Instructions Table of Changes

TABLE OF CHANGES

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

INSTRUCTIONS

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

Reason for Revision: Minor modifications are needed, including reformatting form instructions into single-column display, deleting language requiring applicant to sign at the end of the immigration medical examination, and inserting clarifying language regarding signature requirements.

Current Section and Page Number	Current Text	Proposed Section and Page Number (If Changing)	Proposed Text
Page 1 Instructions	Read these instructions carefully to properly complete this form. If you need more space to complete an answer, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if you have one, at the top of each sheet and indicate the number of the item that refers to your answer.		[Deleted]
Page 1 What Is the Purpose of Form I-693?	Generally, all applicants filing for adjustment of status to that of a permanent resident must submit Form I-693 completed by a designated civil surgeon. Form I-693 is used to report results of a medical examination to U.S. Citizenship and Immigration Services (USCIS). The examination is required to establish that you are not inadmissible to the United States on public health grounds. A list of those health grounds can be found in section 212(a)(1) of the Immigration and Nationality Act. The list is also available in Question 8 of Section III, Frequently Asked Questions. *** NOTE: If you are applying for adjustment of status as a refugee, an asylee dependent, or as a “K” or “V” nonimmigrant visa holder, see Questions 1-4 in Section III, Frequently Asked Questions, before proceeding any further.		Form I-693 is used to report results of a medical examination to U.S. Citizenship and Immigration Services (USCIS). The examination is required to establish that you are not inadmissible to the United States on public health grounds. A list of those health grounds can be found in section 212(a)(1) of the Immigration and Nationality Act (INA). The list is also available in Question 9 of Section III, Frequently Asked Questions. *** NOTE: If you are applying for adjustment of status as a refugee, an asylee dependent, or as a “K” or “V” nonimmigrant visa holder, see Questions 2-5 in Section III, Frequently Asked Questions, before proceeding any further.
Page 1 How Do I File Form I-693?	A separate Form I-693 is required for each applicant. There is no filing fee for this form. Follow these steps: Step 1 - Carefully read all these instructions, including Section III, Frequently Asked Questions. Step 2 - Call a designated physician (also known as a civil surgeon) to make an appointment. Step 3 - Fill out Part 1 of the form. Do not sign the form. Step 4 - Attend your medical exam appointment and all follow-up exams, as may be required. Sign Form I-693 in front of the civil surgeon Step 5 - Submit Form I-693 in the sealed envelope to USCIS according to the instructions on Form I-485, Application to Register Permanent Residence, or Adjust Status. USCIS will return the form to you and/or request another Form I-693 if it is not in a sealed envelope or if the envelope has been opened or altered.		A separate Form I-693 is required for each applicant. There is no filing fee for this form. 1. … 2. … 3. Fill out Part 1 of the form. Do not sign the form until the civil surgeon tells you to sign. You must sign Form I-693 in the presence of the civil surgeon. 4. Attend your medical exam appointment and all follow-up exams, as may be required. 5. The civil surgeon is required to give you the completed Form I-693 in a sealed envelope. Do not accept the form from the civil surgeon if it is not in a sealed envelope.  USCIS will return the form to you if it is not in a sealed envelope or if the envelope has been opened or altered. Submit Form I-693 in the sealed envelope to USCIS. a. If you are applying for adjustment of status, submit Form I-693 according to the instructions on Form I-485, Application to Register for Permanent Residence or Adjust Status. b. For all other applicants, follow the instructions on or included with the application form or the instructions given to you by the office requesting the medical exam.
		General Instructions Page 2	Each application or petition must be properly signed and filed. A photocopy of a signed application or a typewritten name in place of a signature is not acceptable. Copies. Unless specifically required that an original document be filed with an application or petition, a legible photocopy may be submitted. Original documents submitted when not required may remain a part of the record, and will not be automatically returned to you. Translations. Any document containing a foreign language submitted to USCIS must be accompanied by a full English language translation which the translator has certified as complete and accurate, and by the translator’s certification that he or she is competent to translate from the foreign language into English.
Page 1 How Do I Fill Out My Portion of Form I-693?	1. Use black ink only. Type or print clearly. If an item does not apply to you, write "N/A" unless the specific instruction states otherwise. 2. You must fill out only Part 1 and identifying information at the top of each page. The civil surgeon and any other doctors, clinics, or health departments receiving a referral are required to complete the remaining parts of the form. *** H. A-Number – This is your alien registration file number. . . . If you do not have one or if you cannot remember what it is, leave this space blank. I. U.S. Social Security Number – If you do not have a U.S. Social Security Number, leave this blank. J. Applicant’s Certification – Do not sign here until the civil surgeon tells you to do so.	Page 2 How to Fill Out My Portion of Form I-693	1. Use black ink only. Type or print clearly. If an item does not apply to you or the answer is "none", leave the space blank. 2. If you need more space to complete an answer, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if you have one, at the top of each sheet and indicate the number of the item to which your answer refers. 3. You must fill out only Part 1 and identifying information at the top of each page. The civil surgeon and any other doctors, clinics, or health departments receiving a referral are required to complete the remaining parts of the form. *** 7. A-Number – This is your alien registration file number. . . . If you do not have one or if you cannot remember what it is, leave this space blank. 8. Applicant’s Certification – Do not sign here until the civil surgeon tells you to do so. You must sign Form I-693 in the presence of the civil surgeon. If the applicant is under 14 years of age, a parent or guardian may sign Form I-693. If the applicant is 14 years of age or older, he or she must sign Form I-693.
