing, such as dexamethasone suppression tests or challenge administration of various
pharmaceuticals, is usually not indicated in the diagnosis of applicants.
Other possible uses of laboratory support depend on the availability of such laboratory services and the
clinical judgment of the civil surgeon as to their usefulness in classification of the individual applicant.
For example, therapeutic levels of prescribed anticonvulsant medications, antipsychotic medications, or
other medicines used in psychiatry (such as lithium levels) might be of value to the civil surgeon in • Determining the applicant’s adherence to a prescribed course of treatment.
• Possibly changing or adjusting the applicant’s medications, and therefore contributing to remission
of illness and reduction of associated harmful behavior.
Random screening for drugs on short notice to the applicant can provide additional evidence to aid in
diagnosis and classification. For example, the civil surgeon might request that three random screenings
for drugs within a 3- to 6-month period be done with only 24- to 48-hour notification to the applicant.
The period of advance notification should be the minimum practical time for the applicant to arrive at
the screening facility, preferably 24 or 48 hours after notification.

Table 1. Indications for Laboratory Drug Screening
Include (but are not limited to) • History of any substance abuse or dependence with a specific substance listed in Schedules I
through V of Section 202 of the Controlled Substances Act. (See Appendix C)
• Applicant-provided information that appears to contradict information provided by family
members or from other records, such as police, military, school, and employment.
• Unexplained gaps of time in the applicant’s past schooling or employment.
• Evidence of unreliable or false information given during the interview or examination.
• Any demeanor, presentation, or findings that the examining physician associates with
substance abuse or dependence, such as motor ability and interpersonal skills; deepened skin
coloring, needle scarring, or skin ulcers along the veins in the arms or legs; or a hard, bumpy,
or shrunken liver.
• Evidence or appearance of intoxication with any substance during the examination.
• Disturbed behavior that might be associated with a substance-related disorder.
• Follow-up of an initial positive drug screen or a history of a positive drug-screening test.

It is the civil surgeon’s responsibility to know the reliability and validity of the laboratory tests and
laboratory methods used during the medical evaluation. All drug testing is to be done by using
materials licensed by the U.S. Food and Drug Administration or by the equivalent licensing office in
other countries. Rapid testing or semi-quantitative testing may be used for the screening test; however,
gas chromatography/mass spectrometry (GC/MS), performed at a reference laboratory, needs to be
used as the confirmatory test. Positive and negative controls must be used with any testing and only
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test kits that are for medical diagnosis and treatment must be used. Forensic testing is minimally
regulated and will be labeled “not for medical diagnosis and treatment” and, therefore, should not be
used because it is not sensitive enough for medical purposes.

