I-693 Instructions TOC

I693-INS-TOC-LimitedRev-30Day-01312019.docx

Report of Medical Examination and Vaccination Record

I-693 Instructions TOC

OMB: 1615-0033

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1615-0033 can be found here:

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TABLE OF CHANGES – INSTRUCTIONS

Form I-693, Report of Medical Examination and Vaccination Record

OMB Number: 1615-0033

01/31/2019

Reason for Revision: Limited revision.

Black font = Current text
Purple font = Standard language
Red font = Changes

Current Page Number and Section

Current Text

Proposed Text

Page 1, What Is the Purpose of Form I-693?

[Page 1]

What Is the Purpose of Form I-693?

Form I-693 is used to report results of a medical examination to U.S. Citizenship and Immigration Services (USCIS). The examination is required to establish that applicants who are seeking immigration benefits are not inadmissible to the United States on public health grounds. You can find a list of those health-related grounds in section 212(a)(1) of the Immigration and Nationality Act (INA). The list is also available in these Instructions in Item Number 9. under the section entitled Frequently Asked Questions.

The results of your medical examination are confidential and are used primarily for immigration purposes. When required by law, the civil surgeon may share your results with public health authorities. USCIS will generally not discuss your medical issues with other individuals, such as your attorney or BIA-accredited representative, immigration officers, or other government officials, unless they have a need to know the information.

NOTE: If you are applying for adjustment of status as a refugee, a derivative of an asylee, or a K or V nonimmigrant visa holder, before reading any further, see section entitled Frequently Asked Questions, Item Numbers 2. - 5., of these Instructions.

[Page 1]

What Is the Purpose of Form I-693?

Form I-693 reports results of a medical examination to U.S. Citizenship and Immigration Services (USCIS). USCIS requires the examination to establish that applicants who are seeking immigration benefits are not inadmissible to the United States on public health grounds. You can find a list of those health-related grounds in section 212(a)(1) of the Immigration and Nationality Act (INA). The list is also available in these Instructions in the Frequently Asked Questions section, Item Number 9.

The results of your medical examination are confidential, and USCIS uses them primarily for immigration purposes. When required by law, the civil surgeon may share your results with public health authorities. USCIS will generally not discuss your medical issues with other individuals, such as your attorney or BIA-accredited representative, immigration officers, or other government officials, unless they have a need to know the information.

Page 1, Applicant Instructions

[Page 1]

Applicant Instructions

How Do I File Form I-693?

A separate Form I-693 is required for each applicant. There is no filing fee for this form.

1. Carefully read all these instructions, including the section entitled Frequently Asked Questions.

2. Contact a doctor who is designated by USCIS as a civil surgeon to make an appointment.

3. Fill out Part 1. Information About You of Form I-693. Do not sign the form until the civil surgeon tells you to sign it. You must sign in the presence of the civil surgeon.

4. Attend your medical examination appointment and all follow-up examinations, as required. If you have any medical records, including vaccination records, take them with you to the initial appointment.

5. The civil surgeon is required to give you the completed Form I-693 in a sealed envelope for you to submit to USCIS. Do not accept the form from the civil surgeon unless it is in a sealed envelope. USCIS will return your Form I-693 to you if it is not in a sealed envelope or if the envelope is opened or altered in any way. The civil surgeon should also give you a copy of the completed Form I-693 for your records.

6. Submit your completed Form I-693 in the sealed envelope to USCIS. Please see our website at www.uscis.gov/I-693.

A. If you are applying for adjustment of status, Form I-485: Submit Form I-693 according to the instructions on Form I-485, Application to Register for Permanent Residence or Adjust Status.

B. For all other applicants: Follow the application’s instructions, follow the instructions that the office requesting the medical examination gave you, or call the USCIS National Customer Service Center at 1-800-375-5283 for the most current information on where to file this benefit request. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

[Page 2]

NOTE: The civil surgeon will ask you to verify your identity. Bring a valid government-issued photo identification to your appointment (for example, your unexpired passport or driver’s license). If you are under 14 years of age, acceptable documents for proof of identity must show your name, date and place of birth, parents’ full names, and any other identifying information about you. Acceptable documents include birth certificates (with a translation, if necessary) or affidavits.

How Do I Find A Designated Civil Surgeon In My Area?

To find a designated civil surgeon in your area, call the USCIS National Customer Service Center at 1-800-375-5283. Follow the instructions in the automated menu. The telephone service is available in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833. A list of the designated civil surgeons in your area is also available at www.uscis.gov. (Select “TOOLS,” choose “Find a civil surgeon,” enter your ZIP Code, and click “Find civil surgeons.”)

[Page 1]

Applicant Instructions

How Do I File Form I-693?

You must submit a separate Form I-693 for each applicant. There is no filing fee for this form.

1. Carefully read all these instructions, including the Frequently Asked Questions section.

2. Contact a doctor who is designated as a civil surgeon by USCIS to make an appointment.

3. Fill out Part 1. Information About You of Form I-693. Do not sign the form until the civil surgeon tells you to sign it. You must sign in the presence of the civil surgeon.

5. The civil surgeon must give you the completed Form I-693 in a sealed envelope for you to submit to USCIS. Do not accept the form from the civil surgeon unless it is in a sealed envelope. USCIS will return your Form I-693 to you if it is not in a sealed envelope or if the envelope is opened or altered in any way. The civil surgeon should also give you a copy of the completed Form I-693 for your records.

