Form I-693, Report of Medical Examination and Vaccination Record-FORM TOC
OMB No. 1615-0033
11/16/2016
Reason for Revision: Changes in law, Standard Language updates
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Current Page and Section |
Current Language |
Proposed Language
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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. Name Family Name (Last Name) Given Name (First Name) Middle Name
2. Home Address Street
Number and Name
3. Gender Male/Female
4. Daytime Telephone Number
5. Mobile Telephone Number (if any)
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)
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[Page 1]
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.
Your
Full
Name
2.
Physical
Address
3. Other Information
A. Sex Male/Female
[Deleted- already in Applicant’s Signature section]
B. Date of Birth (mm/dd/yyyy)
C. City/Town/Village of Birth
D. Country of Birth
E. Alien Registration Number (A-Number) (if any)
F. USCIS Online Account Number (if any)
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Page 1, 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) |
[Page 1]
Part 2. Applicant’s Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-693 Instructions before completing this Part. You must submit Form I-693 in a sealed envelope to USCIS as directed in the Form I-693 Instructions.
Applicant’s Statement NOTE: Select the box for either Item A. or B. in Item Number 1.
1. Applicant’s Statement Regarding the Interpreter
A. [] I can read and understand English, and I have read and understand every question and instruction on this form and my answer to every question.
B. [] The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything.
Applicant’s Contact Information
2. Applicant’s Daytime Telephone Number
3. Applicant’s Mobile Telephone Number (if any)
4. Applicant’s Email Address (if any)
Applicant’s Certification I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this form, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
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 form 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.
Applicant’s Signature NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.
5. Applicant’s Signature Date of Signature (mm/dd/yyyy)
NOTE TO ALL APPLICANTS AND CIVIL SURGEONS: If you or the civil surgeon do not completely fill out this form according to the instructions USCIS may deny your immigration benefit. |
Page 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. [fillable field] 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 [Fillable Field], which is the same language specified in Part 12., 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
The applicant 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 has also informed me that he or she understands the Applicant’s Certification.
Interpreter’s Signature 6. Interpreter’s Signature Date of Signature (mm/dd/yyyy) |
[Page 2]
Part 3. Interpreter’s Contact Information, Certification, and Signature
Provide the following information about 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. [fillable field] City or Town State ZIP Code Province Postal Code Country
Interpreter’s Contact Information 4. Interpreter’s Daytime Telephone Number
5. Interpreter’s Mobile Telephone Number (if any)
6. Interpreter’s Email Address (if any)
Interpreter’s Certification I certify, under penalty of perjury, that:
I am fluent in English and [Fillable Field], which is the same language specified in Part 2., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this form and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the form, including the Applicant’s Certification, and has verified the accuracy of every answer.
Interpreter’s Signature 7. Interpreter’s Signature Date of Signature (mm/dd/yyyy) |
Page 2, Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon) |
14. To be completed by the civil surgeon:
1. Form of identification presented by the applicant (for example, passport or driver's license)
2. Identification Number |
[Page 3]
Parts 4-9 of this form must be completed by the civil surgeon.
Part 4. Applicant's Identification Information (To be completed by the civil surgeon)
1. Form of identification presented by applicant (for example, passport or driver's license)
2. Document Identification Number |
Page 5, Part 3. Summary of Medical Examination (To be completed by the civil surgeon)
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1. Summary of Overall Findings:
A. [] No Class A or Class B Condition
B. [] Class B Conditions (See Item Numbers 1. - 4. in Part 5. Civil Surgeon Worksheet
C. [] Class A Conditions (See Item Numbers 1. - 3. in Part 5. Civil Surgeon Worksheet
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) |
[Page 4]
Part 5. Summary of Medical Examination (To be completed by the civil surgeon)
1. Summary of Overall Findings:
A. [] No Class A or Class B Condition
B. [] Class B Conditions (See Item Numbers 1. - 4. in Part 7. Civil Surgeon Worksheet)
C. [] Class A Conditions (See Item Numbers 1. - 3. in Part 7. Civil Surgeon Worksheet)
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) |
Page 5, 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)
2. Name of Medical Practice, Facility, or Health Department
Physical Address
3.
Street Number and Name City or Town State ZIP Code
Contact Information
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;
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
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) |
[Page 5]
Part 6. Civil Surgeon's Contact Information, Certification, and Signature
NOTE: Do not sign Form I-693 and do not have the applicant sign in Part 2. until all health-related follow-up requirements are met.
Civil Surgeon's Information
1.
Family Name (Last Name)
2. Name of Medical Practice, Facility, or Health Department
Physical Address
3.
