Fillable Printable Form I-693

What is a Form I-693 ?

Form I-693, whose full name is Report of Medical Examination and Vaccination Record, is a USCIS form used to report results of a medical examination. The applicant of Form I-693 is one who is seeking immigration benefits. USCIS provides Form I-693 free of charge through the USCIS Web site. Get fillable form I-693 online at Handypdf.com. You can fill, edit, sign, save, print, download form I-693.

Fillable Printable Form I-693

What is a Form I-693 ?

Form I-693

Form I-693 02/07/17 N Page 1 of 13

Report of Medical Examination and Vaccination Record

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-693

OMB No. 1615-0033

Expires 02/28/2019

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)

Family Name (Last Name) Given Name (First Name) Middle Name

Street Number and Name

Physical Address

Other Information

Flr.Ste.Apt. Number

City or Town State ZIP Code

Sex

Male Female

Country of Birth

►

A-

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

Applicant's Statement

B. The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question

in , a language in which I am fluent, and I understood everything.

I can read and understand English, and I have read and understand every question and instruction on this form and my

answer to every question.

NOTE:

Select the box for either Item A. or B. in Item Number 1.

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

Your Full Name

City/Town/Village of Birth

F. USCIS Online Account Number (if any)

►

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form I-693 Instructions before completing this Part. You must submit

Form I-693 in a sealed envelope to USCIS as directed in the Form I-693 Instructions.

Applicant's Statement Regarding the Interpreter

Applicant's Contact Information

2. Applicant's Mobile Telephone Number (if any)3.Applicant's Daytime Telephone Number

Applicant's Email Address (if any)4.

Form I-693 02/07/17 N Page 2 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Applicant's Signature (sign in ink) Date of Signature5.

(mm/dd/yyyy)

Applicant's Signature

Part 2. Applicant's Statement, Contact Information, Certification, and Signature (continued)

Applicant's Certification

I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the

immigration benefit I seek.

I further authorize release of information contained in this form, in supporting documents, and in my USCIS records to other entities

and persons where necessary for the administration and enforcement of U.S. immigration laws.

I certify, under penalty of perjury that I am the person who is identified in Part 1. of this Form I-693, and that the information in

Part 1. of this form is complete, true, and correct. I understand the purpose of this 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 medical examination, I understand that any immigration benefit I derived from

this 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.

I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or

signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:

1) I reviewed and provided or authorized all of the information in my form;

2) I understood all of the information contained in, and submitted with, my form; and

3) All of this information was complete, true, and correct at the time of filing.

NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon.

NOTE TO ALL APPLICANTS AND CIVIL SURGEONS: If you or the civil surgeon do not completely fill out this form

according to the instructions USCIS may deny your immigration benefit.

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

Provide the following information about the interpreter.

Interpreter's Given Name (First Name)Interpreter's Family Name (Last Name)1.

Interpreter's Business or Organization Name (if any)2.

Interpreter's Full Name

Form I-693 02/07/17 N Page 3 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and

in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this form and his or

her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the

form, including the Applicant's Certification, and has verified the accuracy of every answer.

, which is the same language specified in Part 2., Item B.

City or Town State ZIP Code

Postal CodeProvince

Street Number and Name Apt. Flr. NumberSte.

Country

Interpreter's Mailing Address

Part 3. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Contact Information

Interpreter's Mobile Telephone Number (if any)5.Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)6.

Date of SignatureInterpreter's Signature (sign in ink)

Interpreter's Signature

(mm/dd/yyyy)

Parts 4. - 9. of this form must be completed by the civil surgeon.

Part 4. Applicant's Identification Information (To be completed by the civil surgeon)

Please complete the following about the applicant:

Form of identification presented by applicant (for example, passport or driver's license)

Document Identification Number

Form I-693 02/07/17 N Page 4 of 13

Part 5. Summary of Medical Examination (To be completed by the civil surgeon)

Summary of Overall Findings:

Class B Conditions (See Item Numbers 1. - 4. in Part 7. Civil Surgeon Worksheet)

Dates of Follow-up Examinations, if required:

Date of First Examination

Date of Examination Date of Examination Date of Examination

(mm/dd/yyyy)

(mm/dd/yyyy)(mm/dd/yyyy) (mm/dd/yyyy)

Civil Surgeon's Information

Family Name (Last Name)

Name of Medical Practice, Facility, or Health Department

Given Name (First Name) Middle Name (if applicable)1.

