I-690 Supp1 TOC

TABLE OF CHANGES – FORM

Form I-690, Supplement 1, Applicants With a Class A Tuberculosis Condition (As Defined by Health and Human Services Regulations)

OMB Number: 1615-0032

08/31/2018

Reason for Revision:

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Current Page Number and Section	Current Text	Proposed Text
Page 1, Applicant’s Name	[Page 1] Applicant's Name Given Name (First Name) Middle Name (if applicable) Family Name (Last Name) Alien Registration Number (A-Number) (if any) USCIS Online Account Number (if any)	[Page 1] Part 1. Applicant's Information 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 2. Alien Registration Number (A-Number) (if any) 3. USCIS Online Account Number (if any)
Page 1, Section A. Applicant’s Sponsor in the United States	[Page 1] 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 Item 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	[Page 1] Part 2. Responsibilities of Applicant's Sponsor in the United States The responsibilities of the applicant’s sponsor in the United States are to make arrangements for the applicant's medical care, have the attending physician or facility complete Part 4., and to obtain the necessary endorsements: endorsement of a local health department if providing treatment, endorsement of a private physician or other private or public facility if providing treatment, and endorsement of a State Health Department Official. If a local health department will provide the necessary care and/or treatment to the applicant, that facility should select the appropriate checkbox in Part 4., Item Number 1. If a private physician, private medical facility, or public medical facility (other than a local health department) will provide the applicant's medical care and/or treatment, that facility should select the appropriate checkbox in Part 4., Item Number 1. If a State Health Department Official will provide the necessary care and/or treatment, that facility should complete Part 5. 1. Provide the 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
Page 1, Section B. Applicant’s Statement	[Page 1] 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)	[Page 1] Part 3. Applicant's Statement Upon admission to the United States, I will: Go directly to the physician named in Part 4., Item Number 2. or health facility named in Part 4., Item Number 3.; present copies of diagnostic tests used during my visa examination to verify my diagnosis; attend counseling, examinations, treatment, and medical regimen as required; and remain under prescribed treatment or observation, regardless of inpatient or outpatient basis, until I am discharged. 1. Applicant's Signature Date of Signature (mm/dd/yyyy)
Page 2, Section C. Statement by Physician or Health Facility	[Page 2] 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 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 Immigration and Nationality Act (INA) section 212(a)(4)). 4. I represent: (Select the appropriate box and provide the information requested below.) A. Local Health Department B. Other Public Health Facility C. Private Medical Practice 5. I agree to submit a copy of my evaluation to the health official indicated in Section D. 6. Name of Physician Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Name of Facility 7. Address of Physician or Facility Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 8. Signature of Physician Date of Signature (mm/dd/yyyy)	[Page 2] Part 4. Statement by Physician or Health Facility I agree to supply counseling and any treatment or observation necessary for the proper management and continued care of the applicant's tuberculosis condition. 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: Division of Global Migration and Quarantine (E03) Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, Georgia 30329-4027 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 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 Part 5. of the applicant's failure to appear. I agree that 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 U.S. Citizenship and Immigration Services (USCIS), to establish that he or she is unlikely to become a public charge (another ground of inadmissibility under Immigration and Nationality Act (INA) section 212(a)(4)). 1. I represent (select only one box): Local Health Department Other Public Health Facility Private Medical Practice I agree to submit a copy of my evaluation to the health official indicated in Part 5. 2. Name of Physician Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 3. Name of Facility 4. Address of Physician or Facility Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code 5. Signature of Physician Date of Signature (mm/dd/yyyy)
Page 3, Section D. Endorsement of State Health Department Official	[Page 3] 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 Date of Signature (mm/dd/yyyy) 3. Address of Health Department Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code	[Page 3] Part 5. 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 Part 4. 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 2. Name of Official Providing Endorsement 3. Title of Official Providing Endorsement 4. Signature of State Health Department Official Date of Signature (mm/dd/yyyy) 5. Address of Health Department Street Number and Name Apt./Ste./ Flr. Number City or Town State ZIP Code

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