Page 1
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[Page 1]
START
HERE - Type or print in black ink.
Please
read the instructions before examining the applicant and filling
out this form.
Only
medical doctors, doctors of osteopathy, or clinical psychologists
licensed to practice in the United States (including the U.S.
territories of the Commonwealth of the Northern Mariana Islands
(CNMI), Guam, Puerto Rico, and the Virgin Islands) are authorized
to certify the form. While staff of the medical practice
associated with the medical professional certifying the form may
assist in its completion, the medical professional is responsible
for the accuracy of the form's content. Failure to fully and
accurately complete this form, including all applicable
signatures, may result in the form being found insufficient.
If
you are using an interpreter during the examination (either in
person or by phone), you must ask the interpreter the following
questions and affirm their response:
Do
you certify that you are fluent in English and the following
language, [Fillable field]?
Do you further certify that you will
accurately and completely interpret all communications between the
applicant [Fillable field] and me (the medical professional)?
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[Page 1]
START HERE - Type or print in
black ink.
Please read the instructions
before examining the applicant and filling out this form.
In general,
applicants for naturalization must demonstrate that they
understand the English language, including the ability to read,
write, and speak words in ordinary usage. They must also
demonstrate knowledge and understanding of the fundamentals of the
history, principles, and form of government of the United States.
These are called the “English and civics requirements.”
This form is used for applicants to seek an exception to the
English and civics requirements due to a physical or developmental
disability or mental impairment that has lasted, or is expected to
last, 12 months or more. Applicants seeking such an exception
should submit this form as an attachment to the Form N-400,
Application for Naturalization.
Please note:
Only
medical doctors, doctors of osteopathy, or clinical psychologists
can
certify the form.
Additionally,
they must be licensed
to practice in the United States (including the U.S. territories
of the Commonwealth of the Northern Mariana Islands,
Guam, Puerto
Rico, and the Virgin Islands)
to
certify the form.
While
staff of the medical practice associated with the certifying
medical
professional certifying the form may assist in its completion,
the certifying
medical
professional is responsible for the accuracy of the form's
content
and therefore must sign it.
Answer
all the questions regarding medical information, using common
terminology that a person without medical training can
understand, with no abbreviations. Failure
to
fully and accurately complete this form, including all applicable
signatures, may result in the form being found insufficient.
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Page 2-7,
Part 3. Information
About Disabilities and/or Impairments
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[Page 2]
Part
3. Information About Disabilities and/or Impairments
1.
Provide the
clinical diagnosis of all
physical or developmental disabilities and/or mental impairments
that may affect the applicant’s ability to demonstrate an
understanding of the English language and/or a knowledge and
understanding of the fundamentals of the history and the
principles and form of government of the United States. If
applicable, please provide the relevant medical code as accepted
by the Department of Health and Human Services (HHS). This
includes the Diagnostic and Statistical Manual of Mental Disorders
(DSM) and the International Classification of Diseases (ICD). For
example, “DSM-V
318.1 Intellectual Disability (Severe)”
or “2015/16
ICD-10-CM F72 Severe intellectual disabilities.”
[Fillable
box with lines]
[Page
3]
2.
Provide a basic
description of all the disabilities and/or impairments listed in
Part 3,
Item 1.
For example, “Intellectual Disability (Severe) is a genetic
disorder that causes lifelong intellectual disability,
developmental delays, and other problems.”
[Fillable
box with lines]
3.
When did each disability or impairment listed in
Part 3, Item
1, begin?
Date
(mm/dd/yyyy) If you
need extra space to complete this section, use the space provided
in below.
[Fillable
box with lines]
4.
Date(s) of Diagnosis (mm/dd/yyyy) If
you need extra space to complete this section, use the space
provided below.
[Fillable
box with lines]
5.
What caused each of this applicant’s medical disabilities
and/or impairments listed in Part
3., Item
Number 1., if
known?
[Fillable
box with lines]
[Page
4]
6.
What clinical methods did you use to diagnose each of the
applicant’s medical disabilities and/or impairment(s) listed
in Part 3.,
Item Number 1.?
[Fillable
box with lines]
7.
Describe the severity
of each disability and/or impairment listed in Part
3, Item
1. Explain the
basis of your assessment, i.e. known symptoms of condition, tests
conducted, observations, etc.
[Fillable
box with lines]
8.
