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Page 2,
Supplement
for Applicants With Tuberculosis (TB)
Part A. Applicant’s
Sponsor in the United States
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Make
arrangements for the applicant’s medical care and have the
attending physician or facility complete Part
C.
Obtain
the necessary endorsements.
Treatment
is being provided by a state or local health department:
If a state or local health department will provide the necessary
care and/or treatment to the applicant, that facility should
check block (a) in Number4 under Part C. The health department
is not required to complete anything else on this form.
Treatment
is being provided by a private physician or by any other private
or public facility:
If a private physician, private medical facility or a public
medical facility (other than a state or local health department)
will provide the applicant’s medical care and/or treatment,
that facility should check block (b) or (c) under Number 4 of
Part C, as applicable. In that case, the state or local health
department in the jurisdiction where the applicant will reside
must complete Part D.
3.
Address in the United States where the applicant plans to reside:
Address
(Number and Street)
(Apartment
No.)
City,
State and Zip Code
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Page 1,
Supplement
1., Applicants With a Class A Tuberculosis Condition (As Defined
by Health and Human Services Regulations)
[new]
Applicant’s
Name
Given
Name (First Name)
Middle
Name (if applicable)
Family
Name (Last Name)
Alien
Registration Number (A-Number) (if any)
USCIS
ELIS Account Number (if any)
Section
A. Applicant’s Sponsor in the United States
Make
arrangements for the applicant’s medical care and have the
attending physician or facility complete Section
C.
Obtain
the necessary endorsements.
Treatment
is being provided by a local health department.
If a local health department will provide the necessary care
and/or treatment to the applicant, that facility should select
block
(A.)
in
Item
Number 4. under
Section C.
Treatment
is being provided by a private physician or by any other private
or public facility.
If a private physician, a private medical facility or a public
medical facility (other
than a local health department) will provide the applicant's
medical care and/or treatment, that facility should select block
(B.)
or (C.)
in Item
Number 4.
of Section
C.,
as applicable.
Endorsement
of State Health Department Official.
3.
Physical
Address in the United States where the applicant plans to reside
Street
Number and Name
Apt.
Ste. Flr. Number
City
or Town
State
ZIP
Code
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Page 2,
Part
B. Applicant’s Statement
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Upon
admission to the United States, I will:
Go
directly to the physician or health facility named in Number 5 of
Part C.
Present
copies of diagnostic tests used on the visa examination to
substantiate diagnosis;
Submit
to counseling and such examinations, treatment and medical
regimen as may be required; and
Remain
under prescribed treatment or observation whether on inpatient or
outpatient basis, until discharged.
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Page 1,
Section
B. Applicant’s Statement
Upon
admission to the United States, I will:
1.__
Go directly to the physician or health facility named in Item
Number 6 of
Section
3.
2.__
Present
copies of diagnostic tests used during my visa examination to
verify my diagnosis;
3.__
Attend
counseling and examinations, treatment and medical regimen as
required;
and
4.__
Remain
under prescribed treatment or observation, regardless of whether I
am on an inpatient or an outpatient basis, until I am discharged.
Applicant’s
Signature
Date
of Signature (mm/dd/yyyy)
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Page 2,
Part
C. Statement by Physician or Health Facility
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I
agree to supply counseling and any treatment or observation
necessary for the proper management of the applicant’s
condition.
I
agree to submit a copy of my evaluation to the Division of Global
Migration and Quarantine (E03), Centers for Disease Control and
Prevention, Atlanta, Georgia 30333, and certify the following:
I
will submit a copy of my evaluation within 30 days of the date
the applicant is required to appear for evaluation and/or care;
and
If
at the end of the 30-day period the applicant fails to appear for
evaluation and/or care as required, I will submit a report to
that effect to the CDC.
Satisfactory
financial arrangements have been made for the applicant’s
medical care and treatment. (This statement does not relieve the
applicant from submitting evidence, as required by the consular
officer or USCIS, to establish that he or she is not likely to
become a public charge (another ground of inadmissibility under
section 212(a)(4) of the Immigration and Nationality Act.)
I
represent: (Check
the appropriate box and provide the information requested below.)
-
Local
Health Department
Other
Public Health Facility
Private
Medical Practice
I
agree to submit a copy of my evaluation to the health officer
indicated in Part D. (Required
if you checked block (b) or (c) in Number 4 directly above.)
Name
of Physician or Facility (Please type or print)
Address
(Number and Street)
City,
State, and Zip Code
Signature
of Physician
Date
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Page 1,
Section
C. Statement
by Physician or Health Facility
I agree to supply counseling
and any treatment or observation necessary for the proper
management and
continued care of
the applicant's tuberculosis
condition.
I
agree to submit a summary
of my initial
evaluation of the applicant’s
condition, indicating presumptive diagnosis, test results, and
plans for the applicant’s future care,
to:
The
Division of Global Migration and Quarantine (E03)
Centers
for Disease Control and Prevention
Atlanta,
Georgia 30333
I will submit the
summary referenced above
within 30 days of the date the applicant is required to appear
for evaluation and/or care;
and
If
at the end of the 30-day period the applicant fails to appear for
evaluation and/or care as required, I will submit a report to
notify the Centers for Disease Control and Prevention (CDC) and
the health official indicated in Section
D.
of the applicant’s failure to appear.
Satisfactory
financial
arrangements
have
been
made
for
the
applicant's
medical
care
and
treatment.
(The
applicant
must still submit
evidence,
as
required
by
the
consular
officer
or
USCIS,
to
establish
that
he
or
she
is
unlikely
to
become
a
public
charge
(another
ground
of
inadmissibility
under
section
212(a)(4)
of
the
Immigration
and
Nationality
Act).
I
represent: (Select the appropriate box and provide the
information requested below.)
Local
Health Department
Other
Public Health Facility
Private
Medical Practice
5.
__I agree to submit a
copy of my evaluation to the health official
indicated in
Section
D.
6.
Name
of Physician
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name (if applicable)
Name
of Facility
7.
Address of Physician or Facility
Street
Number and Name
Apt.
Ste. Flr. Number
City
or Town
State
ZIP
Code
Signature
of Physician
Date
of Signature (mm/dd/yyyy)
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Page 2,
Part D. Endorsement
of Local or State Health Officer:
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Endorsement signifies
recognition of the physician or facility for the purpose of
providing care for tuberculosis. If the facility physician who
signed in Part C. is
not in your health jurisdiction or is not familiar to you, you may
wish to contact the health officer responsible for the
jurisdiction, and/or the physician, before you sign this
endorsement.
Official
Name of Department (Please type or print)
Signature
Date
Name
of Health Department to receive the required notice from the CDC
following the Applicant’s arrival in the United
States/adjustment of status. (Please
type or print.)
Address
(Number and Street)
City,
State and Zip Code
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Page 2,
Section
D. Endorsement
of State
Health
Department
Official:
Your
endorsement signifies that you recognize the physician or facility
providing the applicant’s treatment for tuberculosis. If
the facility physician who signed in Section
C. is
not in your health jurisdiction or is not familiar to you, you may
wish to contact the health officer responsible for the
jurisdiction, and/or the physician, before you sign this
endorsement.
Official
Name of Department and Name and Title of Official Providing
Endorsement (Type or Print)
Signature
of State Health Department Official
Date
of Signature (mm/dd/yyyy)
3.Address
of Health Department
Street
Number and Name
Apt.
Ste. Flr. Number
City
or Town
State
ZIP
Code
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