6. Submit your completed Form I-693 in the sealed envelope to USCIS. Please see our website at www.uscis.gov/I-693. The Form I-693 must be dated no earlier than 60 days before you filed your underlying application. A properly and timely completed Form I-693 remains valid for two years from the date of the civil surgeon’s signature.

A. If you are applying for adjustment of status, Form I-485: Submit Form I-693 according to the instructions on Form I-485, Application to Register for Permanent Residence or Adjust Status.

[Page 2]

_B. For all other applicants: Follow the application’s instructions, follow the instructions that the office requesting the medical examination gave you, or visit the USCIS Contact Center at www.uscis.gov/contactcenter to learn more, including where to file this application. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: _{1-800-767-1833}_.

NOTE: The civil surgeon will ask you to verify your identity. Bring a valid government-issued form of photo identification to your appointment (for example, your unexpired passport or driver’s license). If you are under 14 years of age, acceptable documents for proof of identity must show your name, date and place of birth, parents’ full names, and any other identifying information about you. Acceptable documents include birth certificates (with a translation, if necessary) or affidavits.

How Do I Find A Designated Civil Surgeon In My Area?

To find a designated civil surgeon in your area, visit the USCIS website at www.uscis.gov. (Select “TOOLS,” choose “Find a Doctor,” enter your ZIP Code or address, and click “Search.”)

Page 2, General Instructions

[Page 2]

General Instructions

USCIS provides forms free of charge through the USCIS website. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have Internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that we mail a form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Signature. Each Form I-693 must be properly signed and filed. In general, USCIS will not accept a stamped or typewritten name in place of a signature. If you are under 14 years of age, your parent or legal guardian may sign the form on your behalf. A legal guardian may also sign for a mentally incompetent person.

There are special rules for blanket designated health departments or military physicians. Refer to these Instructions for additional information on how blanket designated civil surgeons may sign the form. (See section entitled How Do I, as a Civil Surgeon, Fill Out My Portion of This Form I-693?, subsection “Military physicians performing the medical examination for members and veterans of the U.S. Armed Forces or U.S. Coast Guard and certain eligible dependents”.)

Filing Fee. There is no filing fee for this form.

Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Specific Instructions section of these Instructions.

Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you must submit an original document. USCIS may request an original document at the time of filing or at any time during processing of an application, petition, or request. If USCIS requests an original document from you, it will be returned to you after USCIS determines it no longer needs your original.

NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be immediately destroyed upon receipt.

Translations. If you submit a document with information in a foreign language, you must also submit a full English translation. The translator must sign a certification that the English language translation is complete and accurate, and that he or she is competent to translate from the foreign language into English. The certification must include the translator’s signature, should contain the translator’s printed name and the date, and it may also contain the translator’s contact information.

Type or print legibly in black ink.

[Page 3]

Extra Space. If you (the applicant or the civil surgeon) need extra space to complete any item within this form, use the space provided in Part 10. Additional Information or 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; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

[Page 2]

General Instructions

USCIS provides forms free of charge through our website. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have internet access, you may order USCIS forms by calling the Forms Request Line at 1-800-870-3676. The Forms Request Line provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

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[Page 3]

How To Fill Out Form I-693

1. Type or print legibly in black ink.

2. If you (the applicant or the civil surgeon) need extra space to complete any item within this application, use the space provided in Part 11. Additional Information or 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; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been married and the question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many children do you have” or “How many times have you departed the United States”), type or print “None” unless otherwise directed.

Page 3, Specific Instructions

[Page 3]

Specific Instructions

How To Fill Out My (the Applicant’s) Portion of Form I-693

Form I-693 is divided into 10 parts. These instructions will help you and the civil surgeon complete Form I-693.

Only complete Part 1. of Form I-693 and the identifying information at the top of each page. The civil surgeon and any other doctors, clinics, or health departments that you are referred to will complete the remaining parts of Form I-693.

Part 1. Information About You

Complete this part before your medical examination appointment. Fill out your name and A-Number (if any) at the top of each page of Form I-693. The civil surgeon will check that this information matches Part 1.

Item Number 1. Your Full Name. Use your legal name, which is the name that appears on your birth certificate, unless it was changed after birth by a legal action such as marriage or a court order. If you do not have and cannot obtain your birth certificate, use your full legal name as it appears on government issued identity documents such as a passport, refugee travel document, or similar official record. Do not provide a nickname. If you have two last names, include both and use a hyphen (-) between the names, if appropriate.

Item Number 2. Physical Address. Provide your physical street address. This must include a street number and name or a rural route number. Do not provide a post office box (PO Box) number here.

Item Number 3.A. Sex. Select the box that indicates whether you are male or female.

Item Number 3.B. Date of Birth. Use eight numbers to show your date of birth in mm/dd/yyyy format (for example, type or print May 1, 1979 as 05/01/1979).

Item Number 3.C. City/Town/Village of Birth. Provide the name of the city, town, or village where you were born.

Item Number 3.D. Country of Birth. Provide the name of the country where you were born.