Describe how each relevant disability and/or impairment affects
specific functions of the applicant’s daily life, including
the ability to work or go to school, that may be related to the
ability to learn civics and/or English, including the ability to
read, write and speak words in ordinary usage of the English
language. Explain the basis of your assessment, including known
symptoms of condition, tests conducted, observations, etc.
[Fillable
box with lines]
9.
Have any of the
applicant’s disabilities and/or impairments lasted, or do
you expect any of them to last, 12 months or more?
Yes
No
[Page
5]
10.
Provide an explanation as to which disabilities or impairments are
expected to last over 12 months and why.
NOTE:
If you answered “No,” the applicant is not eligible
for this exception and you need to go directly to Part
6. Medical Professional’s Certification.
11.
Are any of the
disabilities and/or impairment(s) the result of the applicant’s
illegal use of drugs?
Yes
No
12.
If yes, provide an explanation as to which disabilities or
impairments are the result of the applicant’s illegal use of
drugs.
[Fillable
box with lines]
NOTE:
If you answered “Yes” and all of the applicant’s
disabilities and/or impairments are the result of the applicant’s
illegal use of drugs, the applicant is not eligible for this
exception and you need to go directly to Part
6. Medical
Professional’s Certification.
13.
Clearly describe
how each of the applicant’s disabilities and/or impairments
affects his or her ability to demonstrate knowledge and
understanding of English and/or civics.
[Fillable
box with lines]
[new]
14.
In your
professional medical opinion, do any of the applicant’s
disabilities or impairments prevent him or her from demonstrating
the following requirements?
(Select all that
apply. If none applies, the applicant is not eligible for this
exception.)
The
ability to:
Read
English
Write
English
Speak
English
Answer
questions regarding United States history and civics, even in a
language the applicant understands.
[new]
15.
Date and location
you first examined the applicant regarding the condition(s) listed
in Part 3.,
Item Number 1.
A.
Date (mm/dd/yyyy)
[Page
6]
B.
Location (if different from business address provided in Part
2., otherwise
select “same as business address”)
[]
Same as business address
Street
Number and Name
Apt./Ste./Flr./Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
16.
Date and location
you last examined the applicant regarding the conditions listed in
Part 3.,
Item Number 1.,
if different from above.
A.
Date (mm/dd/yyyy)
B.
Location (if different from business address provided in Part
2., otherwise
select “same as business address”)
[]
Same as business address
Street
Number and Name
Apt./Ste./Flr./Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
17.
Are you the
medical professional who regularly treats this applicant for the
conditions listed in Part
3., Item
Number 1.?
Yes
No
18.
If you answered “Yes,” indicate the duration of
treatment and skip Items
20. -22.
Years
Months
Yearly
19.
Please indicate the frequency of treatment.
Weekly
Monthly
Yearly
Other:
(text box)
20.
Name of Regularly
Treating Medical Professional
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name (if applicable)
21.
Business Address and Phone Number of Regularly Treating Medical
Professional
Street
Number and Name
Apt./Ste./Flr./Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page
7]
22.
Explanation for
why you are certifying this form instead of the regularly treating
medical professional.
[Fillable
box with lines]
23.
Did you use an
interpreter when you examined the applicant?
Yes
No
NOTE:
If you answered
“Yes,” the interpreter must complete Part
4. Interpreter’s Certification.
If you used a telephonic interpreter, please complete all Items
in Part 4.
except
Item Numbers 6.
and 7.
Additional
Comments (Optional)
[Fillable box with lines]
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[Page 2]
Part
3. Information About Disabilities and/or Impairments
1. Provide the clinical
diagnosis and medical code for all
physical or developmental disabilities and/or mental impairments
that affect the applicant’s
ability to meet the English and/or civics
requirements. Also, clearly describe how each disability and/or
impairment prevents the applicant from learning English and/or
civics. Responses should use common terminology, without
abbreviations, that a person without medical training can
understand. Refer to page 2 of the Instructions for an example.
Please provide the relevant medical code as accepted by the
U.S. Department of Health and Human
Services (HHS). This includes the Diagnostic and Statistical
Manual of Mental Disorders (DSM) and the International
Classification of Diseases (ICD). For example, “DSM-V 318.1
Intellectual Disability (Severe)” or “2022
ICD-10-CM F72 Severe intellectual disabilities.”
[Fillable
box with lines]
[deleted]
[Page
4]
2.
What clinical
or
laboratory diagnostic techniques did
you use to diagnose each of the applicant’s
disabilities and/or
impairment(s) listed in Part
3., Item
Number 1.?
[Fillable
box with lines]
[deleted]
3.
