Toc I-602

TABLE OF CHANGES – FORM and INSTRUCTIONS

Form I-602, Application By Refugee For Waiver of Grounds of Excludability

OMB Number: 1615-0069

Date 11/21/2016

Reason for Revision: Extension

Current Page Number and Section	Current Text	Proposed Text
FORM
Page 2, Part 3. To be completed for applicants with active or suspected tuberculosis or who have or have had a physical or mental disorder and behavior associated with the disorder.	Statement by Applicant Upon admission to the United States I will: Go directly to the physician or health facility named in Part B below; and Present copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and 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 I am discharged. Signature Date NOTE to Applicant’s Sponsor in the United States: Arrange for medical care of the applicant and have the physician complete Section B below. Statement by Physician and/or Health Facility This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or military hospital. NOTE: Upon arrival of the alien in the United States, Form CDC 75.18, Report on Alien With Tuberculosis Waiver, will be sent to the address given below. I agree to supply any treatment or observation necessary for the proper management of the alien’s tuberculosis condition. I agree to submit Form CDC 75.18 to the health officer named below (in Section C.) either (a) within 30 days of the alien’s reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the alien; or (b) 30 days after receiving Form CDC 75.18, if the alien has not reported. (NOTE: Military Hospitals should submit this form directly to the Centers for Disease Control, Atlanta, GA. 30333.) Satisfactory financial arrangements have been made. (NOTE: this statement does not relieve the alien of submitting such evidence as the U.S. Consulate may require to establish that the alien is not likely to become a public charge.) I represent: (Check the appropriate box and give the complete name and address of the facility.) __ Local Health Department Outpatient Clinic __ Military Hospital __ Other Public or Private Health Facility __ Private Practice Signature of Physician Date Address: (If military, enter name and address of receiving hospital.) NOTE to Applicant’s Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in Section B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant plans to reside in the United States. Provide the health officers with the address where the applicant plans to reside in the United States. Endorsement by Local or State Health Officer Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or physician who signed in Section B is not in your health jurisdiction and is not familiar to you, you may wish to contact the health officer responsible for the jurisdiction of the facility or physician prior to endorsing. Signature Date (mm/dd/yyyy) Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis Waiver, will be sent when the alien arrives in the United States. Local Health Department Address	Statement by Applicant Upon admission to the United States I will: Go directly to the physician or health facility named in Part B below; and Present copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and 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 I am discharged. Signature Date NOTE to Applicant’s Sponsor in the United States: Arrange for medical care of the applicant and have the physician complete Section B below. Statement by Physician and/or Health Facility This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or military hospital. NOTE: Upon arrival of the applicant in the United States, Form CDC 75.18, Report on Alien With Tuberculosis Waiver, will be sent to the address given below. I agree to supply any treatment or observation necessary for the proper management of the applicant’s tuberculosis condition. I agree to submit Form CDC 75.18 to the health officer named below (in Section C.) either (a) within 30 days of the applicant’s reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the applicant; or (b) 30 days after receiving Form CDC 75.18, if the applicant has not reported. (NOTE: Military Hospitals should submit this form directly to the Centers for Disease Control, Atlanta, GA. 30333.) Satisfactory financial arrangements have been made. (NOTE: this statement does not relieve the applicant of submitting such evidence as the U.S. Consulate may require to establish that the applicant is not likely to become a public charge.) I represent: (Check the appropriate box and give the complete name and address of the facility.) __ Local Health Department Outpatient Clinic __ Military Hospital __ Other Public or Private Health Facility __ Private Practice Signature of Physician Date Address: (If military, enter name and address of receiving hospital.) NOTE to Applicant’s Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in Section B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant plans to reside in the United States. Provide the health officers with the address where the applicant plans to reside in the United States. Endorsement by Local or State Health Officer Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or physician who signed in Section B is not in your health jurisdiction and is not familiar to you, you may wish to contact the health officer responsible for the jurisdiction of the facility or physician prior to endorsing. Signature Date (mm/dd/yyyy) Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis Waiver, will be sent when the applicant arrives in the United States. Local Health Department Address
INSTRUCTIONS
		[Page 3] [NEW] USCIS Privacy Act Statement AUTHORITIES: The information requested on this application, and the associated evidence, is collected under Sections 207 and 209 of the Immigration and Nationality Act, as amended, as well as 8 CFR 207.3. PURPOSE: The primary purpose for providing the requested information on this application is for a refugee who has been found inadmissible to the United States for reasons such as a criminal conviction or certain health conditions to apply for a waiver of such inadmissibility on grounds of humanitarian reasons, family unity or national interest. DHS will use the information you provide to grant or deny the waiver. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of the waiver. ROUTINE USES: DHS may share the information you provide on this application with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine uses described in the associated published system of records notices [DHS/USCIS-007 - Benefits Information System and DHS/USCIS-001 - Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.

1