Item Number 3.E. Alien Registration Number (A-Number) (if any). This is your alien registration file number. If you are not sure if you have one, look at any letters or notices that you have received from the Department of Homeland Security (DHS). Look for a number that begins with a letter “A” followed by 8 or 9 digits (for example: A 000 000 000). If you do not have one, or if you cannot remember what it is, leave this space blank.

Item Number 3.F. USCIS Online Account Number (if any). If you have previously filed an application, petition, or request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)), provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions, or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The USCIS Online Account Number is not the same as an A-Number.

[Page 4]

Part 2. Applicant’s Statement, Contact Information, Certification, and Signature

Item Numbers 1. - 5. Select the appropriate box to indicate that you either read this form yourself or whether you had an interpreter assist you. Further, you must sign and date your Form I-693 in front of the civil surgeon, and provide your daytime telephone number, mobile telephone number (if any), and email address (if any). Every Form I-693 MUST contain the signature of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

Note Regarding Applicant’s Signature: The civil surgeon must witness you signing Form I-693. The civil surgeon will type or print the form of applicant identification document presented, and the identification number from your identification document.

Part 3. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1.- 7. If you used anyone as an interpreter to read the Instructions and questions on this form to you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number (if any), and his or her email address (if any). The interpreter must sign and date Form I-693

[Page 3]

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How To Fill Out My (the Applicant’s) Portion of Form I-693

Form I-693 is divided into 11 parts. These instructions will help you and the civil surgeon complete Form I-693.

Part 1. Information About You

Item Number 3.A. Gender. Select the box that indicates whether you are male or female.

Item Number 3.B. Date of Birth. Use eight numbers to show your date of birth in mm/dd/yyyy format (for example, type or print May 1, 1979 as 05/01/1979).

Item Number 3.C. City/Town/Village of Birth. Provide the name of the city, town, or village where you were born.

Item Number 3.D. Country of Birth. Provide the name of the country where you were born.

[Page 4]

Part 2. Applicant’s Statement, Contact Information, Certification, and Signature

Item Numbers 1. - 6. Select the appropriate box to indicate that you either read this application yourself or whether you had an interpreter assist you. If someone assisted you in completing the application, select the box indicating that you used a preparer. Further, you must sign and date your Form I-693 in front of the civil surgeon, and provide your daytime telephone number, mobile telephone number (if any), and email address (if any). Every Form I-693 MUST contain the signature of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

Part 3. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1.- 7. If you used anyone as an interpreter to read the Instructions and questions on this application to you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number (if any), and his or her email address (if any). The interpreter must sign and date Form I-693. A stamped or typewritten name in place of a signature is not acceptable.

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Item Numbers 1. - 8. This section must contain the signature of the person who completed your application, if other than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete both Part 3. and Part 4. If the person who completed this application is associated with a business or organization, that person should complete the business or organization name and address information. Anyone who helped you complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he or she may also need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with your application.

We recommend that you print or save a copy of your completed application to review in the future and for your records.

Page 4, Civil Surgeon’s Instructions

[Page 4]

Civil Surgeon’s Instructions

What Are My Responsibilities as a Designated Civil Surgeon?

1. Truthfully and accurately report the results. You are responsible for reporting the results of the medical examination and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon’s certification provided on the form.

You must take reasonable steps to ensure that the person appearing for the medical examination is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued photo identification or another form of government-recognized identity documentation. You must note in Part 4., Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification presented and identification number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical examination.

You should direct the applicant to complete and sign in Part 2., Item Numbers 1. - 5., in your presence. You should also ensure that the applicant’s name and A-Number (if any) are at the top of each page of the Form I-693 and match the information provided in Part 1.

2. Follow U. S. Department of Health and Human Services (HHS) regulations and Centers for Disease Control and Prevention (CDC) guidelines. As a USCIS-designated civil surgeon, you are required to perform the medical examination according to HHS regulations. These regulations include the specific guidelines found in the Technical Instructions for the Medical Examination of Aliens in the United States, published by the CDC. The Technical Instructions (including periodic updates posted by the CDC) are available at www.cdc.gov/immigrantrefugeehealth/ exams/ti/civil/technical-instructions-civil-surgeons.html.

3. Make referrals and file case reports, as required. According to the CDC’s Technical Instructions, you are required to:

A. Refer the applicant to the local health department if a chest X-ray suggests TB or other circumstances described in the CDC’s Technical Instructions.

B. Ensure that any applicant diagnosed with syphilis is treated with the standard treatment regimen described in the CDC’s Technical Instructions.

[Page 5]

C. Ensure that the applicant is tested for gonorrhea and given therapy, if diagnosed.

D. Refer the applicant to a Hansen’s disease specialist for evaluation to confirm a suspected diagnosis of Hansen’s disease (leprosy).

E. File a case report with the appropriate public health authorities if a case report is required by local laws or _regulations._Y_{ou
must also advise the applicant that a case report is being filed.}

How Do I, as a Civil Surgeon, Fill Out My Portion of This Form I-693?

You, as the civil surgeon, are responsible for ensuring that Form I-693 is completed and signed as follows.

1. Part 4. Applicant’s Identification Information. You are responsible for verifying the identity of the applicant and noting in Part 4., Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification that the applicant presents to you and the identification number, if applicable. You are also required to check the top of each page of Form I-693 to make sure the name and A-Number (if any) are correct. Finally, you must require the applicant to sign the Applicant’s Certification in Part 2. in your presence. The applicant should not sign Part 2. until the medical examination is completed and all health-related follow-up requirements, if any, are met.

