Form I-693 Report of Medical Examination and Vaccination Record

Report of Medical Examination and Vaccination Record
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-693
OMB No. 1615-0033
Expires 01/31/2015

► START HERE - Type or print in black ink.

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the
civil surgeon)
1.

2.

3.

Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

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Home Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Gender

Male

4.

Daytime Telephone Number

5.

ZIP Code

Mobile Telephone Number (if any)

Female

6.

Email Address (if any)

7.

Date of Birth
(mm/dd/yyyy)

8.

City/Town/Village of Birth

9.

Country of Birth

10. Alien Registration Number (A-Number) (if any)
► A-

Applicant's Certification

I certify, under penalty of perjury, that I am the person who is identified in Part 1. of this Form I-693, and that the information in
Part 1. of this benefit request is complete, true, and correct. I understand the purpose of this medical examination, and I authorize the
required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or
altered information or documents with regard to my medical examination, I understand that any immigration benefit I derived from
this medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal
penalties.
NOTE: Select the box for either Item Number 11. or 12.
11.

I can read and understand English, and have read and understand every question and instruction in Part 1. of this Form I-693,
as well as my answer to every question in Part 1. I have read and understand the above Applicant's Certification.

12.

The interpreter named in Part 2. has read to me every question and instruction in Part 1. of this Form I-693, as well
as my answer to every question in Part 1., in

, a language in which I am fluent.

I understand every question and instruction in Part 1. of this Form I-693 as translated to me by my interpreter, and have
provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 2. also has
read the above Applicant's Certification to me, in a language in which I am fluent, and I understand the Applicant's
Certification as read to me by my interpreter.

Applicant's Signature
13. Signature - Do not sign or date Form I-693 until instructed to do so by the civil surgeon Date of Signature
(mm/dd/yyyy)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the
civil surgeon) (continued)
14. To be completed by the civil surgeon:
A. Form of applicant identification presented (for example, passport or driver's license)

B. Identification Number

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Part 2. Interpreter's Contact Information, Certification and Signature
Provide the following information concerning the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Interpreter's Certification
I certify that:

I am fluent in English and

, which is the same language provided in Part 1., Item Number 12.;

I have read to this applicant every question and instruction in Part 1. of this Form I-693, as well as the answer to every question in
Part 1., in the language provided in Part 1., Item Number 12.; and
I have read the Applicant's Certification to the applicant in the same language provided in Part 1., Item Number 12.
The applicant has informed me that he or she understands every instruction and question in Part 1. of this Form I-693, as well as the
answer to every question in Part 1., and the applicant verified the accuracy of every answer; and
The applicant also has informed me that he or she understands the Applicant's Certification.
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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 2. Interpreter's Contact Information, Certification and Signature (continued)
Interpreter's Signature
6.

Interpreter's Signature

Date of Signature
(mm/dd/yyyy)

Part 3. Summary of Medical Examination (To be completed by the civil surgeon)
1.

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Summary of Overall Findings:
A.
B.
C.

No Class A or Class B Condition

Class B Conditions (See Item Numbers 1. - 4. in Part 5. Civil Surgeon Worksheet of this benefit request.)

Class A Conditions (See Item Numbers 1. - 3. in Part 5. Civil Surgeon Worksheet of this benefit request.)

2.

Date of First Examination
(mm/dd/yyyy)

3.

Dates of Follow-up Examinations, if required:
Date of Examination
(mm/dd/yyyy)

Date of Examination
(mm/dd/yyyy)

Date of Examination
(mm/dd/yyyy)

Part 4. Civil Surgeon's Contact Information, Certification, and Signature (Do not sign Form I-693 and do
not have the applicant sign in Part 1. until all health-related follow-up requirements are met.)
Civil Surgeon's Information
1.

Family Name (Last Name)

Given Name (First Name)

2.

Name of Medical Practice, Facility, or Health Department

Middle Name (if applicable)

Physical Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Contact Information
4.

Daytime Telephone Number

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5.

Email Address (if any)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 4. Civil Surgeon's Contact Information, Certification, and Signature (Do not sign Form I-693 and do
not have the applicant sign in Part 1. until all health-related follow-up requirements are met.) (continued)
Civil Surgeon's Certification
I certify under penalty of perjury under United States law that:
I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the United States OR a physician who
qualifies under a blanket designation specified by policy or law;

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I have a currently valid and unrestricted license to practice medicine in the state where I am performing medical examinations, unless
otherwise exempted;
I performed an examination of the person identified in Part 1. of this Form I-693, after having made every reasonable effort to verify
that the person whom I examined is in fact the person identified in Part 1.;
I performed the examination in accordance with the Centers for Disease Control and Prevention's (CDC) Technical Instructions, as
well as all supplemental information or updates; and
All the information I provided on this Form I-693 is complete, true, and correct - based on the information provided to me by the
applicant.

Civil Surgeon's Signature
6.