Physical Address

3. Street Number and Name Flr.Ste.Apt. Number

City or Town State ZIP Code

No Class A or Class B Condition

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Class A Conditions (See Item Numbers 1. - 3. in Part 7. Civil Surgeon Worksheet)

Part 6. Civil Surgeon's Contact Information, Certification, and Signature

NOTE: Do not sign Form I-693 and do not have the applicant sign in Part 2. until all health-related follow-up requirements are met.

Mailing Address

4. Street Number and Name (PO Box) Flr.Ste.Apt. Number (if applicable)

City or Town State ZIP Code

Mobile Telephone Number (if any)6.

Contact Information

Daytime Telephone Number

Email Address (if any)7.

Form I-693 02/07/17 N Page 5 of 13

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-related medical

examinations, unless otherwise exempted;

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, 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 Certification

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Part 6. Civil Surgeon's Contact Information, Certification, and Signature (continued)

Civil Surgeon's Signature

Date of SignatureCivil Surgeon's Signature (sign in ink)8.

(mm/dd/yyyy)

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

(official stamp or seal here)

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-related medical examinations.

Form I-693 02/07/17 N Page 6 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

T-Spot

(To be completed by the civil surgeon, according to the Technical Instructions at

www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)

Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted

on the CDC's website):

(2)

QuantiFERON

Select only one box.

Negative (including indeterminate, or borderline/equivocal) (no chest X-ray required)

Positive (chest X-ray required)

Result:

Initial Screening Test Result and Chest X-Ray Determinations:

(3)

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 (such as HIV)

Chest X-ray required due to TST or IGRA exception (Clearly specify the TST or IGRA exception in the Remarks

section below.)

Result:

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 (such as HIV).

(4)

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

Normal Abnormal (describe results in Remarks section below.)

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 the Technical Instructions. The civil

surgeon should perform only one type of initial screening test, followed by further evaluation if needed (chest X-ray).

1. Communicable Disease of Public Health Significance

(1) Tuberculin Skin Test:

Not administered (TST exception; please explain in Remarks section below)

Date TST Applied (mm/dd/yyyy) Date TST Read (mm/dd/yyyy) Size of Reaction (mm)

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

Part 7. Civil Surgeon Worksheet

Result:

Negative (4mm or less of induration) Positive (> 5mm; chest X-ray required)

Date Blood Sample Drawn (mm/dd/yyyy)

TB Classification/Findings (Select only if chest X-ray was performed):

No Class A or Class B TB

Class A Pulmonary TB Disease

Was applicant referred for treatment (not required to complete Form

I-693)?

Class B2 Pulmonary TB

Class B, Latent TB Infection (Answer the following question.)

Class B, Other Chest Condition (non-TB)

Yes No

Class B1 Pulmonary TB

Class B1 Extra Pulmonary TB

Indeterminate, borderline, or equivocal) (no chest X-ray required)

Form I-693 02/07/17 N Page 7 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

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 TST or IGRA, give the reason why an exception applies.)

(5)

Syphilis

(e) Date Confirmation Run (mm/dd/yyyy)

Serologic Test for Syphilis (Required for applicants 15 years of age and older)

Date Screening Run (mm/dd/yyyy)

(1)

(b)

(c)

(f) Confirmation Nonreactive

Findings:

Remarks: (Include any therapy given with doses and dates)

(2)

(3)

Confirmation Reactive

No Class A or Class B Syphilis Syphilis, Class A (untreated) Syphilis, Class B (treated in the last year)

Screening Nonreactive (mm/dd/yyyy)

Screening Reactive, Titer 1:

Part 7. Civil Surgeon Worksheet (continued)

Name of Screening Test(a)

If Reactive, Name of Confirmatory Test(d)

Drug: Dosage:

Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)

GonorrheaC.

(1) Laboratory Test for Gonorrhea (Required for applicants 15 years of age and older)

Date Specimen Reported (mm/dd/yyyy)

(b)

Screening Test Name(a)

Positive

Form I-693 02/07/17 N Page 8 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

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 10. Additional Information.