Have any of
the applicant’s disabilities and/or impairments
listed in Part
3.,
Item
Number 1. lasted,
or do you expect any of them to last, 12 months or more?
If your answer is “No,” do not complete this form
because the applicant is not eligible for this exception.
Yes
No
[deleted]
4.
Are
any of the disabilities and/or impairment(s) listed
in Part
3.,
Item
Number 1. the
result of the applicant’s illegal use of drugs?
If your answer is “Yes” for all of the disabilities
or impairments, do not complete this Form because the applicant is
not eligible for this exception.
Yes
No
5.
If yes, for
some disabilities or impairments, identify which
disabilities or impairments are the result of the applicant’s
illegal use of drugs.
[Fillable
box with lines]
[deleted]
6.
For
disabilities and/or impairments listed in Part
3.,
Item Number 1.,
provide
the date you last examined the applicant.
Date
(mm/dd/yyyy)
7.
Do
any of the
disabilities or
impairments
listed in Part
3.,
Item
Number 1. prevent
the applicant from
demonstrating the
following?
Select
all that
apply. If none applies,
do not complete this Form
because the
applicant is not
eligible for this exception.
The
ability to:
[]
Read English
[]
Write English
[]
Speak English
[]
Answer questions regarding
United States
history and civics, even in a language the applicant understands.
8.
Is
this applicant unable to understand or communicate that they
understand the meaning of the Oath of Allegiance to the United
States, because of the disabilities or impairments listed in Part
3.,
Item
Number 1.
even
in a language the applicant understands?
Yes
No
[deleted]
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Page 7-8,
Part 4. Interpreter’s
Certification
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[Page 7]
Part
4. Interpreter’s Certification
The
interpreter must complete and certify the section below if an
interpreter interpreted communications between the applicant and
medical professional on the day of the examination that formed the
basis of this Form N-648.
[new]
1.
Interpreter’s Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name (if applicable)
2.
Interpreter’s
Mailing Address
Street
Number and Name
Apt./Ste./Flr./Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Interpreter’s
Contact Information
3.
Interpreter’s Daytime Telephone Number
4.
Interpreter’s Mobile Telephone Number (if any)
5.
Interpreter’s Email Address (if any)
[Page
8]
Interpreter’s
Certification
6.
I certify that I
am fluent in English and the following language, [fillable field].
I further certify that I have accurately and completely
interpreted all communications between the medical professional
and the applicant that occurred on [fillable field], the dates of
the examinations that form the basis of this certification.
7.
Interpreter’s Signature
Date
of Signature
(mm/dd/yyyy)
Certification
for Telephonic Interpreter (to be completed by the medical
professional)
8.
Was a telephonic
interpreter used during the examination of the applicant?
Yes
(go to question 9.)
No
9.
If you answered yes, did you ask the interpreter to affirm that he
or she speaks fluent English and the applicant’s language
and that he or she will accurately and completely interpret all
communications between you and the applicant?
Yes
No
10.
If yes, did the interpreter answer in the affirmative?
Yes
No
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[Page 4]
Part
5.
Interpreter Information and
Certification
[deleted]
If
in-person interpretation services were used during the medical
examination, the interpreter must fill out this section, sign, and
date the certification. If telephonic interpretation services were
used during the medical examination, the certifying medical
professional must complete all items in this section, except Item
Number 6.
1.
Was
a telephonic or video facilitated interpreter used during the
examination of the applicant?
Yes
No
2.
Interpreter’s
Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name (if
applicable)
[deleted]
Interpreter’s
Contact Information
3.
Interpreter’s
Daytime Telephone Number
4.
Interpreter’s
Mobile Telephone Number (if any)
5.
Interpreter’s Email Address (if any)
Interpreter’s
Certification
I
certify that I am fluent in English and the following language,
[fillable field]. I further certify that I have accurately and
completely interpreted all communications between the certifying
medical
professional and the applicant that occurred on [fillable field],
the date(s)
of the examination(s)
that form the basis of this certification.
6.
Interpreter’s
Signature (not
required for telephonic interpretations)
Date
of Signature (mm/dd/yyyy)
[deleted]
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Page 8,
Part 5. Applicant’s
(Patient’s) Attestation/Release of Information
|
[Page 8]
Part
5. Applicant’s (Patient’s) Attestation/Release of
Information
1.
I, [fillable field] (Applicant’s Name), authorize [fillable
field] (Licensed medical doctor, doctor of osteopathy, or clinical
psychologist) to
release to U.S. Citizenship and Immigration Services all relevant
physical and mental health information related to my medical
status for the purpose of applying for an exception from the
English language and U.S. civics requirements for naturalization.
