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 02/28/2019

► 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.

Your Full Name
Family Name (Last Name)

DRAFT
Given Name (First Name)

Middle Name

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Other Information
A. Sex
Male

ZIP Code

NOT FOR
C. City/Town/Village of Birth

B. Date of Birth (mm/dd/yyyy)

Female

D. Country of Birth

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

F. USCIS Online Account Number (if any)
►

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.

PRODUCTION

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
, a language in which I am fluent, and I understood everything.

Applicant's Contact Information
2.

Applicant's Daytime Telephone Number

4.

Applicant's Email Address (if any)

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3.

Applicant's Mobile Telephone Number (if any)

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Page 1 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 2. Applicant's Statement, Contact Information, Certification, and Signature (continued)
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.

DRAFT

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 understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my form;
2) I understood all of the information contained in, and submitted with, my form; and
3) All of this information was complete, true, and correct at the time of filing.
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

NOT FOR

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.

PRODUCTION

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)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

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Page 2 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 3. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

DRAFT

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

NOT FOR

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

, 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.

PRODUCTION

Interpreter's Signature

Date of Signature
(mm/dd/yyyy)

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)
Please complete the following about the applicant:
1.

Form of identification presented by applicant (for example, passport or driver's license)

2.

Document Identification Number

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

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)

DRAFT

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 6. Civil Surgeon's Contact Information, Certification, and Signature

NOT FOR

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)

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

PRODUCTION

City or Town

State

ZIP Code

Mailing Address
4.

Street Number and Name (PO Box)

Apt. Ste. Flr. Number (if applicable)

City or Town

State

ZIP Code

Contact Information

09/29/2017

5.

Daytime Telephone Number

7.

Email Address (if any)

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6.

Mobile Telephone Number (if any)

Page 4 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 6. Civil Surgeon's Contact Information, Certification, and Signature (continued)
Civil Surgeon's Certification
I certify under penalty of perjury under United States law that:

DRAFT

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.

NOT FOR

Civil Surgeon's Signature
8.

Civil Surgeon's Signature

Date of Signature
(mm/dd/yyyy)

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

PRODUCTION
(official stamp or seal here)

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Page 5 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

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

DRAFT

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:

Not administered (TST exception; please explain in Remarks section below)
Date TST Applied (mm/dd/yyyy)

Date TST Read (mm/dd/yyyy)

Negative (4mm or less of induration)

Result:

Size of Reaction (mm)

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

(2) Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted
on the CDC's website):

NOT FOR

Not administered (IGRA exception; please explain in Remarks section below)
Select only one box.
QuantiFERON

T-Spot

Date Blood Sample Drawn (mm/dd/yyyy)

Date Blood Sample Drawn (mm/dd/yyyy)

Result:

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

PRODUCTION
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)

Result:

Normal

Date Chest X-Ray Read (mm/dd/yyyy)

Abnormal (describe results in Remarks section below.)

TB Classification/Findings (Select only if chest X-ray was performed):

09/29/2017

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 Extra Pulmonary TB

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

Class B1 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 7. Civil Surgeon Worksheet (continued)
(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.)

DRAFT
B. Syphilis
(1) Serologic Test for Syphilis (Required for applicants 15 years of age and older)
(a) Name of Screening Test
(b) Date Screening Run (mm/dd/yyyy)
(c)

Screening Nonreactive (mm/dd/yyyy)

NOT FOR

Screening Reactive, Titer 1:

(d) If Reactive, Name of Confirmatory Test
(e) Date Confirmation Run (mm/dd/yyyy)
(f)

Confirmation Nonreactive

Confirmation Reactive

(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)

PRODUCTION
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)
(a) Screening Test Name
(b) Date Specimen Reported (mm/dd/yyyy)
(c)

09/29/2017

Positive

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Negative

Page 7 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 7. Civil Surgeon Worksheet (continued)
(2) Findings:
No Class A or Class B Gonorrhea

Gonorrhea, Class A (untreated)

DRAFT

Gonorrhea, Class B (treated in the last year)

(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 Health Significance
(1) Findings:
(a)

No Class A/B Condition

(b)

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

NOT FOR

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)
(c)

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) If you need extra space to complete this section,
use the space provided in Part 10. Additional Information.

2.

PRODUCTION

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

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Page 8 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 7. Civil Surgeon Worksheet (continued)
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

DRAFT

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.

NOT FOR

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.

PRODUCTION

4.

Other Medical Conditions (List any other Class B conditions, such as hypertension or diabetes, and all required evaluation
components as found in HHS's Technical Instructions for Medical Examinations of Aliens in the United States.)

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 as recommended referral for LTBI treatment.)

09/29/2017

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 7. Civil Surgeon Worksheet (continued)
B. Address
Street Number and Name

Apt. Ste. Flr. Number

DRAFT

City or Town

State

ZIP Code

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.

NOT FOR

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)
Given Name (First Name)

Middle Name

B. Health Department 's Name

2.

PRODUCTION

Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

3.

Signature of Health Department Individual or Other Doctor Performing Referral Evaluation
Signature
Date Signed (mm/dd/yyyy)

4.

Name of Medical Practice or Health Department

09/29/2017

5. Daytime Telephone Number

NOTE: If you need extra space to complete this section, use the space provided in Part 10. Additional Information.

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Page 10 of 13

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

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.

DRAFT

Vaccine History Transferred From A Written Record

Vaccine

Complete
Series

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

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

Specify Vaccine:
DT
DTaP
DTP
Specify Vaccine:
Td

Vaccine
Given

Tdap

NOT FOR

Text

Text

Specify Vaccine:
OPV

Text

IPV

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

Text

Hib

Text

PRODUCTION

Hepatitis B

Text

Varicella

Text

Pneumococcal

Text

Influenza
Rotavirus

Text

Hepatitis A

Text

Meningococcal

09/29/2017

Text

NOTE: Give a copy to the applicant.

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 9. Vaccination Record (continued)
Results:

FOR USCIS USE ONLY

Applicant may be eligible for blanket waivers as indicated above

Remarks (if any)

DRAFT

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.)

NOT FOR
PRODUCTION
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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)

2.

A-Number (if any) ► A-

3.

A. Page Number

Given Name (First Name)

Middle Name

DRAFT

B. Part Number

C. Item Number

D.

4.

A. Page Number

D.

5.

A. Page Number

NOT FOR

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

PRODUCTION
6.

A. Page Number

B. Part Number

C. Item Number

D.

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