Mental or Physical Disorders With Associated Harmful Behavior
Only mental or physical disorders during which the applicant engages in or has engaged in harmful
behavior that is associated with (due to) the mental or physical disorder will make an applicant
inadmissible. As previously stated, no diagnosis of a mental or physical disorder by itself provides a
basis for inadmissibility. There must also be a determination made regarding current harmful behavior
or a history of harmful behavior, associated with or caused by the disorder, and the likelihood of
associated harmful behavior to recur, in order to provide basis for inadmissibility.
Thus, when evaluating an applicant for possible mental disorders, it is vital to assess for the likelihood
of harmful behavior. Because there are mental disorders that are commonly associated with harmful
behavior, it may be helpful to first look for the harmful behavior when assessing an applicant for a
possible mental disorder. (See Figure 1)
Mental disorders most frequently associated with harmful behavior include • major depression,
• bipolar disorder,
• schizophrenia, and
• mental retardation.
These disorders occur within broader categories of disorders that can be grouped as • Mood disorders that include major depression and bipolar disorders and can be associated with
high rates of suicide and aggression.
• Anxiety disorders that include post-traumatic stress disorder, panic disorders, phobias, and
anxiety disorders and can be associated with harmful behavior.
• Personality disorders that include antisocial, paranoid, and borderline personality disorders and
can be associated with impulsive acts of violence.
• Sexual disorders that include paraphilias.
• Schizophrenia and other psychotic disorders that can be associated with delusions, paranoia,
suicide, and aggressive acts.
• Disorders usually first diagnosed in childhood that include mental retardation and conduct
disorder and are often associated with harmful behaviors. In addition, other cognitive
disorders, such as dementia, can be associated with harmful behaviors.
• Substance-related disorders that include substance dependence or abuse. For specific
substances listed in Schedule I-V of Section 202 of the Controlled Substances Act (see
Appendix C), no associated harmful behavior is required for the applicant to have a medically
inadmissible condition based on substance abuse/dependence (please see above for the
determination of substance abuse/dependence). The civil surgeon is reminded that for
substances not listed in Schedule I-V (such as alcohol), that abuse or dependence is evaluated as
a mental disorder and determination of associated harmful behavior is required for applicant to
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have a medically inadmissible condition. With alcohol dependence or abuse there is often
associated harmful behavior during periods of intoxication and withdrawal.
Physical Disorder
Physical disorders are rarely associated with harmful behavior. It may happen in delirious or confused
states due to metabolic disturbances, hypoglycemia; and some psychomotor epilepsies and in the
aftermath of generalized seizure disorders and various forms of seizure disorders. When evaluating an
applicant for a physical disorder with associated harmful behavior, the civil surgeon should diagnosis
physical disorders according to the conventions used in the current edition of the ICD published by the
World Health Organization.
Current Harmful Behavior
If the applicant is currently engaging in harmful behavior, that is, harmful behavior (see definition
above) that has continuously occurred and seems ongoing, the civil surgeon must evaluate whether the
actions may be indicative of a mental disorder.
Future Harmful Behavior
If the applicant presently is or in the past has engaged in harmful behavior associated with a physical or
mental disorder, the civil surgeon must evaluate whether the harmful behavior is likely to recur. Many
factors enter into this determination of classification, and the decision requires clinical judgment. At a
minimum, the underlying physical or mental disorder must be either in remission or reliably controlled
by medication or other effective treatment.
As a general guideline, when a mental or physical disorder has a favorable prognosis and is in remission
or under control but there was associated harmful behavior, if it has been 12 months since the harmful
behavior occurred, the harmful behavior is less likely to recur (see Table 3).
Remission
The current version of the DSM defines sustained, full remission as a period of at least 12 months
during which no substance use or mental disorder-associated behaviors have occurred. These new
technical instructions reflect the current medical knowledge and standards of the DSM. The panel
physician and his or her consultant must use their clinical judgment in determining if 12 months is an
acceptable period of time for the individual applicant to demonstrate sustained, full remission. This
time period must be based on the reliability of the evidence provided, such as clinical reports of
participation in a program, such as a drug treatment program.
Remission must also be considered in two contexts: (1) general mental disorders and (2) substancerelated disorders.
For general mental disorders, the determination of remission must be made based on the assessment of
associated harmful behavior, either current or history of judged likely to recur and DSM criteria. This
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includes substance-related disorders for those substances, including alcohol, not listed in Schedules I
through V of Section 202 of the Controlled Substances Act.
For substance-related disorders for those substances listed in Schedule I through V of Section 202 of
the Controlled Substances Act, the determination of remission must be made based on applicant’s
substance use and DSM criteria.
The practical significance for diagnosis of remission is that applicants who are or have been determined
to be Class A for abuse or addiction for those substances listed in Schedule I through V of Section 202
of the Controlled Substance Act are not eligible for a waiver and must complete the time period for
sustained, full remission before reapplying for admission.
The civil surgeon must exercise judgment in reevaluating applicants with a previous Class A
determination who are reapplying for admission. If the disorder is in the past, the decision is whether
to classify the applicant as Class A or B. If the disorder is current, the decision becomes whether the
applicant is still Class A or is in a period of remission sufficient to lend confidence that remission is
sustained and full. In other words, if the applicant is currently in remission, what is the likelihood that
the remission will be sustained? (See Table 2)