Street Number and Name City or Town State ZIP Code
4. Mailing Address A. Street Number and Name or PO Box B. [] Apt. [] Ste. [] Flr. Number (if applicable) C. City or Town D. State E. ZIP Code
Contact Information
5. Daytime Telephone Number
6. Mobile Telephone Number (if any)
7. Email Address (if any)
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;
I have a currently valid and unrestricted license to practice medicine in the state where I am performing immigration-related medical examinations, unless otherwise exempted;
I have not had my license to practice medicine revoked, and I am not subject to any restrictions on any license to practice medicine in any other jurisdiction in the United States in which I conduct immigration-related medical examinations.
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
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) |
Page 7, 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).
(1)
Tuberculin Skin
Test:
Date
TST Applied (mm/dd/yyyy) Size of Reaction (mm)
Result:
(2) Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted on the CDC's Web site):
Result:
(3)
Initial Screening Test Result and Chest X-Ray Determinations:
(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).
Result:
TB
Classification/Findings (Select only if chest X-ray was
performed): []
Class B1 Extra Pulmonary TB Was applicant referred for treatment (not required to complete Form I-693)? Yes/No
(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.)
B. Syphilis (1)
Serologic Test for Syphilis (Required for applicants 15 years of
age and older)
[] Screening Reactive, Titer 1:
(c) If Reactive, Date Confirmation Run (mm/dd/yyyy) (d)
[] Confirmation Nonreactive
(2) Findings: []
No Class A or Class B Syphilis
(3) Remarks: (Include any therapy given with doses and dates)
C. Other Class A/Class B Conditions for Communicable Diseases of Public Heath Significance
(1) Findings: (a) [] No Class A/B Condition
(b) [] Chacroid, Class A
(c) [] Granuloma Inguinale, Class A
(d) [] Gonorrhea, Class A
(e) []Lymphogranuloma Venereum, Class A
(f) [] Hansen's Disease (leprosy, any classification) untreated, Class A
[]
Indeterminate, tuberculoid, borderline tuberculoid
(paucibacillary) [] Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
(g) [] Hansen's Disease (leprosy, any classification) treated or partially treated, Class B
[] Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)
(2) Remarks: (Include any therapy given and any counseling or referrals)
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 that involve any 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).
A. Findings: (1) [] No Class A or B Physical or Mental Disorder (2) [] Current Physical/Mental Disorder with Associated Harmful Behavior, Class A (3) [] History of Physical/Mental Disorder with Associated Harmful Behavior Likely to Recur, Class A (4) [] Current Physical/Mental Disorder without Associated Harmful Behavior, Class B (5) [] 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.)
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) [] No Class A or B Substance (Drug) Abuse/Addiction
(2) [] Substance (Drug) Abuse/Addition, Listed in section 202 of the Controlled Substances Act, Class A
(3) [] 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 for a recommended referral for LTBI treatment.)
A. Type or Print Name of Doctor or Health Department Receiving Required Referral ________________________ B.
Address
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.) |
[Page 6]
Part 7. 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).
(1)
Tuberculin Skin
Test: Date
TST Applied (mm/dd/yyyy) Size of Reaction (mm)
Result:
(2) Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted on the CDC's website):
Result: [] Positive (chest X-ray required) [] Indeterminate, borderline, or equivocal) (no chest X-ray required)
(3)
Initial Screening Test Result and Chest X-Ray Determinations:
(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)
Result:
TB
Classification/Findings (Select only if chest X-ray was
performed): Was applicant referred for treatment (not required to complete Form I-693)? Yes/No
(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.)
B. Syphilis (1)
Serologic Test for Syphilis (Required for applicants 15 years of
age and older)
(b)
Date Screening
Run (mm/dd/yyyy) [] Screening Reactive, Titer 1:
(d) If Reactive, Name of Confirmatory Test
(e) Date Confirmation Run (mm/dd/yyyy)
(f) [] Confirmation Nonreactive
(2) Findings: []
No Class A or Class B Syphilis
(3) Remarks: (Include any therapy given with doses and dates)
Drug: Dosage: Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)
C. Gonorrhea (1)
Laboratory Test for Gonorrhea (Required for applicants 15 years of
age and older)
(b) Date Specimen Reported (mm/dd/yyyy)
(c) [] Positive []
Negative
(2) Findings: [] No Class A or Class B Gonorrhea
(3) Remarks: (Include any treatment given with doses and dates) Drug: Dosage: Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)
D. Other Class A/Class B Conditions for Communicable Diseases of Public Heath Significance
(1) Findings: (a) [] No Class A/B Condition
[Deleted]
[Deleted]
[Deleted]
[Deleted]
(b) [] Hansen's Disease, (leprosy, any classification) untreated, Class A
[] Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
(c) [] Hansen's Disease , (leprosy, any classification) treated or partially treated, Class B
[] Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)
(2) Remarks: (Include any therapy given and any counseling or referrals) If you need extra space to complete this section, use the space provided in Part 10. Additional Information.