2. Part 5. Summary of Medical Examination. After the medical examination and any required follow-up, summarize the results in Part 5.

3. Part 6. Civil Surgeon’s Contact Information, Certification, and Signature. You must sign the certification after the medical examination is complete. Fill out your identifying information in this part before referring an applicant for further tests or evaluation. Do not sign and date this part until the referral or follow-up evaluation (if required) is completed and the applicant is medically cleared. Your signature must be original. Stamped signatures or typewritten names are not acceptable.

In signing the Form I-693 in this part, you certify under penalty of perjury that you have a valid, unrestricted license in the jurisdiction in the United States in which you are conducting immigration related medical examinations. You also certify under penalty of perjury that no other jurisdiction in the United States in which you conduct immigration- related medical examinations has revoked or placed restrictions on your license to practice medicine in that jurisdiction.

For health departments performing the vaccination assessment for refugee adjustment applicants ONLY: You must complete Part 6. Civil Surgeon’s Contact Information, Certification, and Signature of Form I-693. The original or stamped signature of the physician on staff at the health department must be present in Part 6. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed physicians. Health departments must also place either the official stamp or raised seal, whichever is customarily used, in Part 6. where indicated.

Military physicians performing the medical examination for members and veterans of the U.S. Armed Forces or U.S. Coast Guard and certain eligible dependents must also complete Part 6. The original or stamped signature of the military physician operating under the blanket civil surgeon designation must appear in Part 6. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed physicians. Military treatment facilities must also place either their official stamp or raised seal in Part 6. where indicated.

4. Part 7. Civil Surgeon Worksheet and Part 9. Vaccination Record. You must fill out this worksheet and provide the results of each component of the medical examination relating to: communicable diseases of public health significance, physical or mental disorders with associated harmful behavior, drug abuse or drug addiction, and vaccinations. You must also include the results of any lab work or other studies required to determine whether the applicant is inadmissible on health-related grounds. You must instruct applicants who have had a tuberculin skit test (TST) to return to your office within 48 - 72 hours to have the TST read.

[Page 6]

5. Part 8. Referral Evaluation. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 7. Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign Part 8. Referral Evaluation. Do not complete Item Number 5. in Part 7. if the referral is recommended and not required.

How Do I Complete Form I-693 If I Need to Make a Required Referral?

Advise applicants that they must complete all health-related follow-up requirements before you can certify Form I-693. You must fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 7. Civil Surgeon Worksheet with the contact information of the physician or public health facility that will conduct further evaluation or provide treatment. You should also specify the type of examination and additional tests or treatment that the applicant should receive in the Remarks section of Item Number 5. The health care professional receiving the referral must fill out and sign Part 8. Referral Evaluation. Do not complete Item Number 5. in Part 7. if the referral is recommended and not required. Complete your identifying information in Part 6., but do not sign or date the form. Make a copy of the Form I-693 for your records and give the original to the applicant in a sealed envelope. (See the next section for additional instructions for sealing the envelope.)

What Should I Do After the Medical Examination and Health-Related Follow-Up Requirements (If Required) Are Completed?

After the medical examination and any health-related required follow-up is complete, summarize the results in Part 5. of Form I-693. Do not sign Form I-693 until the applicant has met all health-related follow-up requirements. After that, sign the civil surgeon’s certification in Part 6., Item Number 8.

Make two copies of the completed and signed Form I-693 and any supporting documents. Keep one copy for your records. Give the other copy to the applicant. The vaccination portion of Form I-693 will serve as the applicant’s official vaccination record for future use (for example, school or employment purposes.)

Prepare the original of the completed and signed Form I-693 for submission to USCIS.

Follow these steps:

1. Place the Form I-693 and any supporting documentation into an envelope.

2. Seal the envelope.

3. On the front, write in capital letters: “DO NOT OPEN. FOR USCIS USE ONLY.”

4. On the back, write your initials across the seal where the flap meets the envelope.

5. Seal the entire flap with clear tape. Make sure the tape covers your initials as well as the flap.

_6. _Give_the_sealed_envelope_to_the_applicant.

The applicant must submit the sealed envelope to USCIS.

IMPORTANT: USCIS will not accept Form I-693 unless it is in a sealed envelope that is not opened or altered in any way.

Return to the applicant all supporting medical documents that you were not required to include in the sealed envelope.

[Page 5]

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You must take reasonable steps to ensure that the person appearing for the medical examination is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued form of photo identification another form of government-recognized identity documentation. You must note in Part 5., Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification presented and identification number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical examination.

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3. Make referrals and file case reports, as required. According to the CDC’s Technical Instructions, you are required to:

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1. Part 5. Applicant’s Identification Information. You are responsible for verifying the identity of the applicant and noting in Part 5., Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification that the applicant presents to you and the identification number, if applicable. You are also required to check the top of each page of Form I-693 to make sure the name and A-Number (if any) are correct. Finally, you must require the applicant to sign the Applicant’s Certification in Part 2. in your presence. The applicant should not sign Part 2. until the medical examination is completed and all health-related follow-up requirements, if any, are met.

2. Part 6. Summary of Overall Findings. After the medical examination and any required follow-up, summarize the results in Part 6.

3. Part 7. Civil Surgeon’s Contact Information, Certification, and Signature. You must sign the certification after the medical examination is complete. Fill out your identifying information in this part before referring an applicant for further tests or evaluation. Do not sign and date this part until the referral or follow-up evaluation (if required) is completed and the applicant is medically cleared. Your signature must be original. Stamped signatures or typewritten names are not acceptable (except for blanket-designated health department or military physicians as described below).

For health departments performing the vaccination assessment for refugee adjustment applicants ONLY: You must complete Part 7. Civil Surgeon’s Contact Information, Certification, and Signature of Form I-693. The original or stamped signature of the physician on staff at the health department must be present in Part 7. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed physicians. Health departments must also place either the official stamp or raised seal, whichever is customarily used, in Part 7. where indicated.

Military physicians performing the medical examination for members and veterans of the U.S. Armed Forces or U.S. Coast Guard and certain eligible dependents must also complete Part 7. The original or stamped signature of the military physician operating under the blanket civil surgeon designation must appear in Part 7. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed physicians. Military treatment facilities must also place either their official stamp or raised seal in Part 7. where indicated.

4. Part 8. Civil Surgeon Worksheet and Part 10. Vaccination Record. You must fill out this worksheet and provide the results of each component of the medical examination relating to: communicable diseases of public health significance, physical or mental disorders with associated harmful behavior, drug abuse or drug addiction, and vaccinations. You must also include the results of any lab work or other studies required to determine whether the applicant is inadmissible on health-related grounds.

5. Part 9. Referral Evaluation. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 8. Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign Part 9. Referral Evaluation. Do not complete Item Number 5. in Part 8. if the referral is recommended and not required.

How Do I Complete Form I-693 If I Need to Make a Required Referral?

Advise applicants that they must complete all health-related follow-up requirements before you can certify Form I-693. You must fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 8. Civil Surgeon Worksheet with the contact information of the physician or public health facility that will conduct further evaluation or provide treatment. You should also specify the type of examination and additional tests or treatment that the applicant should receive in the Remarks section of Item Number 5. The health care professional receiving the referral must fill out and sign Part 9. Referral Evaluation. Complete your identifying information in Part 7., but do not sign or date the application. Make a copy of the Form I-693 for your records and give the original to the applicant in a sealed envelope. (See the next section for additional instructions for sealing the envelope.)

[Page 7]

What Should I Do After the Medical Examination and Health-Related Follow-Up Requirements (If Required) Are Completed?

After the medical examination and any health-related required follow-up is complete, summarize the results in Part 6. of Form I-693. Do not sign Form I-693 until the applicant has met all health-related follow-up requirements. After that, sign the civil surgeon’s certification in Part 7., Item Number 8.

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Page 7, Frequently Asked Questions

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_{Frequently
Asked Questions}

1. Who must submit Form I-693?

Most applicants filing for adjustment of status to become a lawful permanent resident must submit Form I-693 completed by a designated civil surgeon. Certain other applicants may also be required to submit Form I-693 completed by a civil surgeon.

2. What if I am a refugee and already had a medical examination overseas?

If you are now applying for adjustment of status under INA section 209 one year after your first admission, you only need to repeat the entire examination if the panel physician found a class A medical condition during your overseas examination. If you need a new medical examination because of a class A medical condition, you also need to comply with the vaccination requirements found in Form I-693.

Even if you do not need a complete medical examination, you still need to comply with the vaccination requirements. This means you only need to submit Part 9. Vaccination Record and Parts 1., 2., 3., 4., and 6. of Form I-693. Contact your state or local refugee health coordinator to find out whether a state or local health department can complete the Part 9. of Form I-693. The health department must also complete Part 6. of the benefit request.

3. What if I am a K nonimmigrant visa holder and already had a medical examination overseas?

If you were admitted as a:

A. K-1 fiancé(e) or a K-2 child of a K-1 fiancé(e); or

B. K-3 spouse of a U.S. citizen or a K-4 child of a K-3 spouse of a U.S. citizen; and

C. You received a medical examination prior to admission, then:

(1) You are not required to have another medical examination as long as you file your Form I-485 within one year of an overseas medical examination; and

(a) The panel physician did not find a class A medical condition during your overseas examination; or

(b) The panel physician did find a class A medical condition, you received a waiver of inadmissibility, and you have complied with the terms and conditions of the waiver.

(2) Even if a new medical examination is not required, you must still show proof that you complied with the vaccination requirements. If the vaccination record (DS 3025) was not properly completed and included as part of the original overseas medical examination report, you will have to have the Part 9. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1., 2., 3., 4., 6., and 9. of Form I-693.

4. What if I am a V nonimmigrant visa holder and already had a medical examination overseas?

If you were admitted to the United States or obtained status while in the United States as a:

A. V-1 spouse of a lawful permanent resident or are waiting for a V-1 visa; or

B. V-2 child of a V-1 spouse of a lawful permanent resident; or

C. V-3 child of a V-2 unmarried son or daughter of a V-1 spouse of a lawful permanent resident; and

D. You received a medical examination prior to admission or obtaining V status, then:

(1) You are not required to have another medical examination as long as you file your Form I-485 within one year of an overseas examination, and:

(a) The panel physician did not find a class A medical condition; or

(b) The panel physician did find a class A medical condition, you received a waiver of inadmissibility, and you have complied with the terms and conditions of the waiver.