Table 2. Sustained, Full Remission During the Most Recent 12 Months Before
Reexamination
Means that during that interval • The civil surgeon has received reliable evidence of the applicant’s remission for that time
period.
• The applicant did not meet DSM criteria (no behavior) for dependence or abuse.
• The general mental disorder (non-substance related) is under control (by medication or by
the natural history of the disorder) and recurrence of specific life events or unusual
circumstances that precipitated an episode(s) of illness are judged unlikely to recur.
• The applicant was not in a controlled environment where access to alcohol or drugs was
restricted, such as a treatment facility, jail, or halfway house.
• No use other than indicated medical treatment of any of the substances listed in Schedules IV of Section 202 of the Controlled Substances Act.
Sexually Dangerous People
Not all sexually dangerous people have behaviors attributable to a psychiatric or general medical
disorder. For instance, rapist is not a psychiatric diagnosis. However, people diagnosed with
paraphilias might commit rape when their intense sexual fantasy, urge, or fetish is enacted with a child
or other non-consenting person. People who have harmful behaviors associated with sexual acts,
whether reported as a criminal act or psychiatric disorder, have been shown not to benefit reliably from
treatment programs. Documented or acknowledged episodes of paraphilia might represent only a
fraction of the sexually dangerous person’s history of related harmful behaviors. Given the pattern of
recurring harmful behaviors in paraphilia and the high relapse rate of sexual offenders, applicants with a
history of harmful behavior associated with sexual acts are almost always likely to have a recurrence of
harmful behavior and therefore remain medically classifiable as a Class A mental disorder with
associated harmful behavior.
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Table 3. Factors Affecting the Applicant's Likelihood of Maintaining Remission of a
Mental Disorder or Having a Disorder Under Control • The availability of effective treatments.
• The applicant's faithfulness with previous treatment, willingness to remain on treatment,
and his or her insight into disorder. He or she stating in writing a willingness to continue
medication or other effective treatment to control the disorder can help demonstrate this.
• The natural history of the disorder (for instance, bipolar mood disorders without ongoing
treatment are characterized by multiple episodes of illness and remission).
• The number of and interval between previous episodes of illness (for instance, episodes of
schizophrenia with prominent psychotic symptoms were 3 years apart at the beginning of
the illness but are now happening every year).
• Any trend towards increasing severity of episodes of illness or emergence of treatmentresistant symptoms.
• The likelihood of recurrence of specific life events that precipitated previous episodes of
illness or likelihood of severe life stresses that might precipitate further episodes of illness
(for instance, postpartum depression in a young woman).
• Unusual circumstances that precipitated a single episode of illness judged unlikely to recur.

Referring the Applicant to a Specialist for Psychiatric Examination
After reviewing the applicant's available records (such as medical, psychiatric, police, military, school,
and employment) and performing mental status and physical examinations (including an Activities
Assessment and Mental Status Assessment), the civil surgeon may feel that a more specialized
psychiatric examination is indicated. (See Table 4)
If an applicant has been referred to a specialist for psychiatric evaluation and the civil surgeon still
needs guidance and assistance in determining the diagnosis and classification of a Class A or Class B or
No Class A or Class B condition, DGMQ may be consulted to provide additional assistance.
A copy of all the pertinent medical information may be faxed to 404-639-4441, sent via secure files to
[email protected], or mailed to the following address:
Quality Assessment Program
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention, Mailstop E-03
1600 Clifton Road, Atlanta, Georgia 30333, USA

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Table 4. Referring Applicant to a Specialist Consultant
The Civil Surgeon may refer the applicant to a specialist consultant if after interview, review of
records, and examination, he or she is unable to •
Arrive at a probable psychiatric diagnosis for purposes of the determination of a mental
disorder with associated harmful behavior (past or present)
•
Arrive at a probable diagnosis of substance-related disorder according to DSM criteria.
•
Arrive at a probable diagnosis for past episodes of mental disorder according to current
DSM criteria, or determine that previous difficulties in functioning were the result of a
mental disorder.
•
Rule out the presence of a mental disorder.
•
Determine if harmful behavior has been associated with a physical or mental disorder.
•
Determine if any associated harmful behavior is likely to recur.
•
Determine if any diagnosed physical or mental disorders that affect behavior are in
remission or under control.
•
Determine the likelihood of maintaining remission or effective control of diagnosed
physical or mental disorders that affect behavior.

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Mental Health Screening Results
The mental health screening is complete when all required aspects of the medical
examination have been finalized, including if indicated, the report of the specialist and
laboratory test results. At this time, the civil surgeon should be able to assign to the
applicant a classification regarding a physical or mental disorder or substance-related
disorder.