(2)

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-related 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-related 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 more information.

No Class A or B Physical or Mental Disorder

Current Physical/Mental Disorder with Associated Harmful Behavior, Class A

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

Current Physical/Mental Disorder without Associated Harmful Behavior, Class B

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

Physical or Mental Disorders With Associated Harmful Behavior2.

Findings:A.

(1)

(2)

(3)

(4)

(5)

Part 7. Civil Surgeon Worksheet (continued)

Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance

Findings:

No Class A/B Condition

(1)

(a)

(b)

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

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

Hansen's Disease (leprosy, any classification) treated or partially treated,

Class B

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

(c)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

Remarks: (Include any treatment given with doses and dates)(3)

Drug: Dosage:

Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)

Findings:(2)

Gonorrhea, Class B (treated in the last year)

Gonorrhea, Class A (untreated)No Class A or Class B Gonorrhea

Form I-693 02/07/17 N Page 9 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Remarks: (Include any therapy given, rehabilitation, counseling or referrals. If you need extra space to complete this

section, use the space provided in Part 10. Additional Information.

4. Other Medical Conditions (List any other Class B conditions, such as hypertension or diabetes.)

5. Required Referral to Health Department or Other Doctor (To be completed by civil surgeon, if a referral is medically

required. Do not complete if a referral is not required, such as recommended referral for LTBI treatment.)

Type or Print Name of Doctor or Health Department Receiving Required ReferralA.

(1)

(2)

(3)

Substance (Drug) Abuse in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B

(5) Substance (Drug) Addiction in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B

(4)

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

Substance (Drug) Abuse, Listed in section 202 of the Controlled Substances Act, Class A

Substance (Drug) Addiction, Listed in section 202 of the Controlled Substances Act, Class A

Findings:A.

Part 7. Civil Surgeon Worksheet (continued)

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" is "current substance use disorder or substance-induced disorder, mild,” 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.

"Drug addiction" is "current substance use disorder or substance-induced disorder, 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.

Drug Abuse/ Drug Addiction3.

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 more information.

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 10. Additional Information.

Form I-693 02/07/17 N Page 10 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

Daytime Telephone Number

Signature of Health Department Individual or Other Doctor Performing Referral Evaluation

Signature (sign in ink) Date Signed (mm/dd/yyyy)

Name of Medical Practice or Health Department

NOTE: If you need extra space to complete this section, use the space provided in Part 10. Additional Information.

Address

Street Number and Name

Flr.Ste.Apt. Number

City or Town

State ZIP Code

The applicant identified on this Form I-693 was referred to me by the civil surgeon named in Part 6. 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.

Evaluating Physician or Health Department's Full Name

Family Name (Last Name) Given Name (First Name)

Middle Name

Health Department 's Name

Part 8. Referral Evaluation (To be completed by the health department or other doctor performing the

referral evaluation)

Part 7. Civil Surgeon Worksheet (continued)

Address

Street Number and Name Flr.Ste.Apt. Number

City or Town State ZIP Code

Date of Referral (mm/dd/yyyy)

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 10. Additional Information.

Form I-693 02/07/17 N Page 11 of 13

Family Name (Last Name) Given Name (First Name) Middle Name

►

A-

A-Number (if any)

TdapTd

Part 9. Vaccination Record

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 page with Part 1., Part 2., Part 3., Part 4., and Part 6. 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

OPV IPV

Hib

Hepatitis B

Varicella

Pneumococcal

Influenza

Rotavirus

Hepatitis A

Meningococcal

MMR (measles,

mumps-rubella) or

if monovalent or

other combination

of the vaccines are

given, specify

vaccines

DTP

DTaP

Vaccine

Given

Date Given

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)

Vaccine

Date

Received

(mm/dd/yyyy)

Date

Received

(mm/dd/yyyy)

Date

Received

(mm/dd/yyyy)

Date

Received

(mm/dd/yyyy)

Specify Vaccine:

Not Age -

Appropriate

Contra-

indication

Insufficient

Time

Interval

Not

Flu

Season

Text

Specify Vaccine:

NOTE: Give a copy to the applicant.

NOTE: See Technical Instructions at

www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html for list of required vaccines.