[Page 8]

(2) Even if a new medical examination is not required, you still must show proof that you complied with the vaccination requirements. If the vaccination record was not properly completed and included as part of the original medical examination report, you will have to have the Part 9. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1., 2., 3., 4., 6., and 9. of Form I-693.

5. What if I am an asylee derivative applying for adjustment of status and already had a medical examination overseas?

If you were admitted to the United States as an asylee derivative, you generally do not need to repeat, at the time you submit Form I-485, the entire medical examination you had overseas, provided that:

A. The panel physician found no class A condition during your overseas examination; and

B. You are applying for adjustment of status within one year of becoming eligible to file.

You must, however, comply with the vaccination requirement and submit Part 9. Vaccination Record and Parts 1., 2., 3., 4., and 6. of Form I-693 with your Form I-485.

6. May any doctor perform the required medical examination?

Only a doctor who was designated by USCIS as a civil surgeon may perform the medical examination. USCIS will not accept a Form I-693 completed by a doctor who is not a currently designated civil surgeon.

7. How do I know if a doctor is a designated civil surgeon?

Doctors found through the USCIS website at www.uscis.gov or through the USCIS National Customer Service Center are generally current in their designation as civil surgeons. Applicants who are unsure should ask doctors to confirm their status as a civil surgeon.

8. Who pays for the medical examination?

You, the applicant, are responsible for paying all costs of the medical examination, including the cost of any follow-up tests or treatment that is required. Make payments directly to the civil surgeon or other health care provider.

9. What are the health-related grounds of inadmissibility?

U.S. immigration law divides the health-related grounds of inadmissibility into the following four general categories:

A. Communicable diseases of public health significance;

B. Lack of proof of having received required vaccinations;

C. Physical or mental disorders with associated harmful behavior or a history of associated harmful behavior; and

D. Drug abuse or addiction.

_See INA section 212(a)(1)(A). HHS regulations classify these and other medical conditions into class A or B _conditions._Class_A_conditions_result_in_{inadmissibility}_while_class_B_conditions_{do not.}_See_{42 CFR 34.2(d) - (e).}

_{[Page 7]}

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If you do not have a Class A medical condition and therefore do not need to repeat the full medical examination, you must still comply with the vaccination requirements. This means you only need to submit Part 10. Vaccination Record and Parts 1. - 5., and Part 7. of Form I-693. Contact your state or local refugee health coordinator to find out whether a state or local health department can complete the Part 10. of Form I-693. The health department must also complete Part 7. of the benefit request.

[Page 8]

[no change]

(2) Even if a new medical examination is not required, you must still show proof that you complied with the vaccination requirements. If the vaccination record (DS 3025) was not properly completed and included as part of the original overseas medical examination report, you will need to have the Part 10. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1. - 5., 7., and 10. of Form I-693.

[no change]

(2) Even if a new medical examination is not required, you still must show proof that you complied with the vaccination requirements. If the vaccination record was not properly completed and included as part of the original medical examination report, you will have to have the Part 10. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1. - 5., 7., and 10. of Form I-693.

[no change]

You must, however, comply with the vaccination requirement and submit Part 10. Vaccination Record and Parts 1. - 5., and 7. of Form I-693 with your Form I-485.

6. May any doctor perform the required medical examination?

[Page 9]

7. How do I know if a doctor is a designated civil surgeon?

Doctors found through the USCIS website at www.uscis.gov or through the USCIS Contact Center are generally current in their designation as civil surgeons. Applicants who are unsure should ask doctors to confirm their status as a civil surgeon.

8. Who pays for the medical examination?

You, the applicant, must pay all costs of the medical examination, including the cost of any follow-up tests or treatment that is required. Make payments directly to the civil surgeon or other health care provider.

[no change]

Page 8, Medical Evaluations

[Page 8]

Medical Evaluations

1. Communicable Diseases of Public Health Significance

The civil surgeon is required to perform specific tests for tuberculosis, syphilis, and gonorrhea. The medical examination also requires the civil surgeon to evaluate for other sexually transmitted diseases and Hansen’s disease (leprosy).

If you have a communicable disease of public health significance, the civil surgeon will advise you on how to obtain treatment. USCIS will inform you of whether you also need to apply for a waiver of inadmissibility. To learn more about this waiver, visit the USCIS website at www.uscis.gov.

[Page 9]

A. Testing for Tuberculosis

All applicants two years of age and older require testing for tuberculosis (TB) with an initial screening test. Civil surgeons may require an applicant younger than two years of age to undergo testing if there is evidence of contact with a person known to have TB or other reasons to suspect TB. The physician may use either the tuberculin skin test (TST) or an interferon gamma release assay (IGRA).

(1) TST given by the Mantoux technique: After the skin test, you will need to return to the civil surgeon within 48 to 72 hours to check the result. If you have a reaction of 4 millimeters or less, you will generally not need any further tests for TB. If the reaction is 5 millimeters or more, you are required to have a chest X-ray. The civil surgeon will explain the medical requirements to you in more detail.

(2) IGRA: Civil surgeons have the option to use an IGRA in place of the TST (see the update to the Technical Instructions at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/updates/index.html.) You will not have to return to the civil surgeon’s office to check the result. The result is generally available within 24 hours. If the test is negative or indeterminate, borderline, or equivocal, you generally will not need any further tests for TB. In other cases, you may require further evaluation with a chest X-ray.

The CDC recognizes the following IGRAs for purposes of this immigration medical examination: the QuantiFERON - TB Gold (QFT-G) test; the QuantiFERON - TB Gold in Tube (QFT-G IT) test; and the T-Spot TB test. In the future, the CDC may recognize additional tests; if it does, it will publish the information in its Technical Instructions at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical- instructions-civil-surgeons.html. Civil surgeons may use only tests listed in the materials published at this link for this examination.

NOTE: The civil surgeon will explain the medical requirements and the suitability and availability of IGRA testing to you in more detail.

B. Testing for Syphilis

All applicants 15 years of age and older must have a blood test for syphilis. Civil surgeons may require tests for applicants under 15 years of age if there is reason to suspect the possibility of infection.

C. Testing for Gonorrhea

All applicants 15 years of age and older must be tested for gonorrhea. Civil surgeons may require tests for applicants under 15 years of age if there is reason to suspect the possibility of infection.

2. Physical or Mental Disorders

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). Mental disorders are diagnosed according to the diagnostic criteria in the most recent edition of the Diagnostic and Statistical Manual (DSM) or by another authoritative source as determined by the CDC director. Physical disorders are diagnosed 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 by another authoritative source as determined by the CDC director. See the CDC’s Technical Instructions for more information.

The presence of a physical or mental disorder alone does not make you inadmissible on health-related grounds. The civil surgeon must also determine that there is behavior associated with the disorder that is harmful to you, to others, or to property. USCIS will only consider you inadmissible if there is a current associated harmful behavior or a history of associated harmful behavior that is likely to recur.

The civil surgeon will ask you general questions during the medical examination to determine whether you have such a condition. The civil surgeon may refer you to a specialist for further evaluation, if necessary.

If the civil surgeon finds that you have a physical or mental disorder with associated harmful behavior, you may apply for a waiver. If the waiver is granted, you may be subject to terms, conditions, and controls as determined by USCIS in consultation with HHS. For more information about these waivers, visit the USCIS website at www.uscis.gov.

[Page 10]

3. Drug Addiction and Drug Abuse

HHS sets the medical guidelines for determining drug abuse and drug addiction. The terms are defined at 42 CFR 34.2(h) and (i). The civil surgeon will review your medical history during the medical examination and ask you questions necessary to determine whether you are currently using any drugs or other psychoactive substances or have used them in the past.

“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. The diagnosis is made according to the diagnostic criteria in the most current edition of the DSM or by another authoritative source as determined by the CDC director.

“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. The diagnosis is made according to the diagnostic criteria in the most current edition of the DSM or by another authoritative source as determined by the CDC director. See the CDC’s Technical Instructions for more information.

If the civil surgeon determines you have a substance-related disorder, you are not eligible to apply for a waiver unless you are applying for adjustment of status one year after you were admitted as a refugee or granted asylum.

You will no longer be inadmissible based on drug abuse or drug addiction if, after a later medical examination by a civil surgeon, the civil surgeon finds your drug abuse or addiction is in remission. The diagnosis of remission is made according to the diagnostic criteria in the most current edition of the DSM or another authoritative source as determined by the CDC director.

[Page 9]

[no change]

A. Testing for Tuberculosis

All applicants two years of age and older must be tested for tuberculosis (TB) with an initial screening test. Civil surgeons may require an applicant younger than two years of age to undergo testing if there is evidence of contact with a person known to have TB or other reasons to suspect TB. Testing must be completed per CDC guidelines, which can found at the CDC’s website at https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

[deleted]

B. Testing for Syphilis

All applicants 15 years of age and older must have a blood test for syphilis. Civil surgeons may require testing for applicants under 15 years of age if there is reason to suspect the possibility of infection.

Civil surgeons should consult the latest version of CDC’s Technical Instructions to ensure they are using an approved type of test and following appropriate screening and testing procedures: https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

C. Testing for Gonorrhea

All applicants 15 years of age and older must be tested for gonorrhea. Civil surgeons may require testing for applicants under 15 years of age if there is reason to suspect the possibility of infection.

2. Physical or Mental Disorders

[no change]

“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. The civil surgeon will make a diagnosis according to the diagnostic criteria in the most current edition of the DSM or by another authoritative source as determined by the CDC director. See the CDC’s Technical Instructions for more information.

[no change]

Page 10, Vaccination Requirements

[Page 10]

Vaccination Requirements

All applicants for adjustment of status must present documents showing they were vaccinated against a broad range of vaccine-preventable diseases. The civil surgeon will review your vaccination history with you to determine whether you have had all the required vaccinations. Make sure you take your vaccination records with you to your appointment with the civil surgeon.

NOTE: Do not attempt to meet the requirements before the civil surgeon evaluates you, in case any of the required vaccines are not medically appropriate for you.

You can find a list of the required vaccines at www.cdc.gov/immigrantrefugeehealth/exams/medical-examination-faqs.html#6.

If you never received certain vaccines, or you are unable to prove you received them, the civil surgeon can provide them to you. You also have the option to ask your family doctor to administer those vaccines to you after your evaluation by the civil surgeon. If you choose that option, show the records to the civil surgeon to note on Form I-693.

If you initially did not have documents proving you received all the required vaccines, but later submit those documents, USCIS may grant you a waiver based on the civil surgeon’s certification on Part 9. Vaccination Record of Form I-693. USCIS may also grant you a waiver if the civil surgeon certifies that it is not medically appropriate for you to have one or more of the required vaccines.

HHS has determined that a vaccine is “not medically appropriate” if:

1. The vaccine is not recommended for your specific age group;

2. There is a medical reason why it would not be safe to have the vaccine (for example, you are allergic to eggs and/or yeast or you had bad reactions to prior vaccines);

3. You are unable to complete the entire series of a required vaccine within a reasonable amount of time; or

4. For the influenza vaccine, it is not the flu season.

[Page 11]

If you object to required vaccinations because of sincerely held religious beliefs or moral convictions, you may apply for a waiver of these requirements. If you hold these objections, inform the civil surgeon that you will apply for a waiver. If USCIS denies the waiver application, we may also deny the immigration benefit that you are seeking. For more _information_about_these_waivers,_visit_the_{USCIS website}_at_ww_w_.uscis.gov_.

[Page 11]

Vaccination Requirements

[no change]

If you initially did not have documents proving you received all the required vaccines, but later submit those documents, USCIS may grant you a waiver based on the civil surgeon’s certification on Part 10. Vaccination Record of Form I-693. USCIS may also grant you a waiver if the civil surgeon certifies that it is not medically appropriate for you to have one or more of the required vaccines.

[no change]

Page 11, USCIS Information

[Page 11]

USCIS Information

Address Change (For Applicant’s Only)

An applicant or petitioner who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his or her previous residence. For information on filing a change of address, go to the USCIS website at www.uscis.gov/addresschange or contact the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not process change of address requests.

[Page 12]

[deleted]

Address Change (For Applicants Only)

An applicant or petitioner who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his or her previous residence. For information on filing a change of address, go to the USCIS website at www.uscis.gov/addresschange or reach out to the USCIS Contact Center at www.uscis.gov/contactcenter for help. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not process change of address requests.

Page 11, USCIS Forms and Information

[Page 11]

USCIS Forms and Information

To ensure you (the applicant or the civil surgeon) are using the latest version of this form, visit the USCIS website at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at www.uscis.gov. Select “Schedule an appointment online” and follow the screen prompts to set up your appointment. Once you finish scheduling an appointment, the system will generate an appointment notice for you.

[Page 12]

USCIS Forms and Information

To ensure you (the applicant or the civil surgeon) are using the latest version of this form, visit the USCIS website at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USCIS forms by calling the Forms Request Line at 1-800-870-3676. The Forms Request Line offers services in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at www.uscis.gov. Select “Tools,” then under “Self Service Tools,” select “Appointments” and follow the screen prompts to set up your appointment. Once you finish scheduling an appointment, the system will generate an appointment notice for you.

Page 11, Penalties

[Page 11]

Penalties

If you (the applicant or the civil surgeon) knowingly and willfully falsify or conceal a material fact or submit a false document with the Form I-693, you will face severe penalties provided by law and may be subject to criminal prosecution.

[Page 12]

Penalties

Page 11, USCIS Privacy Act Statement

[Page 11]

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act, section 101.

PURPOSE: The primary purpose for providing the requested information on this form is to determine if you (the applicant) have established eligibility for the immigration benefit for which you (the applicant) are filing. DHS will use the information you provide to grant or deny the immigration benefit you are seeking.

DISCLOSURE: The information you (the applicant) provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision in your case or result in denial of your application for an immigration benefit.

[Page 12]

ROUTINE USES: DHS may share the information you and the civil surgeon provide on this form with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine uses described in the associated published system of records notices [DHS/USCIS-007 - Benefits Information System and

DHS/USCIS-001 - Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.

[Page 12]

DHS Privacy Notice

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act section 212(a)(1)(a).

PURPOSE: The primary purpose for providing the requested information on this form is to report results of a medical examination and provide vaccination records to USCIS. DHS uses the information to assist with determining eligibility for the immigration benefit you are seeking.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your Social Security number (if applicable), and any requested evidence, may delay a final decision or result in denial of your form.

[Page 12]

ROUTINE USES: DHS may share the information you provide on this form and any additional requested evidence with other Federal, state, local, and foreign government agencies and authorized organizations in accordance with approved routine uses described in the associated published system of records notices [DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System and DHS/USCIS-007 Benefits Information System] and the published privacy impact assessments [DHS/USCIS/PIA-003 Integrated Digitization Document Management Program (IDDMP) and DHS/USCIS/PIA-067 Civil Surgeon Designation] which you can find at www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law enforcement purposes or in the interest of national security.

Page 12, Paperwork Reduction Act

[Page 12]

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 2 hours and 30 minutes per response, including the time for reviewing instructions, gathering the required documentation and information, completing the form, preparing statements, attaching necessary documentation, and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0033. Do not mail your completed Form I-693 to this address.

[Page 13]

Paperwork Reduction Act

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