For physical or mental disorders with associated harmful behavior (past and present), or substancerelated disorders, the civil surgeon should use the below outlined screening results to classify applicants
as Class A or Class B.
Pertinent information relating to physical or mental disorders, and substance related disorders should
be indicated on the I-693.
Screening Results
•
•
•

•
•

•
•
•
•

Applicants without findings suggestive of mental or physical disorders, or substance abuse or
addiction. (No Class A or B Physical or Mental Disorder, No Class A or B Drug
Abuse/Addiction).
Applicants with physical and mental disorders that affect behavior but no associated harmful
behavior, and who do not have substance abuse or addiction. (No Class A or B Physical or Mental
Disorder, No Class A or B Drug Abuse/Addiction).
Applicants with “addiction” (dependence) or abuse of any of the substances listed in Schedule I-V
of Section 202 of the Controlled Substances Act (see Appendix C) with or without associated
harmful behavior. (Class A Substance (Drug) Use, Listed in Section 202 of the Controlled
Substance Act.). Applicants may not apply for a waiver of eligibility.
Applicants with a diagnosis of a current physical or mental disorder (including other substancerelated disorders such as alcohol-related disorders) with associated harmful behavior. (Class A,
Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with a history of a physical or mental disorder (including other substance-related
disorders, such as alcohol-related disorders) with associated harmful behavior and whose harmful
behavior is likely to recur or lead to other harmful behavior. (Class A, Physical/Mental Disorder
with Associated Harmful Behavior).
Applicants with a history of alcohol-related arrests or convictions (e.g., driving under the influence
[DUI]) who currently continues to drink alcohol and who meets DSM criteria for alcohol abuse.
(Class A, Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with single alcohol related arrest or conviction within the last five years, or two or more
arrests or convictions within the last ten years should be evaluated for alcohol abuse (mental health
classification pending).
Applicants who meet DSM criteria for mood disorders or schizophrenic disorders with associated
harmful behavior, either current or judged likely to recur. (Class A, Physical/Mental Disorder with
Associated Harmful Behavior).
Applicants with sustained, full remission of “addiction” (dependence) or abuse of any of the
specific substances listed in Schedule I-V of Section 202 of the Controlled Substances Act (see
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•

•

•
•
•

Appendix C) may be assigned a Class B, Prior Substance (Drug) Use in Remission.
Applicants with a history of a diagnosable physical or mental disorder (including other substancerelated disorders, such as alcohol-related disorders) with associated harmful behavior when the
harmful behavior is judged unlikely to recur or lead to other harmful behavior may be assigned a
Class B, Physical/Mental Disorder without Associated Harmful Behavior.
Applicants who are diagnosed with a physical disorder that affects behavior or a mental disorder
(including substance-related disorders) that is significant enough to require clinical attention but
who have has had no associated harmful behavior (such as those with seizure disorders, mental
retardation, or schizophrenia without associated harmful behavior) may be assigned a Class B,
Physical/Mental Disorder without Associated Harmful Behavior.
Applicants with history of alcohol related arrests or convictions that currently meets DSM criteria
for full, sustained remission, may be assigned a Class B Physical/Mental Disorder Without
Associated Harmful Behavior.
Applicant with a current or past history of mood disorders or schizophrenic disorders without
associated harmful behavior may be assigned a Class B Physical/Mental Disorder
Without Associated Harmful Behavior.
Applicants with history of non-medical use of specific categories of substances that currently meets
DSM criteria for full, sustained remission may be assigned a Class B, Prior Substance (Drug) Use in
Remission.

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Waivers
A provision allows applicants diagnosed with a mental or physical disorder with
associated harmful behavior to apply for a Class A waiver.

Most applicants diagnosed with substance abuse or addiction are not eligible to apply
for a Class A waiver.

Applicants diagnosed with substance abuse or addiction who are subsequently found
to be in remission and reclassified as Class B do not need to apply for a waiver.