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 that involve any 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). Diagnose mental disorders according to the diagnostic criteria in the most recent edition of the Diagnostic and Statistical Manual (DSM) or another authoritative source, as determined by the director of the CDC. Diagnose physical disorders according to the diagnostic criteria in the most recent edition of the World Health Organization’s Manual of the International Classification of Diseases, Injuries, and Causes of Death (ICD) or another authoritative source as determined by the director of the CDC. See the CDC’s Technical Instructions for more information.
A. Findings: (1) [] No Class A or B Physical or Mental Disorder (2) [] Current Physical/Mental Disorder with Associated Harmful Behavior, Class A (3) [] History of Physical/Mental Disorder with Associated Harmful Behavior Likely to Recur, Class A (4) [] Current Physical/Mental Disorder without Associated Harmful Behavior, Class B (5) [] 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 extra space to complete this section, use the space provided in Part 10. Additional Information.
3. Drug Abuse/ Drug Addiction The U.S. Department of Health and Human Services (DHHS) sets the medical guidelines for determining drug abuse and drug addiction. The terms are defined at 42 CFR 34.2(h) and (i).
Include here any diagnosis of drug abuse or drug addiction.
"Drug abuse” is “current substance use disorder or substance-induced disorder, mild,” but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. Make the diagnosis according to the diagnostic criteria in the most current edition of the DSM, or by another authoritative source as determined by the director of the CDC.
Drug addiction" is “current substance use disorder or substance-induced disorder, moderate or severe,” but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. Make the diagnosis according to the diagnostic criteria in the most current edition of the DSM.
You may also make a diagnosis of full remission, according to the diagnostic criteria in the most current edition of the DSM or another authoritative source as determined by the director of the CDC. See the CDC’s Technical Instructions for more information.
A. Findings: (1) [] No Class A or B Substance (Drug) Abuse/Addiction
(2) [] Substance (Drug) Abuse, Listed in section 202 of the Controlled Substances Act, Class A
(3) [] Substance (Drug) Addiction, Listed in section 202 of the Controlled Substances Act, Class A
(4) [] Substance (Drug) Abuse in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B
(5) [] Substance (Drug) 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 extra space to complete this section, use the space provided in Part 10. Additional Information.
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 a referral is medically required. Do not complete if a referral is not required, such for a recommended referral for LTBI treatment.)
A. Type or Print Name of Doctor or Health Department Receiving Required Referral ________________________ B.
Address
C. Date of Referral (mm/dd/yyyy)
D. Remarks: Include the name of medical condition and the reasons for referral. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. |
Page 11, 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. Address Street
Number and Name
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. |
[PAGE 10]
Part 8. 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 6. 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. Evaluating Physician or Health Department’s Full Name
A.
Family Name
(Last Name)
B. Health Department’s Name
2. Address Street
Number and Name
3.
Signature
of
Health Department Individual or Other Doctor Performing Referral
Evaluation
4. Name of Medical Practice or Health Department
5. Daytime Telephone Number
NOTE: If you need extra space to complete this section, use the space provided in Part 10 Additional Information.
|
Page 12, 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 and 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
MMR
(measles, mumps-rubella) or if monovalent or other combination of
the vaccines are given, specify vaccines)
Vaccine
Given
Complete
Series
Blanket
Waivers to be Requested from USCIS (Not Medically Appropriate)
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.)
For USCIS USE
ONLY |
[PAGE 11]
Part 9. Vaccination Record
NOTE: 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., Part 3. Part 4., and Part 6. of Form I-693 (If you need an interpreter, complete Part 3. Interpreter’s Contact Information, Certification, and Signature.) For more information, see Form I-693 Instructions, Frequently Asked Questions.
Vaccine
History Transferred From A Written Record MMR
(measles, mumps-rubella) or if monovalent or other combination of
the vaccines are given, specify vaccines)
Vaccine
Given
Complete
Series
Blanket
Waivers to be Requested from USCIS (Not Medically Appropriate)
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.)
For
USCIS USE ONLY
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[Page 13]
Part 10. Additional Information
If you (the applicant or the civil surgeon) need extra space to provide any additional information within this form use the space below. If you (the applicant or civil surgeon) need more space than what is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print the applicant’s name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
1. Family Name (Last Name) Given Name (First Name) Middle Name
2. A-Number (if any)
3. A. Page Number B. Part Number C. Item Number D. [Fillable field]
4. A. Page Number B. Part Number C. Item Number D. [Fillable field]
5. A. Page Number B. Part Number C. Item Number D. [Fillable field]
6. A. Page Number B. Part Number C. Item Number D. [Fillable field] |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Elizabeth |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |