I-693 Report of Medical Examination and Vaccination Record

Report of Immigration Medical Examination
and Vaccination Record

USCIS
Form I-693

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0033
Expires 07/31/2025

► START HERE - Type or print in black ink.

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the
civil surgeon.)
1.

2.

Your Full Legal Name (Do not provide a nickname)
Family Name (Last Name)
Given Name (First Name)

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Current Physical Address
In Care Of Name (if any)

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Middle Name (if applicable)

Postal Code

Other Information
A. Gender
Male

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

ZIP Code

Country

C. City/Town/Village of Birth

Female

D. Country of Birth

E.

Alien Registration Number (A-Number) (if any)
►

A-

F. USCIS Online Account Number (if any)
►
4.

Immigration Medical Examination Requirement
A.
I am eligible for completion of the vaccination record portion only, because I previously completed an overseas
immigration medical examination, signed by a panel physician (refugee or derivative asylee adjustment of status
applicants under Immigration and Nationality Act (INA) section 209 and K nonimmigrant visa holders applying for
adjustment of status).
NOTE: If you selected this box for Item A. in Item Number 4., you, the applicant, and the civil surgeon are responsible
for completing Parts 1. - 5., Part 7., and Part 10.

Form I-693 Edition 07/19/22

Page 1 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 2. Applicant's Statement, Contact Information, Certification, and Signature
Applicant's Contact Information
Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

3.

Applicant's Email Address (if any)

2.

Applicant's Mobile Telephone Number (if any)

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Applicant's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 3.,
understood, all of the responses and information contained in, and submitted with, my form, and that all of the responses and the
information are complete, true, and correct. I understand the purpose of this immigration medical examination, and I authorize the
required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or
altered information or documents with regard to my immigration medical examination, I understand that any immigration benefit I
derived from this immigration medical examination may be revoked, that I may be removed from the United States, and that I may be
subject to civil or criminal penalties. Furthermore, I authorize the release of any information from any and all of my records that
USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.
4.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

Part 3. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Form I-693 Edition 07/19/22

4.

Interpreter's Mobile Telephone Number (if any)

Page 2 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 3. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Certification and Signature
I certify, under penalty of perjury, that I am fluent in English and
, and I have
interpreted every question on the application and Instructions and interpreted the applicant's answers to the questions in that language,
and the applicant informed me that they understood every instruction, question, and answer on the application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

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Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature

I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of the responses and information contained in and submitted with the application are complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

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

Part 5. Applicant's Identification Information (To be completed by the civil surgeon)
Please complete the following about the applicant:
1.

Form of Identification Presented by Applicant (for example, passport or driver's license)

2.

Document Identification Number

Form I-693 Edition 07/19/22

Page 3 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 6. Summary of Medical Examination (To be completed by the civil surgeon)
1.

Summary of Overall Findings:
A.

No Class A or Class B Condition

B.

Class B Conditions (See Item Numbers 1. - 4. in Part 8. Civil Surgeon Worksheet)

C.

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

2.

Date of First Examination (Date applicant signed in Part 2.)
(mm/dd/yyyy)

3.

Dates of Follow-up Examinations, if required:

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Date of Examination (mm/dd/yyyy)

Date of Examination (mm/dd/yyyy)

Date of Examination (mm/dd/yyyy)

Part 7. Civil Surgeon's Contact Information, Certification, and Signature
NOTE: Do not sign Form I-693 until all health-related follow-up requirements are met.

Civil Surgeon's Information
1.

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Civil Surgeon Identification Number (CSID) (unless performing the examination under a
health department or military blanket designation)
2.

Name of Medical Practice, Facility, or Health Department

Physical Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Mailing Address
4.

Street Number and Name (PO Box)

Apt. Ste. Flr. Number (if applicable)

City or Town

State

ZIP Code

Contact Information
5.

Daytime Telephone Number

7.

Email Address (if any)

Form I-693 Edition 07/19/22

6.