Page 2 How Do I Submit Form I-693 to USCIS?	1. The civil surgeon is required to give you the completed Form I-693 in a sealed envelope. Do not accept the form from the civil surgeon if it is not in a sealed envelope.  USCIS will return the form to you if it is not in a sealed envelope or if the envelope has been opened or altered. 2. Adjustment of status applicants. If you are applying for adjustment of status, submit Form I-693 according to the instructions on Form I-485, Application to Register for Permanent Residence or Adjust Status. 3. Other applicants.  Follow the instructions on or included with the application form or the instructions given to you by the office requesting the medical exam.		[Combined with “How Do I File Form I-693” on page 1.]
Page 2 What Are My Responsibilities as a Designated Civil Surgeon?	1. Truthfully and Accurately Report the Results. You are responsible for reporting…provided on the form. In this regard, you must take reasonable steps…in connection with this medical exam. The civil surgeon should also ensure that the applicant’s name and A-number, if applicable, at the top of each page of the Form I-693 matches the information provided in Part 1. 2. Follow HHS Guidelines. USCIS has…		1. Truthfully and Accurately Report the Results. You are responsible for reporting…provided on the form. You must take reasonable steps…in connection with this medical exam. The civil surgeon should direct the applicant to sign in Part 1 in the presence of the civil surgeon. The civil surgeon should also ensure that the applicant’s name and A-number, if applicable, are at the top of each page of the Form I-693, and that they match the information provided in Part 1. 2. Follow HHS regulations and CDC guidelines. USCIS has…
Page 3 How Do I Fill Out My Portion of This Form?	The applicant fills out Part 1 of Form I-693 before the medical exam appointment. You, the civil surgeon, are responsible for ensuring the remaining parts are completed and signed, as follows. 1. Civil Surgeon Worksheet … 2. Referral to Health Department or Other Doctor. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out section 5 of the Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign section 6, Referral Evaluation of the Civil Surgeon Worksheet. 3. Part 3 - Civil Surgeon's Certification. You must sign the certification…Stamped signatures are not acceptable, your signature must be original.		[Renumbered.] You, the civil surgeon, are responsible for ensuring the relevant parts of Form I-693 are completed and signed, as follows. 1. Part 1, Applicant's Certification. You, the civil surgeon, are responsible for verifying the identity of the applicant, and noting the form of identification the applicant presents to you, in Part 1. You are also required to check each page of Form I-693 to ensure the name and A-Number, if applicable, are correct. Finally you must require that the applicant sign the Applicant's Certification in your presence. The applicant should not sign Part 1 until all health follow-up requirements have been met. 2. Civil Surgeon Worksheet… 3. Referral to Health Department or Other Doctor. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out section 5 of the Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign section 6 of the Civil Surgeon Worksheet. 4. Part 2, Summary of Medical Examination. After the medical exam and any follow-up (if required) is complete, summarize the results in Part 2 of Form I-693 5. Part 3, Civil Surgeon's Certification. You must sign the certification…Stamped signatures or typewritten names are not acceptable; your signature must be original.
Page 3 How Do I Complete Form I-693 If I Need to Make a Referral?	Advise the applicant that the appropriate follow-up…give the original form to the applicant in a sealed envelope.	Page 4	Advise the applicant that the appropriate follow-up…give the original form to the applicant in a sealed envelope. (See the next section for additional instructions regarding sealing the envelope.)
Page 3 What Do I Do After the Medical Exam and Follow-Up (If Required) Are Completed?	You and the applicant must sign your respective certifications. After the medical exam (and any follow-up if required) is complete, write the results in Part 2 of the Form I-693 as they relate to the specific component of the medical exam. The applicant must sign the certification in Part 1, and you must sign the civil surgeon’s certification in Part 3. Do not sign the form or have the applicant sign the form until the applicant has met all health follow-up requirements. Make two copies of the completed and signed Form I-693, and any supporting documentation (such as x-ray reports or other reports) that you submit to USCIS. You should…requirements (example: school, day care, employment, etc.). Prepare the original of the completed and signed Form I-693 for submission to USCIS. Place the original of the completed and signed Form I-693 and any supporting documentation (such as x-ray reports or other reports) into an envelope, and then seal the envelope….Give the sealed envelope to the applicant. ***	Page 4	After the medical exam (and any follow-up if required) is complete, summarize the results in Part 2 of Form I-693. Certify the form by signing the civil surgeon’s certification in Part 3. Do not sign Form I-693 until the applicant has met all health follow-up requirements. Make two copies of the completed and signed Form I-693 and any supporting documentation that you submit to USCIS. You should… Prepare the original of the completed and signed Form I-693 for submission to USCIS. Place the original of the completed and signed Form I-693 and any supporting documentation into an envelope, and then seal the envelope….Give the sealed envelope to the applicant. ***
