Supporting Statement Appendix A

N-648 60-Day Comments
Commenter	Comment	USCIS Response
Customer Service Comment	The current version (3/11/2015) of the instructions to Form N-648 asks the medical provider to use the DSM IV Code associated with the claimed impairment/disorder, However, it was replaced by DSM-V on or about 5/2013.	USCIS is updating the form to update the DMS code and added language to allow for the new ICD codes.
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Domna Antoniadis	Greetings. Below please find my comments . By way of background, I am a legal service attorney who works in a medical-legal partnership to provide free legal services to low income cancer patients. I work in partnership with medical providers to address social determinants of health. The agency's estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used is inaccurate. While in theory the completion of the N-648 should be straightforward, it is not. One way to minimize the burden of the collection of the information is by allowing Nurse Practitioners and Licensed Clinical Social Workers to complete the medical forms. The inclusion of these two professional groups is consistent with health care reform and does not take away from the integrity of the medical recommendation. Part III. 1. Needs to be updated to DSM V which is the current volume. The cost and time associated with the completion of the form is under valued. In my experience, a doctor requires more than one appointment before they feel comfortable certifying under the penalty of perjury whether or not a disability is likely to last more than 12 months, or that a person's disability will limit their ability to learn, speak, write, or answer questions in English. The financial cost of at least 2 appointments, or diagnostic tests will be well over $100. This fails to take into consideration any time lost by applicants who need to take off from work and spend time waiting for the doctor. The 12 month requirement does not appear necessary for the completion of this form. It is not always clear if a condition (especially neurological, medication induced or psychiatric conditions)will last at least 1 year and a physician may refuse to certify the condition until it has actually lasted a full year. This delay interferes with other federal laws which protect immigrants. For example, only persons defined as "protected individuals" under the INA 274B(a)(3) are protected from citizenship status discrimination. A "protected individual" is defined as "a citizen of the United States, or ... an alien who is lawfully admitted for permanent [or] ... '. but does not include an ... alien who fails to apply for naturalization within six months of the date when the individual first becomes eligible-... to apply for naturalization . . " Since the 12 month requirement is a new addition to the N-648 Form, its exclusion will not substantially impact the quality of the medical opinion. A more efficient way of collecting the information without harming the individual is to ask if the impairment is "likely to last 12 months" (and use that information in reaching a determination) but eliminate the requirement that it must "last 12 months..."	Nurse Practitioner Comment Thank you for your feedback. Currently, our regulations allow only for doctors, doctors of osteopathy or clinical psychologists to certify N-648s. No changes were made based by this comment. DSM USCIS has updated the forms with the new provisions for the DSM and for the new IDC Codes. Thank you for the information. USCIS feels that the time burden is appropriate as it allows time for filing out the form and additional time for a doctor's visit. This form is requesting information about an existing condition that would preclude an applicant for naturalization from establishing the language and civics requirements. The 12 month period is a requirement under 8 CFR 312.1(b)(3) and not a new addition to the form. The questions refers to the condition being expected to last over a year. Otherwise, the applicant is expected to wait and become eligible. No changes were made based on this comment.

Summary of Comments

There were 3 comments, 2 of which mentioned the outdated information regarding the DMS-IV codes for medical conditions. USCIS appreciates the feedback and has updated the language in the form to update the information on the medical codes. There was one comment regarding the time burden to consider multiple doctor's visits. USCIS feels that the time burden is appropriate as it allows time for filing out the form and additional time for a doctor's visit. This form is requesting information about an existing condition that would preclude an applicant for naturalization from establishing the language and civics requirements.