Mobile Telephone Number (if any)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 7. Civil Surgeon's Contact Information, Certification, and Signature (continued)
Civil Surgeon's Certification
I certify under penalty of perjury under United States law that:
I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the United States OR a physician who
qualifies under a blanket designation specified by policy or law;
I have a currently valid and unrestricted license to practice medicine in the state where I am performing immigration medical
examinations, unless otherwise exempted;

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I have not had my license to practice medicine revoked, and I am not subject to any restrictions on any license to practice medicine in
any other jurisdiction in the United States in which I conduct immigration medical examinations.
I performed an examination of the person identified in Part 1. of this Form I-693, after having made every reasonable effort to verify
that the person whom I examined is in fact the person identified in Part 1.;
I performed the examination in accordance with the Centers for Disease Control and Prevention's (CDC) Technical Instructions for
Civil Surgeons, as well as all supplemental information or updates; and
All the information I provided on this Form I-693 is complete, true, and correct, based on the information provided to me by the
applicant.

Civil Surgeon's Signature
8.

Civil Surgeon's Signature

Date of Signature (mm/dd/yyyy)

(Health departments and military treatment facilities MUST place their official stamp or seal here.)

(official stamp or seal here)

Form I-693 Edition 07/19/22

Page 5 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet
(To be completed by the civil surgeon, according to the Technical Instructions for Civil Surgeons at
https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/tuberculosis.html.)
1.

Communicable Disease of Public Health Significance
A. Tuberculosis (TB): An initial screening test, an interferon gamma release assay (IGRA), is required for all applicants 2 years of
age and older; for children under 2 years of age, see the Technical Instructions for Civil Surgeons. The civil surgeon will
perform further evaluation if needed (chest X-ray).
(1) Interferon Gamma Release Assay (for acceptable IGRAs, consult the Technical Instructions for Civil Surgeons and any
updates posted on the CDC's website):

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Not Administered (IGRA exception; please explain in Remarks section below)

Select only one box.
QuantiFERON

T-Spot

Date Blood Sample Drawn (mm/dd/yyyy)

Date Blood Sample Drawn (mm/dd/yyyy)

Result:

Negative (no chest X-ray required)
Positive (chest X-ray required)

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

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

Chest X-ray required due to initial screening test results.

Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV).

Chest X-ray required due to IGRA exception (Clearly specify the IGRA exception in the Remarks section below.).

Sputum Smears and Cultures Results

(3) Chest X-Ray: Required based on IGRA result, or if specific IGRA exceptions apply, or for an applicant with TB signs
or symptoms or immunosuppression (such as HIV).
Date Chest X-Ray Taken (mm/dd/yyyy)

Result:

Date Chest X-Ray Read (mm/dd/yyyy)

Normal

Abnormal findings suggestive of TB that require smears and cultures:

Form I-693 Edition 07/19/22

Infiltrate or consolidation

Miliary findings

Reticular markings suggestive of fibrosis

Discrete linear opacity

Cavitary lesion

Discrete nodule(s) without calcification

Nodule(s) or mass with poorly defined
margins (such as tuberculoma)

Volume loss or retraction

Pleural effusion

Irregular thick pleural reaction

Hilar/mediastinal adenopathy

Other (further describe in Remarks section below)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
(4) Sputum Smears and Cultures Decision
No, not indicated.
Yes, indicated due to signs or symptoms of TB.
Yes, indicated due to chest X-ray suggestive of TB.

Yes, indicated due to known HIV infection or
extrapulmonary TB.
Yes, indicated for end of treatment cultures.

(5) Sputum Smears and Cultures Results
Sputum Smear Results

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Date Specimen Obtained
(mm/dd/yyyy)

1.
2.
3.

Date Smear Result Reported
(mm/dd/yyyy)

Positive

Negative

Sputum Culture Results

Date Specimen Obtained
(mm/dd/yyyy)

1.
2.
3.

Date Culture Result Reported
(mm/dd/yyyy)

Positive

Negative

NTM

Contaminated

(6) TB Classification/Findings (Select only if chest X-ray was performed.):
No Class A or Class B TB

Class B1 Extrapulmonary TB

Class A Pulmonary TB Disease

Class B2 TB, Latent TB Infection

Class B0 Pulmonary TB

Class B, Other Chest Condition (non-TB)

Class B1 Pulmonary TB

(7) Remarks: (Include any signs or symptoms of TB, additional tests and therapy given, with start and stop dates and any
changes. If you did not perform IGRA, give the reason why an exception applies.)

