I-693 Form TOC

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0033

08/24/2021

Reason for Revision: Emergency

Project Phase: OMBReview

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 07/31/2022

Edition Date 07/15/2019

Current Page Number and Section	Current Text	Proposed Text
Pages 12-13, Part 10, Vaccination Record	[Page 12] 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. Vaccine History Transferred From A Written Record Vaccine Specify Vaccine: DT DTaP DTP Specify Vaccine: Td Tdap Specify Vaccine: OPV IPV MMR (measles, mumps-rubella) or if monovalent or other combination of the vaccines are given, specify vaccines Hib Hepatitis B Varicella Pneumococcal Influenza Rotavirus Hepatitis A Meningococcal Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Vaccine Given Date Given by Civil Surgeon (mm/dd/yyyy) Complete Series Mark an X if complete; write date of lab test if immune or “VH” if varicella history Blanket Waivers to be Requested from USCIS (Not Medically Appropriate) Not Age-Appropriate Contraindication Insufficient Time Interval Not Flu Season NOTE: Give a copy to the applicant. [Page 13] Results: Applicant may be eligible for blanket waivers as indicated above Applicant will request an individual waiver based on religious or moral convictions Vaccine history complete for each vaccine, all requirements met Applicant does not meet immunization requirements Remarks: (If needed, provide any comments, such as the reason for contraindication.) FOR USCIS USE ONLY Remarks (if any)	[Page 12] 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, including COVID-19 vaccine guidance. 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. Vaccine History Transferred From A Written Record Vaccine Specify Vaccine: DT DTaP DTP Specify Vaccine: Td Tdap Specify Vaccine: OPV IPV MMR (measles, mumps-rubella) or if monovalent or other combination of the vaccines are given, specify vaccines Hib Hepatitis B Varicella Pneumococcal Influenza Rotavirus Hepatitis A Meningococcal COVID-19 (In “Remarks” section, write “COVID-19” and specify vaccine brand) Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Date Received (mm/dd/yyyy) Vaccine Given Date Given by Civil Surgeon (mm/dd/yyyy) Complete Series Mark an X if complete; write date of lab test if immune or “VH” if varicella history Blanket Waiver(s) to be Requested from USCIS (Not Medically Appropriate) Not Age-Appropriate Contraindication Insufficient Time Interval *See Below Table NOTE: Give a copy to the applicant. *For Influenza vaccine, check the box in this column only if vaccine is not medically appropriate because it is not flu season. *For COVID-19 vaccine, check the box in this column only if vaccine is not routinely available in the state where the civil surgeon practices according to the Technical Instructions blanket waivers for this vaccine. [Page 13] Results: Applicant completed vaccination requirements or may be eligible for blanket waivers as indicated above Applicant will request an individual waiver based on religious or moral convictions [deleted] Applicant does not meet immunization requirements Remarks: (If needed, provide any comments, such as the reason for contraindication.) FOR USCIS USE ONLY Remarks (if any)

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