Form 4 422-1 4 422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM

Form Approved
OMB NO. 0920-0006
Exp. XX/XX/XXXX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY
UNDER SECTION 212(a) (1) (A) (iii) (I) or 212(a) (1) (A) (iii) (II),
IMMIGRATION AND NATIONALITY ACT

INSTRUCTIONS:
Part I-- United States Public Health Service reviewing official completes this Part (after he determines that the applicant’s special medical
report, submitted per form I-601, is acceptable)
Part II--Applicant or sponsoring family member arranges for Part II to be completed, on 4 copies of this form, by the director of a clinic,
hospital, institution, school, or other specialized facility or by a specialist, in the United States. Applicant or sponsoring family member may
contact the mental retardation or mental health agency of the state of intended residence of the applicant for guidance in selecting a specialist or
medical facility. The facility or specialist must be acceptable to the United States Public Health Service. (After completing Part II, the facility
or specialist keeps one copy and returns 3 copies to the applicant or sponsor).
Part III--Applicant or sponsoring family member: (a) completes Part III on all 3 copies returned by the facility or specialist; (b) Keeps one
copy; (c) sends 2 copies to the United States Public Health Service official whose name and address are given in Part I, item (f), below.
Part I
(A) APPLICANT’S NAME

(Family Name)

(First Name)

(Middle Name)

(B) PRESENT ADDRESS

(Number and Street)

(City or Town)

(Country)

C) DATE OF BIRTH

Sex

Ethnicity

INS File Number

(D) ESSENTIAL MEDICAL DETAILS ON GROUNDS OF INADMISSIBILITY
[ ] CLASS A, 212(a) (1) (A) (iii) (I) - has a physical/mental disorder with associated behavior that may pose, or has posed a threat to the
property, safety, or welfare of the alien or others.
[ ] CLASS A, 212(a)(1)(A)(iii)(II) - has had a physical/mental disorder with history of behavior which has posed a threat to the property,
safety, or welfare of the alien or others, and which behavior is likely to recur.
Axis I Axis II Axis III (E) THE FOLLOWING SPECIAL TRAVEL REQUIREMENTS ARE SPECIFIED FOR THIS PERSON :

[ ] Escort Required

[ ] Other

(F) NAME, SIGNATURE, TITLE, AND ADDRESS OF UNITED STATES PUBLIC HEALTH SERVICE REVIEWING OFFICIAL

(NOTE: Applicant’s medical records are on file at this address)

.CDC 4.422-1 (Interim Form)

DATE

Martin S. Cetron, MD
Director
Division of Global Migration and Quarantine (H16-4)
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA 30333

NO FURTHER ACTION WILL BE TAKEN ON WAIVER APPLICATION UNTIL PARTS II AND III ARE COMPLETED.
Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia
30333; ATTN: PRA (0920-0006).

NOTE: PARTS II AND III MUST BE TYPEWRITTEN OR PRINTED PLAINLY IN INK. IF ILLEGIBLE, FORM WILL BE RETURNED WITHOUT PROCESS.

PART II (See instructions on other side)
Identification of the military facility in the United States; or of the clinic, hospital, institution, school, or other specialized facility or of the
specialist, in the United States, issuing the statements in this Part:
(A) NAME OF FACILITY OR SPECIALIST
(B) ADDRESS AND PHONE NO. WITH AREA CODE

I hereby affirm (1) That the facility or specialist named above has agreed to evaluate the person (“applicant”) specified in part I within 30 days after arrival
in the United States.
(2) That the specified person, the sponsoring family member, or other responsible person has made complete financial arrangements for
payment of any charges that may be incurred after arrival for studies, care, training, and service.
(3) That I will send the following data to the Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic
Infectious Diseases, Division of Global Migration and Quarantine (E03), Atlanta, Georgia 30333:
(a) An initial report, giving a complete current evaluation of the specified person’s physical /mental status including information
concerning the person’s harmful behavior associated with the diagnosed physical/mental disorder-- to be sent within 30 days after
his/her arrival at the above facility or office.
(b) A prompt notification of the person’s failure to report to the facility or specialist within 30 days after being notified by the United
States Public Health Service that the person has arrived in the United States.
(4) That the person will be in an outpatient, an inpatient, study, or other specified status as determined by the specialist or facility during the
initial evaluation and for any appropriate clinical follow up and/or medical supervision as may be required.
NAME OF COMMANDER OF MILITARY FACILITY; OR DIRECTOR OF FACILITY IN THE UNITED STATES; OR SPECIALIST IN THE UNITED STATES.
(C,)Signature of Commander, Director, or Specialist)

(D) (Type or print plainly name of person who signed in item C, their official title and date)

Date___________

DO NOT WRITE IN THIS BLOCK
APPROVED _________________________________________
____________
Martin S. Cetron, MD, Director
Date
Division of Global Migration and Quarantine
National Center for Emerging and Zoonotic Infectious Diseases
PART III (See instructions on other side)
I hereby affirm (1) That I will comply with any special travel requirements specified in Part I, Item (E), of this form (other side.)
(2) That upon admission to the United States, I will proceed directly to the facility or specialist identified in Part II above.
(3) That I will submit to such further examinations or treatments as required.
(4) That the necessary expenses required for such further examinations or treatments will be met, and I will not become a public charge.

(Signature of Applicant)

(U.S. Address and Phone No. with Area Code)

(Date)

I hereby affirm - that I am completing this part on behalf of the applicant, and that the above requirements concerning the applicant will be
fulfilled.

(Signature of Sponsor)

(Relationship)

(U.S. Address and Phone No. with Area Code)

(Date)

Note: Failure to comply with the terms, conditions, and controls under which you are entering the U.S. with an approved waiver of inadmissibility may subject you to deportation
under Section 237(c) of the Immigration and Nationality Act.
CDC 4.422-1 (Back) (Interim Form)