A provision allows applicants with a Class A physical disorder or mental disorder with associated
harmful behavior to petition for a Class A waiver. Form I-601 or I-602 (for immigrants or refugees,
respectively) must be completed. These waivers are submitted to the Department of Homeland
Security (DHS), U.S. Citizenship and Immigration Services (USCIS) on an individual basis. DGMQ
also reviews the waivers and supporting medical examination to provide an opinion regarding the case
to the requesting entity (DOS or DHS, USCIS). DGMQ’s review of the waiver and supporting medical
examination documentation is to ensure that the applicant has been classified properly and that an
appropriate U.S. health care provider is identified for the applicant. DHS, USCIS has the final
authority to adjudicate the waiver request.
Most applicants diagnosed with substance abuse or addiction (dependence) for specific substance
categories based on current DSM criteria and classified as Class A are not eligible for a waiver.
Applicants who were previously diagnosed as Class A for substance abuse or addiction and
subsequently found to be in remission and reclassified as Class B do not require a waiver.

20

Mental Health and Substance
Abuse/Addiction Classifications and
Descriptions
Applicants may be assigned one or more mental or physical disorders with
associated harmful behavior and substance-related disorders classification
on the I-693 Form.

The physical and mental disorders with associated harmful behaviors and substance related disorders
are listed below. Applicants may have more than one classification. However, applicants cannot be
classified as both Class A and Class B for the same physical or mental disorder, or substance related
disorder.
No Class A or Class B Classification
•

Applicants with no diagnosis of physical or mental disorder, or substance related disorder.

•

Applicants diagnosed with physical and mental disorders based on current DSM criteria that affect
behavior but do not meet criteria for Class A or Class B.

Class A Physical or Mental Disorder with Associated Harmful Behavior
•
•
•

Applicants diagnosed with current physical or mental disorder based on current DSM criteria with
associated harmful behavior.
Applicants diagnosed with history of physical or mental disorder based on current DSM criteria
with associated harmful behavior judged likely to recur or lead to other harmful behaviors.
Applicants with non medical substance use for non specific substance categories (including alcohol
and other substances NOT provided in Schedule I-V of Section 202 of the Controlled Substances
Act) and diagnosed with substance abuse or dependence based on current DSM criteria with
current associated harmful behavior or history of associated harmful behavior judged likely to recur.

Class A Substance Abuse or Dependence for Specific Substances provided in Schedule I-V of
Section 202 of the Controlled Substances Act
Applicants with non medical substance use for specific substances provided in Schedule I-V of Section
202 of the Controlled Substances Act (see Appendix C), and diagnosed with substance abuse or
dependence based on current DSM criteria with or without associated harmful behavior.
21

Class B Current Physical or Mental Disorder with No Associated Harmful Behavior
•

Applicants with current diagnosable physical or mental disorder (including alcohol related and other
non specific substance categories disorders) based on current DSM criteria with no associated
harmful behavior.

Class B History of Physical or Mental Disorder with Associated Harmful Behavior Unlikely to
Recur
•

Applicants with history of diagnosable physical or mental disorder (including alcohol related or
other non specific substance categories) based on current DSM criteria with associated harmful
behavior when the harmful behavior is judged unlikely to recur or lead to other harmful behavior.

Class B Substance Abuse or Dependence in Full Remission
•

Applicants diagnosed with full, sustained remission of substance abuse or dependence based on
current DSM criteria.

22

Documentation
The I-693 Medical Examination form must be completed in entirety including diagnosis
and classification of mental or physical disorders and substance related disorders.

The original I-693, Report of Medical Examination and Vaccination Record, must be completed in
entirety, signed, and placed in a sealed envelope for submission to the Department of Homeland
Security (DHS), Citizenship and Immigration Services (CIS) office. This includes assigning a
classification on the I-693 if an applicant is Class A or Class B for a physical or mental disorder or
substance related disorder.
For applicants who are referred to a specialist for further evaluation, the civil surgeon is required to
retain a copy of the specialist’s report along with the I-693 form for their records.
For applicants who are referred for psychological or laboratory testing, the civil surgeon is required to
complete Part 3 of the I-693 form. The civil surgeon must also ensure that Part 4 is completed and
provides sufficient information to make a diagnosis and classification of a physical or mental disorder,
or substance related disorder. The civil surgeon should provide pertinent information regarding referral
in the appropriate remarks section in Part 2 or the I-693 form.
A copy of any other documents provided for review regarding the diagnosis or classification of a
physical or mental disorder, or substance related disorder for an applicant should be retained by the
civil surgeon.

