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Report Of Medical Examination And Vaccination Record I-693 - Official Federal Forms
| Report Of Medical Examination And Vaccination Record Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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Report of Medical Examination and Vaccination Record Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in CAPITAL letters (Use black ink) USCIS Form I-693 OMB No. 1615-0033 Expires 01/31/2015 Part 1. Information About You (To be completed by the person requesting a medical examination, not the civil surgeon) Family Name (Last Name) Home Address: Street Number and Name City Date of Birth (mm/dd/yyyy) Place of Birth (City/Town/Village) State Country of Birth Given Name (First Name) Full Middle Name Apt. Number Zip Code Gender: Male Phone Number Female - ( A- ) A-Number (if any) Applicant's Certification I certify under penalty of perjury under United States law that I am the person who is identified in Part 1 of this Form I-693, Report of Medical Examination and Vaccination Record, and that the information in Part 1 of this form is true to the best of my knowledge. I understand the purpose of this medical exam, 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/altered information or documents with regard to my medical exam, I understand that any immigration benefit I derived from this medical exam may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties. Signature - Do not sign or date this form until instructed to do so by the civil surgeon Date of Signature (mm/dd/yyyy) To be completed by civil surgeon: Form of applicant ID presented (e.g., passport, driver's license) ID Number Part 2. Summary of Medical Examination (To be completed by the civil surgeon) Summary of Overall Findings: Date of First Examination (mm/dd/yyyy) No Class A or Class B Condition Class B Conditions (see Civil Surgeon Worksheet, sections 1-4) Class A Conditions (see Civil Surgeon Worksheet, sections 1-3) Date(s) of Follow-up Examination(s) below if required: Date of Exam (mm/dd/yyyy) Date of Exam (mm/dd/yyyy) Date of Exam (mm/dd/yyyy) Part 3. Civil Surgeon's Certification (Do not sign form or have the applicant sign in Part 1 until all health follow-up requirements have been met) 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 U.S. 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 medical examinations unless otherwise exempted; I performed this 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; that I performed the examination in accordance with the Centers for Disease Control and Prevention's Technical Instructions, and all supplemental information or updates; and that all information provided by me on this form is true and correct to the best of my knowledge, and belief. Type or Print Full Name (First, Middle, Last) Address (Street Number and Name, City, State, and Zip Code) Name of Medical Practice, Facility, or Health Department Daytime Phone Number ( ) Form I-693 01/15/13 Y American LegalNet, Inc. www.FormsWorkFlow.com (Health Departments MUST place their official stamp or seal here) Signature Date Signed (mm/dd/yyyy) E-Mail Page 1 of 5 Family Name (Last Name) Given Name (First Name) Full Middle Name A-Number (if any) CIVIL SURGEON WORKSHEET (To be completed by the civil surgeon, according to the Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html) 1. Communicable Diseases of Public Health Significance A. Tuberculosis (TB): An initial screening test, either a Tuberculin Skin Test (TST) or 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 Technical Instructions. The civil surgeon should perform one type of initial screening test only, followed by further evaluation, if needed (chest X-ray). 1. Tuberculin Skin Test (TST): Not administered (TST exception applies; please explain in Remarks section below) Date TST Applied (mm/dd/yyyy) Date TST Read (mm/dd/yyyy) Size of Reaction (mm) Result: Negative (4mm or less of induration) Positive (> 5mm; chest X-ray required) 2. Interferon Gamma Release Assay (IGRA) (for acceptable IGRAs consult the Technical Instructions and any updates posted on CDC's Web site): Not administered (IGRA exception applies; please explain in Remarks section below) Name of Test Date Blood Sample Drawn (mm/dd/yyyy) IU/ml: Result: Negative (including indeterminate, or borderline/equivocal) (no chest X-ray required) Positive (chest X-ray required) 3. Initial Screening Test Result and Chest X-Ray Determination: Chest X-ray not required (medically cleared for TB for USCIS) Chest X-ray required due to initial screening test results Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (e.g. HIV) Chest X-ray required due to TST or IGRA exception (The civil surgeon must clearly specify the TST or IGRA exception in the Remarks section below.) 4. Chest X-Ray: Required based on TST or IGRA result, or if specific TST or IGRA exceptions apply, or for an applicant with TB signs or symptoms or immunosuppression (e.g., HIV). Date Chest X-Ray Taken (mm/dd/yyyy) Date Chest X-Ray Read (mm/dd/yyyy) Result: Normal Abnormal (describe results in remarks) Class B1 Extra Pulmonary TB Class B2 Pulmonary TB Class B, Latent TB Infection Class B, Other Chest Condition (non-TB) TB Classification/Findings (check only if chest x-ray was performed): No Class A or Class B TB Class A Pulmonary TB Disease Class B1 Pulmonary TB Remarks: (If needed, include any signs or symptoms of TB, additional tests and therapy given, with start and stop dates and any changes. If tests were not administered, give reason why exception applies.) Form I-693 01/15/13 Y American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 Family Name (Last Name) Given Name (First Name) Full Middle Name A-Number (if any) CIVIL SURGEON WORKSHEET (Continued) B. Syphilis Serologic Test for Syphilis (Required for applicants 15 years and older) Screening Nonreactive Date Screening Run (mm/dd/yyyy) Screening Reactive, Titer 1: If Reactive, Date Confirmation Run (mm/dd/yyyy)
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