Page 4 Frequently Asked Questions	What if I am a refugee and already had a medical exam overseas? If you were admitted to the United States as a refugee and are now applying for adjustment of status one year following your first admission, you do not need to repeat the entire medical exam you had overseas, unless a Class A medical condition was found during that exam.		Who must submit Form I-693? Generally, all applicants filing for adjustment of status to that of a permanent resident must submit Form I-693 completed by a designated civil surgeon. What if I am a refugee and already had a medical exam overseas? If you were admitted to the United States as a refugee and are now applying for adjustment of status under section 209 of the INA one year following your first admission, you do not need to repeat the entire medical exam you had overseas, unless a Class A medical condition was found during that exam.
		Page 6	[Add heading] Section IV. Medical Evaluations
Page 5 Communicable Diseases of Public Health Significance	The civil surgeon is required to perform specific tests for TB and syphilis. The medical exam…	Page 6	The civil surgeon is required to perform specific tests for tuberculosis and syphilis. The medical exam…
Page 5 chart	All applicants two years of age and older are required to be tested for tuberculosis (TB) with an initial screening test. Civil surgeons may require an applicant younger than two years of age…Interferon Gamma Release Assay (IGRA). Tuberculin Skin Test (TST) given by the Mantoux technique. After the skin test, you will need to return to the civil surgeon within 48 or 72 hours to have the result read. If you have a reaction of four millimeters or less, generally, you will not need any further tests for TB. A chest x-ray is required when the reaction to the TST is five millimeters or more. The civil surgeon will explain the medical requirements to you in more detail. *****	Page 6	[Delete chart format] 1. Testing for Tuberculosis All applicants 2 years of age and older are required to be tested for tuberculosis (TB) with an initial screening test. Civil surgeons may require an applicant younger than 2 years of age… Interferon Gamma Release Assay (IGRA). a. Tuberculin Skin Test (TST) given by the Mantoux technique. After the skin test, you will need to return to the civil surgeon within 48 or 72 hours to have the result read. If you have a reaction of 4 millimeters or less, generally, you will not need any further tests for TB. A chest x-ray is required when the reaction to the TST is 5 millimeters or more. The civil surgeon will explain the medical requirements to you in more detail. b. ***** 2. *****
Page 6 Vaccination Requirements	All applicants for adjustment of status must present documents showing they have been vaccinated against a broad range of vaccine-preventable diseases. The civil surgeon will review your vaccination history with you to determine whether you have all the required vaccinations. Make sure…	Page 7	All applicants for adjustment of status must present documents showing they have been vaccinated against a broad range of vaccine-preventable diseases. The civil surgeon will review your vaccination history with you to determine whether you have had all the required vaccinations. Make sure…
Page 6 Physical or Mental Disorders	Are all physical or mental disorders considered health-related grounds of inadmissibility? No. The emphasis is more on…	Page 7	Not all physical or mental disorders are considered health-related grounds of inadmissibility. The emphasis is more on …
Page 6 Drug Addiction/Drug Abuse	What are the guidelines for determining whether someone is a drug abuser/drug addict? The civil surgeon will review your medical history during the medical exam and ask you questions necessary to determine whether you are currently using or have used in the past any drugs or other psychoactive substances. The medical guidelines for determining drug abuse and drug addiction are determined by HHS. ***	Page 8	The medical guidelines for determining drug abuse and drug addiction are determined by HHS. The civil surgeon will review your medical history during the medical exam and ask you questions necessary to determine whether you are currently using or have used in the past any drugs or other psychoactive substances. ***
Page 7 Processing Information	*** Requests for More Information We may request more information or evidence, or we may request that you appear at a USCIS office for an interview. Unless specifically required that an original document be filed with an application or petition, an ordinary legible photocopy (standard 8 1/2 x 11 letter size) may be submitted. Original documents submitted when not required may remain a part of the record.	Page 9	*** Requests for More Information We may request more information or evidence, or we may request that you appear at a USCIS office for an interview. ****
Page 7 Paperwork Reduction Act	An agency may not conduct or sponsor…Regulatory Products Division, Office of the Executive Secretariat, 20 Massachusetts Ave., N.W., Washington, DC 20529-2020. OMB No. 1615-0033. This form expires October 31, 2012. Do not mail your application to this address.		An agency may not conduct or sponsor…Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave., N.W., Washington, DC 20529-2020. OMB No. 1615-0033. Do not mail your completed Form I-693 to this address.

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