Applicants With a Class A Tuberculosis Condition (As Def

Supplement 1,
Applicants With a Class A Tuberculosis Condition
(As Defined by Health and Human Services Regulations)
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-690
OMB No. 1615-0032
Expires 11/30/2014

Applicant's Name
Given Name (First Name)

Middle Name (if applicable)

DRAFT
NOT FOR
PRODUCTION
02/25/2015

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

Family Name (Last Name)

USCIS ELIS Account Number (if any)
►

Section A. Applicant's Sponsor in the United States
1.

Make arrangements for the applicant's medical care and have the attending physician or facility complete Section C.

2.

Obtain the necessary endorsements.

A. 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.
B. 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.
C. 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

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 C.;

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.

5.

Applicant's Signature

Date of Signature
(mm/dd/yyyy)

Form I-690 Supplement 1 04/02/14 N

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Section C. Statement by Physician or Health Facility
1.

I agree to supply counseling and any treatment or observation necessary for the proper management and continued care of the
applicant's tuberculosis condition.

2.

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

DRAFT
NOT FOR
PRODUCTION
02/25/2015

A. 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
B. 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 Center for Disease Control and Prevention (CDC) and the health official indicated in Section D. of the applicant's
failure to appear.
3.

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).

4.

I represent: (Select the appropriate box and provide the information requested below.)

5.
6.

A.

Local Health Department

B.

Other Public Health Facility

C.

Private Medical Practice

I agree to submit a copy of my evaluation to the health official indicated in Section D.
Name of Physician

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Name of Facility

7.

8.

Address of Physician or Facility
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Signature of Physician

Date of Signature
(mm/dd/yyyy)

Form I-690 Supplement 1 04/02/14 N

ZIP Code

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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.
1.

Official Name of Department and Name and Title of Official Providing Endorsement (Type or Print)

2.

Signature of State Health Department Official

3.

Address of Health Department

Date of Signature
(mm/dd/yyyy)

DRAFT
NOT FOR
PRODUCTION
02/25/2015

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-690 Supplement 1 04/02/14 N

ZIP Code

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