Applicants With a Class A Tuberculosis Condition (As Defined by HHS Regulations)

Supplement 1,
Applicants With a Class A Tuberculosis Condition
(As Defined by Health and Human Services Regulations)

USCIS
Form I-690

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

OMB No. 1615-0032
Expires 12/31/2023

DRAFT
NOT FOR
PRODUCTION
07/12/2022

Part 1. Applicant's Information
1.

Family Name (Last Name)

2.

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

Given Name (First Name)

3.

Middle Name (if applicable)

USCIS Online Account Number (if any)
►

Part 2. Responsibilities of Applicant's Sponsor in the United States

The responsibilities of the applicant's sponsor in the United States are to make arrangements for the applicant's medical care, have the
attending physician or facility complete Part 4., and to obtain the necessary endorsements: endorsement of a local health department
if providing treatment, endorsement of a private physician or other private or public facility if providing treatment, and endorsement
of a State Health Department Official.
If a local health department will provide the necessary care and/or treatment to the applicant, that facility should select the appropriate
checkbox in Part 4., Item A. in Item Number 1.
If a private physician, private medical facility, or public medical facility (other than a local health department) will provide the
applicant's medical care and/or treatment, that facility should select the appropriate checkbox in Part 4., Item Number 1.
If a State Health Department Official will provide the necessary care and/or treatment, that facility should complete Part 5.
1.

Provide the physical address in the United States where the applicant plans to reside.

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Part 3. Applicant's Statement
Upon admission to the United States, I will:
Go directly to the physician named in Part 4., Item Number 2. or health facility named in Part 4., Item Number 3.; present copies
of diagnostic tests used during my visa examination to verify my diagnosis; attend counseling, examinations, treatment, and medical
regimen as required; and remain under prescribed treatment or observation, regardless of inpatient or outpatient basis, until I am
discharged.
1.

Applicant's Signature

Form I-690 Supplement 1 Edition 12/02/21

Date of Signature (mm/dd/yyyy)

Page 1 of 3

Part 4. Statement by Physician or Health Facility
I agree to supply counseling and any treatment or observation necessary for the proper management and continued care of the
applicant's tuberculosis condition.

DRAFT
NOT FOR
PRODUCTION
07/12/2022

I agree to submit a summary of my initial evaluation of the applicant's condition, indicating presumptive diagnosis, test results, and
plans for the applicant's future care, to:
Division of Global Migration and Quarantine (E03)
Centers for Disease Control and Prevention
1600 Clifton Road
Atlanta, Georgia 30329-4027

I will submit the summary referenced above within 30 days of the date the applicant is required to appear for evaluation and/or care,
and if at the end of the 30-day period the applicant fails to appear for evaluation and/or care as required, I will submit a report to notify
the Center for Disease Control and Prevention (CDC) and the health official indicated in Part 5. of the applicant's failure to appear.
I agree that satisfactory financial arrangements have been made for the applicant's medical care and treatment. (The applicant must
still submit evidence, as required by the consular officer or U.S. Citizenship and Immigration Services (USCIS), to establish that he or
she is unlikely to become a public charge (another ground of inadmissibility under Immigration and Nationality Act (INA) section
212(a)(4)).
1.

I represent (select only one box):
Local Health Department
Other Public Health Facility
Private Medical Practice

I agree to submit a copy of my evaluation to the health official indicated in Part 5.
2.

Name of Physician

Family Name (Last Name)

3.

Name of Facility

4.

Address of Physician or Facility

5.

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Signature of Physician

Form I-690 Supplement 1 Edition 12/02/21

ZIP Code

Date of Signature (mm/dd/yyyy)

Page 2 of 3

Part 5. Endorsement of State Health Department Official
Your endorsement signifies that you recognize the physician or facility providing the applicant's treatment for tuberculosis. If the
facility physician who signed in Part 4. is not in your health jurisdiction or is not familiar to you, you may wish to contact the health
officer responsible for the jurisdiction, and/or the physician, before you sign this endorsement.

DRAFT
NOT FOR
PRODUCTION
07/12/2022

1.

Official Name of Department

2.

Name of Official Providing Endorsement

3.

Title of Official Providing Endorsement

4.

Signature of State Health Department Official

5.

Address of Health Department

Date of Signature (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-690 Supplement 1 Edition 12/02/21

ZIP Code

Page 3 of 3