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.

Your Full Name
Family Name (Last Name)

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Given Name (First Name)

Middle Name

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

(USPS ZIP Code Lookup)

3.

Other Information
A. Gender
Male

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

C. City/Town/Village of Birth

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 section. 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. If applicable, select the box for Item Number 2.
1.

2.

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 Statement Regarding the Preparer
At my request, the preparer named in Part 4.,

,

prepared this application for me based only upon information I provided or authorized.

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Page 1 of 14

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 Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

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Applicant's Certification

I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the
immigration benefit I seek.
I furthermore 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 law.
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

NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.
6.

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.

Part 3. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter, if you used one.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

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Interpreter's Given Name (First Name)

Page 2 of 14

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

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City or Town

Province

State

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)

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.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

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Preparer's Given Name (First Name)

Page 3 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

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City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with
the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case
extends
does not extend beyond the preparation of this application.

NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

Parts 5. - 10. of this form must be completed by the civil surgeon.

Part 5. Applicant's Identification Information (To be completed by the civil surgeon) (continued)
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 6. 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 8. Civil Surgeon Worksheet)

C.

Class A Conditions (See Item Numbers 1. - 3. in Part 8. Civil Surgeon Worksheet)

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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 7. 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)

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

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
5.

Daytime Telephone Number

7.

Email Address (if any)

Form I-693 10/19/17

6.

Mobile Telephone Number (if any)

Page 5 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 7. Civil Surgeon's Contact Information, Certification, and Signature (continued)
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;

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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
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)

(official stamp or seal here)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. 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, 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 will perform further
evaluation if needed (chest X-ray).

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(1) Interferon Gamma Release Assay (for acceptable IGRAs, consult the Technical Instructions and any updates posted on
the CDC's website):
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 (no chest X-ray required)
Positive (chest X-ray required)

Indeterminate (including borderline/equivocal) (no chest X-ray required)

(2) Initial Screening Test Result and Chest X-Ray Determinations:
Chest X-ray not required (medically cleared for TB)

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 IGRA exception (Clearly specify the IGRA exception in the Remarks section below.)

(3) Chest X-Ray: Required based on IGRA result, or if specific 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):
No Class A or Class B TB

Class B1 Extra Pulmonary TB

Class A Pulmonary TB Disease

Class B, Latent TB Infection

Class B2 Pulmonary TB

Class B1 Pulmonary TB

Class B, Other Chest Condition (non-TB)

Class B0 Pulmonary TB

(4) 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 IGRA, give the reason why an exception applies.)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
B. Syphilis
(1) Serologic Test for Syphilis (Required for applicants 15 years of age and older)
(a) Name of Screening Test

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(b) Date Screening Run (mm/dd/yyyy)
(c)

Screening Nonreactive (mm/dd/yyyy)
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)

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)

Positive

Negative

(2) Findings:
No Class A or Class B Gonorrhea

Gonorrhea, Class A (untreated)

Gonorrhea, Class B (treated in the last year)
(3) Remarks: (Include any treatment given with doses and dates)

Drug:
Start Date (mm/dd/yyyy)
Form I-693 10/19/17

Dosage:
End Date (mm/dd/yyyy)
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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
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

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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 11. 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 11. Additional Information.

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
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.

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"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 11. Additional Information.

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.)
A. Type or Print Name of Doctor or Health Department Receiving Required Referral

B. Address
Street Number and Name

City or Town

Form I-693 10/19/17

Apt. Ste. Flr. Number

State

ZIP Code

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
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 11. Additional Information.

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Part 9. 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 7. 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.

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

5. Daytime Telephone Number

NOTE: If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 10. 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 Part with Parts 1. - 5., and Part 7. 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.

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Vaccine History Transferred From A Written Record

Vaccine

Vaccine
Given

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:
DTaP
DT

Text

DTP

Specify Vaccine:
Td

Tdap

Text

Specify Vaccine:
OPV

IPV

Text

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

Text

Hib

Text

Hepatitis B

Text

Varicella

Text

Pneumococcal

Text

Influenza
Rotavirus

Text

Hepatitis A

Text

Meningococcal

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 10. Vaccination Record (continued)
Results:
Applicant may be eligible for blanket waivers as indicated above

FOR USCIS USE ONLY
Remarks (if any)

Applicant will request an individual waiver based on religious or moral convictions
Vaccine history complete for each vaccine, all requirements met

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Applicant does not meet immunization requirements

Remarks: (If needed, provide any comments, such as the reason for contraindication.)

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Part 11. 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

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B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

4.

A. Page Number

D.

5.

A. Page Number

D.

6.

A. Page Number

D.

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