B. Syphilis
(1) Serologic Test for Syphilis (Required for applicants 18 to 44 years of age - see CDC's Syphilis Technical Instructions
for Civil Surgeons at https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/syphilis.html for current required
testing age range). All tests must be performed on the same blood sample.
(a) Name of Nontreponemal Test
(b) Date Nontreponemal Test Collected (mm/dd/yyyy)
(c)

Nontreponemal Test Nonreactive Date Reported (mm/dd/yyyy)
Screening Reactive, Titer 1:

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
(d) Name of Treponemal Test
(e) Date Treponemal Test Reported (mm/dd/yyyy)
(f)

Terponemal Test Nonreactive

Treponemal Test Reactive

(g) If using reverse algorithm and treponemal test reactive but nontreponemal test nonreactive: Name of Repeat
Treponemal Test (preferably one based on different antigens)

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(h) Date Repeat Treponemal Test Reported (mm/dd/yyyy)
(i)

Repeat Treponemal Test Nonreactive

Repeat Treponemal Test Reactive

(2) Findings:

No Class A or Class B Syphilis

Syphilis, Class A (untreated)

Syphilis, Class B (treated in the last year)

(3) Remarks: (Include stage of syphilis diagnosed [primary, secondary, early latent, late latent or latent of unknown
duration, tertiary, neurosyphilis, congential] and any therapy given with doses and dates of administration.)

Drug:

Dosage:

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

C. Gonorrhea

(1) Laboratory Test for Gonorrhea (Required for applicants 18 to 24 years of age - see CDC's Gonorrhea Technical
Instructions for Civil Surgeons at https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/gonorrhea.html for
current required testing age range.)
(a) Screening Nucleic Acid Amplification Test (NAAT) Name
(b) Date Result Reported (mm/dd/yyyy)
(c)

Positive

Negative

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

Gonorrhea, Class A (untreated)

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

Drug:

Dosage:

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
D. Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance. For instructions, see the
CDC's Technical Instructions for Civil Surgeons for Hansen's Disease at
https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/hansens-disease-leprosy.html.
(1) Findings:
(a)

No Class A/B Condition

(b)

Hansen's Disease (leprosy, any classification) untreated, Class A

(2)

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(3)

Physical/Mental Disorder with a History of Associated Harmful Behavior Likely to Recur, Class A

(4)

Physical/Mental Disorder without Associated Harmful Behavior, Class B

(5)

Physical/Mental Disorder with a History of Associated Harmful Behavior Unlikely to Recur, Class B

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

(c)

Hansen's Disease (leprosy, any classification) treated or partially treated, Class B
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

(2) Remarks: (If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
Include any therapy given and any counseling or referrals.)

2.

Physical or Mental Disorders With Associated Harmful Behavior

Include here any physical or mental disorders with current associated harmful behavior or history of associated harmful behavior
judged likely to recur. This category of physical or mental disorders includes any diagnosis of substance-use 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-use disorder). Diagnose mental disorders according to the diagnostic criteria in the most recent edition of
the Diagnostic and Statistical Manual (DSM) or another authoritative source, as determined by the director of the CDC. Diagnose
physical disorders according to the diagnostic criteria in the most recent edition of the World Health Organization's Manual of the
International Classification of Diseases, Injuries, and Causes of Death (ICD) or another authoritative source as determined by the
director of the CDC. See the CDC's Technical Instructions for Civil Surgeons for Other Physical or Mental Abnormality, Disease
or Disability at https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/other-abnormality-disease-or-disability.html for
more information.
A. Findings:
(1)

No Class A or B Physical or Mental Disorder

Physical/Mental Disorder with Associated Harmful Behavior, Class A

B. Remarks: (Include diagnosis, likelihood of recurrence of the harmful behavior, therapy given, and any counseling or
referrals. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.)

Form I-693 Edition 07/19/22

Page 9 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
3.

Drug Abuse/Drug Addiction
The U.S. Department of Health and Human Services (DHHS) sets the medical guidelines for determining drug abuse and drug
addiction. The terms are defined at 42 CFR 34.2(h) and (i).
Include here any diagnosis of drug abuse or drug addiction.
"Drug abuse or drug addiction" is "current substance use disorder mild, moderate or severe” but only with respect to substances
listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. Make the diagnosis according to the
diagnostic criteria in the most current edition of the DSM, or by another authoritative source as determined by the director of the
CDC.

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You may also make a diagnosis of full remission, according to the diagnostic criteria in the most current edition of the DSM or
another authoritative source as determined by the director of the CDC. See the CDC's Technical Instructions for Civil Surgeons
for Mental Health at https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/mental-health.html for more information.
A. Findings:
(1)
(2)
(3)
(4)

No Class A or B Substance (Drug) Abuse/Addiction

Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A
Substance (Drug) Abuse in Full Remission, listed in section 202 of the Controlled Substances Act, Class B
Substance (Drug) Addiction in Full Remission, listed in section 202 of the Controlled Substances Act, Class B

B. Remarks: (Include any therapy given and any counseling or referrals. If you need extra space to complete this section, use
the space provided in Part 11. Additional Information.)