23

APPENDIX A: GLOSSARY OF ABBREVIATIONS
CDC
DGMQ
DHS
DOS
DSM
FDA
ICD
WHO

Centers for Disease Control and Prevention, United States
Division of Global Migration and Quarantine
Department of Homeland Security
Department of State
Diagnostic and Statistical Manual of Mental Disorders
Food and Drug Administration
Manual of the International Classification of Diseases
World Health Organization

24

APPENDIX B: USEFUL RESOURCES
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
World Health Organization: Manual of the International Classification of Diseases.

25

APPENDIX C: CONTROLLED SUBSTANCES
Schedules I through V of Section 202 of the Controlled Substances Act are provided below and also
available at the following location: http://www.access.gpo.gov/nara/cfr/waisidx_01/21cfrv9_01.html

26

27

28

29

30

31

32

33

APPENDIX D: SUMMARY OF MENTAL HEALTH EXAMINATION
Summary
•
•

•

•

•

•
•

•
•

The purpose of the examination is to identify health-related conditions that render an
applicant inadmissible and conditions that will need follow-up care.
Health-related conditions that render an applicant inadmissible are $ Dependence on (addiction) or abuse of a specific substance provided in Schedule I-V
of Section 202 of the Controlled Substances Act.
$ A physical or mental disorder (including alcohol-related disorders) that might cause
or has caused harmful behavior.
$ History of physical or mental disorder that has caused harmful behavior and is likely
to recur.
Mental disorders are characterized by alterations in thinking, mood, or behavior.
$ Substance dependence and abuse are determined by DSM criteria.
 Indicated medical use of a substance is not substance abuse.
$ General mental disorders are determined by DSM criteria.
 “V” coded conditions are not mental disorder diagnoses.
Harmful behavior is $ Serious psychological or physical injury to others or to the applicant.
$ A serious threat to health or safety.
$ Major damage to property.
Harmful behavior alone (without mental or physical disorder) or a mental or physical
disorder alone is not a health-related condition that renders an applicant inadmissible.
$ Any antisocial act requires further investigation, but mental disorder diagnoses
involve patterns of behavior, not single events.
The classification (A or B) is used to determine admissibility and the need for follow-up
care.
Remission is determined by DSM criteria.
$ Sustained, full remission for substance-related disorders is at least 12 months.
$ Sustained, full remission is dependent on clinical judgment but requires reliable
evidence.
$ A statement signed by the applicant is helpful in documenting  The applicant’s understanding of his or her condition, and
 Requirements to demonstration remission, such clinical reports.
Harmful behavior unlikely to recur includes the following factors $ Remission or control of the mental disorder for at least 12 months.
$ External circumstances influencing that behavior have changed.
The eligibility to apply for a waiver is determined by law. DHS, USCIS has the final
authority to adjudicate the waiver request.

34

Index
Diagnostic and Statistical Manual of Mental Disorders (DSM) p. 5-6, 8, 10, 14-15, 17-22, 24-25, 34
Division of Global Migration and Quarantine

p. 3, 16, 20, 24

Documentation p. 20, 23
Harmful Behavior p. 3-10, 12-15, 17-22, 34
Current p. 3, 7, 9, 13-14, 21
Future p. 3, 7, 14
Immigration and Nationality Act (INA) p. 3
Laboratory Testing

p. 11-12, 23

Substance-Related Disorders p. 3, 6, 8, 11, 13-15, 18-19, 21, 34
Manuel of the International Classification of Diseases (ICD) p. 5, 14, 24
Medical History

p. 2, 8-10

Mental Disorder p. 2-9, 12-25, 34
Mental Health and Substance Abuse/Addiction Classifications p. 21
Physical Disorder p. 3, 5, 13-14, 18-21, 23, 34
Psychiatric Evaluation

p. 11, 16

Referral to specialist p. 2, 4, 16-18, 23

35

Remission p. 2, 4, 12, 14-20, 22, 34
Screening Results p. 18
Section 202 of the Controlled Substance Act p. 3, 6, 8, 10, 12-13, 15, 18, 21, 26, 34
Sexually Dangerous People

p. 15

“V” Coded Conditions p. 6, 34
Waivers p. 20

36