I certify under penalty of perjury, pursuant to 28 U.S.C. section
1746, that the information I provided to the medical professional
is true and correct. I certify under penalty of perjury, pursuant
to 28 U.S.C. section 1746, that I have attended an appointment
with [fillable field] (Licensed
medical doctor, doctor of osteopathy, or clinical psychologist)
and was then diagnosed by him or her. I am aware that the
knowing placement of false information on Form N-648 and related
documents may also subject me to civil penalties under 8 U.S.C.
section 1324c and INA section 274C. I understand that if this
form is not completely filled out or if I fail to submit any
required documentation, I may be found ineligible for the
requested disability exception.
2.
Applicant or Applicant’s Authorized Representative’s
Signature
Date of Signature (mm/dd/yyyy)
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[Page 4]
Part
6.
Applicant’s
(Patient’s) Attestation/Release of Information
1.
I, [fillable field] (Applicant’s Name), authorize [fillable
field] (the
Licensed medical
doctor, doctor of osteopathy, or clinical psychologist
completing this form) to
release to U.S. Citizenship and Immigration Services (USCIS)
all relevant
physical and mental health information related to my medical
status for the purpose of applying for an exception from the
English language and U.S. civics requirements for naturalization.
I certify under penalty of perjury, pursuant to 28 U.S.C. section
1746, that the information I provided to the certifying
medical
professional is true and correct. I certify under penalty of
perjury, pursuant to 28 U.S.C. section 1746, that I have attended
an appointment with [fillable field] (Licensed medical doctor,
doctor of osteopathy, or clinical psychologist) and was then
diagnosed by him or her. I am aware that the knowing placement
of false information on Form N-648 and related documents may also
subject me to civil penalties under 8 U.S.C. section 1324c and INA
section 274C. I understand that if this form is not completely
filled out or if I fail to submit any required documentation, I
may be found ineligible for the requested medical
disability
exception.
2.
Applicant
Signature (or mark if applicant is unable to sign)
Date
of Signature (mm/dd/yyyy)
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Page 8-9,
Part 6. Medical
Professional’s Certification
|
[Page 8]
Part
6. Medical Professional’s Certification
Complete
the following if you did not use an interpreter to communicate
with the applicant during the examinations that form the basis of
this Form N-648.
1.
I did not use an interpreter during my examinations of this
applicant because:
I
am fluent in English and [fillable field], the language spoken by
this applicant
This
applicant speaks English.
[Page
9]
All
medical professionals must
complete the certification below.
[new]
2.
I certify that this
applicant’s identity has been verified through the following
United States or State
government-issued
photographic identity document:
Permanent
Resident Card:
State
ID Number:
Other
Identification (Indicate type and ID Number):
I
certify, under penalty of perjury under the laws of the United
States of America, that the information on this form and any
evidence submitted with it are all true and correct. I will
furnish relevant medical records to USCIS, if requested to do so
by USCIS, based on the applicant’s consent. I am aware that
the knowing placement of false information on Form N-648 and
related documents may also subject me to criminal penalties
including under 18 U.S.C. section 1546, civil penalties under 8
U.S.C. section 1324c and Immigration and Nationality Act (INA)
section 274C, and civil license suspension or revocation by the
appropriate authorities.
3.
Licensed Medical Professional Signature
Date of Signature (mm/dd/yyyy)
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[Page 5]
Part
7.
Medical
Professional’s Certification
[deleted]
I
certify that:
1.
I have
examined
the applicant/patient listed in Part 1.
above.
2.
I will furnish relevant medical records to USCIS, if requested to
do so by USCIS, based on the applicant’s consent
in Part 6.
3.
This
applicant’s identity has been verified through the following
United States or State
government-issued
photographic identity document:
Permanent
Resident Card:
State
ID Number:
Other
Identification (Indicate type and ID Number):
Additionally,
I certify, under
penalty of perjury under the laws of the United States of America,
that the information on this form and any evidence submitted with
it are all true and correct.
I am aware that
the knowing placement of false information on Form N-648 and
related documents may also subject me to criminal penalties
including under 18 U.S.C. section 1546, civil penalties under 8
U.S.C. section 1324c and Immigration and Nationality Act (INA)
section 274C, and civil license suspension or revocation by the
appropriate authorities.
4.
Certifying
Medical
Professional Signature
Date
of Signature (mm/dd/yyyy)
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