Civil Surgeon's Signature

Date of Signature
(mm/dd/yyyy)

(Health departments and military treatment facilities MUST place their official stamp or seal here)

(official stamp or seal here)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 5. Civil Surgeon Worksheet (To be completed by the civil surgeon, according to the Technical Instructions
at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)
1.

Communicable Disease of Public Health Significance
A. Tuberculosis (TB): An initial screening test, either a tuberculin skin test (TST) or an interferon gamma release assay
(IGRA), is required for all applicants 2 years of age and older; for children under 2 years of age, see the Technical
Instructions. The civil surgeon should perform only one type of initial screening test, followed by further evaluation if
needed (chest X-ray).

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(1) Tuberculin Skin Test:

Not administered (TST exception; please explain in Remarks section below)
Date TST Applied

Date TST Read

(mm/dd/yyyy)

(mm/dd/yyyy)

Negative (4mm or less of induration)

Result:

Size of Reaction (mm)

Positive (> 5mm; chest X-ray required)

(2) Interferon Gama Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted on
the CDC's Web site):
Not administered (IGRA exception; please explain in Remarks section below)
Select only one box.
QuantiFERON

T-Spot

Date Blood Sample Drawn

Date Blood Sample Drawn

(mm/dd/yyyy)

(mm/dd/yyyy)

Result:

Negative (including indeterminate, or borderline/equivocal) (no chest X-ray required)
Positive (chest X-ray required)

(3) Initial Screening Test Result and Chest X-Ray Determinations:

Chest X-ray not required (medically cleared for TB for USCIS)
Chest X-ray required due to initial screening test results

Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)

Chest X-ray required due to TST or IGRA exception (Clearly specify the TST or IGRA exception in the Remarks
section below.)

(4) Chest X-Ray: Required based on TST or IGRA result, or if specific TST or IGRA exceptions apply, or for an applicant
with TB signs or symptoms or immunosuppression (such as HIV).
Date Chest X-Ray Taken (mm/dd/yyyy)

Date Chest X-Ray Read

(mm/dd/yyyy)

(mm/dd/yyyy)

Result:

Normal

Abnormal (describe results in Remarks section below.)

TB Classification/Findings (Select only if chest X-ray was performed):
No Class A or Class B TB

Class B2 Pulmonary TB

Class A Pulmonary TB Disease

Class B, Other Chest Condition (non-TB)

Class B1 Pulmonary TB

Class B, Latent TB Infection (Answer the following question.)

Class B1 Extra Pulmonary TB

Was applicant referred for treatment (not required to complete
Form I-693)?
Yes
No

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 5. Civil Surgeon Worksheet (To be completed by the civil surgeon, according to the Technical Instructions
at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)
(5) Remarks: (Include any signs or symptoms of TB, additional tests and therapy given, with start and stop dates and any
changes. If you did not perform TST or IGRA, give the reason why an exception applies.)

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B. Syphilis

(1) Serologic Test for Syphilis (Required for applicants 15 years of age and older)
(a) Date Screening Run
(b)

(mm/dd/yyyy)

Screening Nonreactive

Screening Reactive, Titer 1:

(c) If Reactive, Date Confirmation Run

(mm/dd/yyyy)

(d)

Confirmation Reactive, Titer 1:

Confirmation Nonreactive

(2) Findings:

No Class A or Class B Syphilis

Syphilis, Class A (untreated)

Syphilis, Class B (treated in the last year)

(3) Remarks: (Include any therapy given with doses and dates)

C. Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance
(1) Findings:
(a)

No Class A/B Condition

(b)

Chancroid, Class A

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

(c)

Granuloma Inguinale,
Class A

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

(d)

Gonorrhea, Class A

(e)

Lymphogranuloma
Venereum, Class A

(f)

(g)

Hansen's Disease (leprosy, any classification) untreated, Class A

Hansen's Disease (leprosy, any classification) treated or partially treated,
Class B
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)
Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

(2) Remarks: (Include any therapy given and any counseling or referrals)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 5. Civil Surgeon Worksheet (To be completed by the civil surgeon, according to the Technical Instructions
at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)
2.

Physical or Mental Disorders With Associated Harmful Behavior
Include here any physical or mental disorders with current associated harmful behavior or history of associated harmful behavior
judged likely to recur. This category of physical or mental disorders includes any diagnosis of substance-related disorders based
on Diagnostic and Statistical Manual (DSM) criteria for a substance that is not listed in Schedule I, II, III, IV, or V of section 202
of the Controlled Substances Act (for example, diagnosis of an alcohol-related disorder).