4.

Other Medical Conditions (List any other Class B conditions, such as hypertension or diabetes, and all required evaluation
components as found in CDC's Technical Instructions for Civil Surgeons at
https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/medical-history-and-physical-exam.html.)

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Page 10 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 8. Civil Surgeon Worksheet (continued)
5.

Required Referral to Health Department or Other Doctor (To be completed by civil surgeon, if a referral is medically required.)
A. Type or Print Name of Doctor or Health Department Receiving Required Referral

B. Address
Street Number and Name

Apt. Ste. Flr. Number

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City or Town

State

ZIP Code

C. Date of Referral (mm/dd/yyyy)

D. Remarks: (Include the name of medical condition and the reasons for referral. If you need extra space to complete this section,
use the space provided in Part 11. Additional Information.)

Part 9. Referral Evaluation (To be completed by the health department or other doctor performing the
referral evaluation.)
The applicant identified on this Form I-693 was referred to me by the civil surgeon named in Part 7. of this Form I-693. I have
provided appropriate evaluation/treatment, having made every reasonable effort to verify that the person whom I have evaluated/
treated is the person identified in Part 1.
1.

Evaluating Physician or Health Department's Full Name
A. Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

B. Health Department 's Name

2.

3.

Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Signature of Health Department Individual or Other Doctor Performing Referral Evaluation
Signature

4.

ZIP Code

Name of Medical Practice or Health Department

Date Signed (mm/dd/yyyy)

5. Daytime Telephone Number

NOTE: If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
Form I-693 Edition 07/19/22

Page 11 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 10. Vaccination Record
NOTE: See Technical Instructions for Civil Surgeons at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civiltechnical-instructions.html for a list of required vaccines, and https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons/
covid-19-technical-instructions.html for COVID-19 specific vaccine guidance.
Please make sure to mark every row. Reserve all comments for the Remarks section below. 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

Specify Vaccine:
Td

Tdap

Specify Vaccine:
OPV

Complete
Series

Blanket Waiver(s) to be
Requested from USCIS (Not
Medically Appropriate)

Mark "X" if
Date Given complete; write date
Insufficient *See
Date
Date
Date
Date
Not Age - Contraby
Time Below
of lab test if immune Appropriate
Received
Received
Received
Received
indication
Civil Surgeon or "VH" if varicella
Interval Table
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
(mm/dd/yyyy)
history

Specify Vaccine:
DT
DTaP
DTP

Vaccine
Given

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Vaccine History Transferred From A Written Record

Text

Text

Text

IPV

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

Text

Hib

Text

Hepatitis B
Varicella
Pneumococcal

Text
Text
Text

Influenza
Rotavirus

Text

Hepatitis A

Text

Meningococcal

Text

COVID-19 (In
“Remarks” section,
write “COVID-19”
and specify vaccine
brand)

NOTE: Give a copy to the applicant.
Form I-693 Edition 07/19/22

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Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)
► A-

Part 10. Vaccination Record (continued)
*For influenza vaccine, check the box in this column only if vaccine is not available in the location where the civil surgeon practices.
The civil surgeon is responsible for knowing local availability of the influenza vaccine.
*For COVID-19 vaccine, check the box in this column only if vaccine is not routinely available in the location where the civil surgeon
practices according to the Technical Instructions for Civil Surgeons blanket waivers for this vaccine.
Results:

FOR USCIS USE ONLY
Applicant completed vaccination requirements or may be eligible for blanket waivers
as indicated above.

Remarks (if any)

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Applicant will request an individual waiver based on religious or moral convictions.
Applicant does not meet immunization requirements.

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

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Part 11. Additional Information
If you (the applicant or the civil surgeon) need extra space to provide any additional information within this form use the space below.
If you (the applicant or civil surgeon) need more space than what is provided, you may make copies of this page to complete and file
with this form or attach a separate sheet of paper. Type or print the applicant's name and A-Number (if any) at the top of each sheet;
indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name (if applicable)

C. Item Number

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A. Page Number

D.

B. Part Number

Given Name (First Name)

A. Page Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

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