Form N-648 Medical Certification for Disability Exceptions

OMB No. 1615-0060

Form N-648, Medical Certification for
Disability Exceptions

Department of Homeland Security
U.S. Citizenship and Immigration Services

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.)

Reminder About Eligibility Requirements

Completing and Certifying This Form

This form is intended for an applicant who seeks an exception
to the English and/or 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.

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 www.uscis.gov. If the medical professional completes
the form by hand, then responses must be legible and appear in
black ink.

Part I. APPLICANT INFORMATION

USCIS USE ONLY

Type or print clearly in black ink.

This N-648 is:
Sufficient

I certify that I have examined:
Last Name

First Name

Middle Name

Insufficient

USCIS A-Number
A-

Address (Street Number and Name)

Continued/RFE

U.S. Social Security Number
Reviewer

City

State or Province

Zip Code or Postal Code

Date of Birth

Gender

Location & Date

Telephone Number

E-Mail Address (if any)

Male

Female

Part II. MEDICAL PROFESSIONAL INFORMATION
Type or print clearly in 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.
Last Name

First Name

Business Address (Street Number and Name)

City

License Number

Licensing State

1. Currently licensed as a (Check all that apply):

Middle Name
State or Province

Zip Code or Postal Code

Telephone Number

E-Mail Address (if any)

Medical Doctor

Doctor of Osteopathy

Clinical Psychologist

2. Medical practice type:
Form N-648 (Rev. 06/17/11) N Page 1

Applicant's Name

USCIS A-Number
A-

Part III. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S)
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". If you
cannot provide a DSM IV code, write "N/A" and explain why you cannot provide a DSM IV code.

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."

3. Date you first examined the applicant regarding the condition(s) listed in number 1.
Date

Location (if different from business address on Page 1; otherwise write "same as business address")

4. Date you last examined the applicant regarding the condition(s) listed in number 1, if different from above.
Date

Location (if different from business address on Page 1; otherwise write "same as business address")

5. Are you the medical professional regularly treating this applicant for the condition(s) listed in number 1?
Yes (If "Yes," indicate duration of treatment.)

Years

Months

No (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.)
Form N-648 (Rev. 06/17/11) N Page 2

Applicant's Name

USCIS A-Number

AName of Regularly Treating Medical Professional and Address.
Last Name

First Name

Business Address

City

Middle Name
State or Province

Zip Code or Postal Code Telephone Number

Explanation:

6. Has the applicant's disability and/or impairment(s) lasted, or do you expect it to last, 12 months or more?
Yes (If "Yes,"continue to complete this form.)
No (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.")
7. Is the applicant's disability and/or impairment(s) the result of the applicant's illegal use of drugs?
Yes (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 (If "No," continue to complete this form.)
8. What caused this applicant's medical disability and/or impairment(s) listed in number 1, if known?

Form N-648 (Rev. 06/17/11) N Page 3

Applicant's Name

USCIS A-Number
A-

9. What clinical methods did you use to diagnose the applicant's medical disability and/or impairment(s) listed in number 1?

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.

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.)
The ability to:
Read English
Write English
Speak English
Answer questions regarding United States history and civics, even in a language the applicant understands.

Form N-648 (Rev. 06/17/11) N Page 4

Applicant's Name

USCIS A-Number
A-

12. Was an interpreter used during your examination of the applicant?
Yes (If "Yes," the interpreter must complete the "Interpreter Certification" section.)
No
Additional Comments (Optional)

MEDICAL PROFESSIONAL' S CERTIFICATION
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
used during my examination(s) of this applicant.

, the language spoken by this patient. Therefore, an interpreter was not

All medical professionals must complete the certification below.
I certify that this applicant's identity has been verified through the following United States or State government-issued
photographic identity document:
Permanent Resident Card

State ID Number:

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 247c of
the Immigration and Nationality Act, and civil license suspension or revocation by the appropriate authorities.
Licensed Medical Professional Signature

Date

Form N-648 (Rev. 06/17/11) N Page 5

Applicant's Name

USCIS A-Number
A-

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

First Name

Address (Street Number and Name)

Middle Name
Zip Code or Postal Code

State or Province

City

Was a phone interpreter used?
Yes If yes, the interpreter is not required to complete the information below.
No If no, the interpreter is required to complete the information below.

Interpreter Certification
As the interpreter, I certify that I am fluent in 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

Date

APPLICANT (PATIENT) ATTESTATION/RELEASE OF INFORMATION
I,

, authorize
(Applicant's Name)

(Licensed medical doctor, doctor of osteopathy, or clinical psychologist)

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. Section 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.
Applicant or Applicant's Authorized Representative Signature

Date

Form N-648 (Rev. 06/17/11) Y Page 6