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A. Findings:
(1)
(2)
(3)
(4)
(5)

No Class A or B Physical or Mental Disorder
Current Physical/Mental Disorder with Associated Harmful Behavior, Class A
History of Physical/Mental Disorder with Associated Harmful Behavior Likely to Recur, Class A
Current Physical/Mental Disorder without Associated Harmful Behavior, Class B
History of Physical/Mental Disorder with Associated Harmful Behavior Unlikely to Recur, Class B

B. Remarks: (Include diagnosis, likelihood of recurrence of the harmful behavior, therapy given, and any counseling or
referrals. If you need more space, attach a separate sheet of paper; type or print the applicant's name and A-Number (if any),
at the top of each sheet; and indicate the Page Number, Part Number, and Item Number to which your answer refers.)

3.

Drug Abuse/ Drug Addiction

"Drug Abuse/Drug Addiction" addresses non-medical use only with respect to substances listed in Schedule I, II, III, IV, or V of
section 202 of the Controlled Substances Act. Include here any diagnosis of substance-related disorders based on DSM criteria
for a substance listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. See CDC's Technical
Instructions for more information.
A. Findings:
(1)
(2)
(3)

No Class A or B Substance (Drug) Abuse/Addiction
Substance (Drug) Abuse/Addiction, Listed in section 202 of the Controlled Substances Act, Class A
Substance (Drug) Abuse/Addiction in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B

B. Remarks: (Include any therapy given, rehabilitation, counseling or referrals. If you need more space, attach a separate sheet
of paper; type or print the applicant's name and A-Number (if any), at the top of each sheet; and indicate the Page Number,
Part Number, and Item Number to which your answer refers.)

4.

Other Medical Conditions (List any other Class B conditions, such as hypertension or diabetes.)

5.

Required Referral to Health Department or Other Doctor (To be completed by civil surgeon, if referral is medically required.
Do not complete if referral is not required, such as recommended referral for LTBI treatment.)
A. Type or Print Name of Doctor or Health Department Receiving Required Referral

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 5. Civil Surgeon Worksheet (To be completed by the civil surgeon, according to the Technical Instructions
at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)
(continued)
B. Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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C. Date of Referral (mm/dd/yyyy)

D. Remarks: (Include name of medical condition and reasons for referral. If you need more space, attach a separate sheet of
paper; type or print the applicant's name and A-Number (if any), at the top of each sheet; and indicate the Page Number,
Part Number, and Item Number to which your answer refers.)

Part 6. Referral Evaluation (To be completed by the health department or other doctor performing the
referral evaluation)
The applicant identified on this Form I-693 was referred to me by the civil surgeon named in Part 4. of this Form I-693. I have
provided appropriate evaluation/treatment, having made every reasonable effort to verify that the person whom I have evaluated/
treated is the person identified in Part 1.
1.

Type or print full name of evaluating physician or health department
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

3.

Signature

Date Signed (mm/dd/yyyy)

4.

Name of Medical Practice or Health Department

5. Daytime Telephone Number

6.

Remarks: If you need more space, attach a separate sheet of paper; type or print the applicant's name and Alien Registration
Number (A-Number) (if any), at the top of each sheet; and indicate the Page Number, Part Number, and Item Number to
which your answer refers.

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ZIP Code

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 7. Vaccination Record (See Technical Instructions at www.cdc.gov/immigrantrefugeehealth/exams/ti/
civil/vaccination-civil-technical-instructions.html for list of required vaccines)
Please make sure to mark every row. Reserve all comments for the Remarks section below. NOTE: For purposes of the influenza
vaccine, the flu season is October 1 through March 31. For applicants who only require a vaccination assessment: Submit only
this page with Part 1., Part 2., and Part 4. of Form I-693 (the applicant, regardless of what is required, may still need an interpreter).
For more information, see Form I-693 Instructions, Part 3. Frequently Asked Questions.
Vaccine History Transferred From A Written Record

Vaccine
Given

Complete Series Blanket Waivers to be Requested
from USCIS
(Not Medically Appropriate)

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Vaccine

Date
Date
Date
Date
Date Given
Mark an X if
Not Age - Contra- Insufficient Not
Received
Received
Received
Received
complete; write Appropriate indication Time
by
Flu
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) Civil Surgeon date of lab test if
Interval Season
(mm/dd/yyyy) immune or "VH"
if varicella history

Specify Vaccine:
DTaP
DT
DTP

Specify Vaccine:
Td
Tdap

Specify Vaccine:
OPV
IPV

MMR (measles
mumps-rubella) or
if monovalent or
other combination
of the vaccines are
given, specify
vaccines
Hib

Hepatitis B
Varicella

Pneumococcal
Influenza
Rotavirus

Hepatitis A

Meningococcal

NOTE: Give a copy to the applicant.
Results:
Applicant may be eligible for blanket waivers as indicated above
Applicant will request an individual waiver based on religious or moral convictions
Vaccine history complete for each vaccine, all requirements met
Applicant does not meet immunization requirements
Remarks: (If needed, provide any comments, such as the reason for contraindication.)

Form I-693 06/04/14 Y

FOR USCIS USE ONLY
Remarks (if any):

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