Form Table of Changes

TABLE OF CHANGES

FORM I-693, Report of Medical Examination and Vaccination Record

Form

OMB Control No. 1615-0033, Expires 10/31/2012

Reason for Revision: Minor modifications are needed, including deletion of the Social Security Number field and revision of findings in the Communicable Diseases section in anticipation of forthcoming updates to the Centers for Disease Control and Prevention (CDC)’s Technical Instructions. Language instructing the civil surgeon to attach an X-ray report (if required of the applicant, as part of the tuberculosis evaluation) was also deleted, in agreement with CDC.

Current Section and Page Number	Current Text	Proposed Section and Page Number (If Changing)	Proposed Text
Page 1 Part 1, Information About You	Item: Phone # (Include Area Cod) no dashes or () Item: Date (mm/dd/yyyy) Item: U.S. Social Security Number (if any)		Item: Phone Number [Reformatted field so that numbers are captured individually, including area code] Item: Date Signed (mm/dd/yyyy) [Field no longer aligned under “Signature” – it shifted to the right to allow more characters in “E-Mail” field] [Delete SS# item]
Page 1 Part 3, Civil Surgeon’s Certification	Item: (For Health Departments Only: Place official stamp or seal here) Item: Name of Medical Practice or Health Department Item: E-mail/Daytime Phone # (Include Area Code) Item: Date (mm/dd/yyyy)		Item: (Health Departments MUST place their official stamp or seal here) Item: Name of Medical Practice, Facility, or Health Department Item: Daytime Phone Number Item: Email [Split field into two separate data captures to collect more accurate information; reformatted Daytime Phone Number field so that numbers are captured individually, including area code] Item: Date Signed (mm/dd/yyyy) [Field no longer aligned under “Signature” – it shifted to the right to allow more characters in “E-Mail” field]
Page 2 Section 1.A., Item Number 4. Chest X-Ray	Attach a copy of X-ray report.		[Deleted]
Page 3 Section 1.B., Syphilis	Item: Syphilis Class B (with residual deficit and treated in the past year)		Item: Syphilis Class B (with or without residual deficit and treated in the past year)
Page 3 Section 1.C., Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance	Item: Hansen’s Disease (Leprosy, Infectious), Class A Item: Hansen’s Disease (Leprosy, Noninfectious), Class B		Item: Hansen’s Disease (Leprosy, any classification) untreated, Class A Item: [Checkbox] Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary) Item: [Checkbox] Mid-borderline, borderline lepromatous, lepromatous (multibacillary) Item: Hansen’s Disease (Leprosy, any classification) treated or partially treated, Class B Item: [Checkbox] Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary) Item: [Checkbox] Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
Page 4 Part 6, Referral Evaluation	Item: Daytime Phone # (Include Area Cod) no dashes or () Item: Date (mm/dd/yyyy)		Item: Phone Number [Reformatted field so that numbers are captured individually, including area code] Item: Date Signed (mm/dd/yyyy) [Field no longer aligned under “Signature” – it shifted to the right to allow more characters in “E-Mail” field]

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