Fillable I-693, Report of Medical Examination and Vaccination Record (ILW.COM)

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I-693, Report of Medical Examination and Vaccination Record (ILW.COM)

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  • 52 check-boxes
  • 175 other fields

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Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0033; Expires 08/31/09
Part 1. Information about you (The person requesting a medical examination or vaccinations must complete this part)
Date of Birth (mm/dd/yyyy)
START HERE - Please type or print in CAPITAL letters (Use black ink)
Place of Birth (City/Town/Village)
I-693, Report of Medical
Examination and Vaccination Record
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.
A-number (if any)
U.S. Social Security # (if any)
Gender:
Signature - Do not sign or date this form until instructed to do so by the civil surgeon
Date (mm/dd/yyyy)
Country of Birth
Phone #
( Include Area Code) no dashes or ()
Family Name (Last Name)
Given Name (First Name)
Full Middle Name
Home Address: Street Number and Name
Apt. Number
City
State
Zip Code
No Class A or Class B Condition
Part 2. Medical examination (The civil surgeon completes this part)
1. Examination
Date of First
Examination
Date(s) of Follow-up Examination(s) if Required:
Date of Exam
Date of Exam
Date of Exam
Summary of Overall Findings:
2.
Communicable Diseases of Public Health Significance
A. Tuberculosis (TB)
Date TST Applied Date TST Read Size of Reaction (mm)
Date Chest X-Ray
Taken
Date Chest X-Ray
Read
Class A Conditions (see 2 through 5 below) Class B Conditions (see 2 through 6 below)
Normal
Results
Abnormal (Describe results in remarks.)
Tuberculin Skin Test (TST) (Required for applicants 2 years of age and older: for children under 2 years of age, see pp. 11-12 of
Technical Instructions at http://www.cdc.gov/ncidod/dq/civil.htm.)
Chest X-Ray - Required ONLY for TST reactions of > 5mm or if specific TST exception criteria met, or for an applicant with TB
symptoms or immunosuppression (e.g., HIV). Attach copy of X-Ray Report.
Form I-693 (Rev. 06/05/08)N
Findings:
No Class A or Class B TB
Class A Pulmonary TB Disease
Class B1 Pulmonary TB
Class B1 Extra Pulmonary TB
Class B2 Pulmonary TB
Class B, Latent TB Infection
Class B, Other Chest
Condition (non-TB)
Remarks: (Include any signs or symptoms of TB, additional tests, and therapy given, with stop and start dates and any changes.)
Male
Female
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signature
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Part 2. Medical Examination (Continued)
B. Syphilis
Form I-693 (Rev. 06/05/08)N Page 2
Date Screening Run
Screening Nonreactive
Screening Reactive, Titer 1:
If Reactive, Date Confirmation Run
Confirmation Nonreactive
Confirmation Reactive
Findings:
No Class A or Class B
Syphilis
Syphilis, Class B (with residual
deficit, treated in the past year)
Syphilis, Class A
(untreated)
HIV/AIDSC.
Serologic Test for HIV Antibody (Required for applicants 15 years and older)
Date Screening Run
Screening Negative
Screening Positive
Findings:
No Class A HIV HIV, Class A
Confirmation Negative
Confirmation Positive
If Positive or Indeterminate,
Date Confirmation Run
Other Class A/Class B Conditions for Communicable Diseases of Public Health SignificanceD.
Findings:
3. Physical or Mental Disorders With Associated Harmful Behavior
Physical/Mental Disorder, With Associated Harmful Behavior, Class A
Remarks: (Include any therapy given with doses and dates.)
Remarks: (Include any signs or symptoms of HIV infection, therapy given, and any counseling, or referrals.)
Remarks: (Include any therapy given and any counseling, or referrals.)
Remarks: (Include diagnosis, with likelihood of harmful behavior to recur, therapy given, and any counseling, or referrals.)
4.
Drug Abuse/Drug Addiction
Substance (Drug) Use, Listed in Section 202 of Controlled Substance Act, Class A
Substance (Drug) Use, Not Listed in Section 202 of Controlled Substance Act, But With Associated Harmful Behavior, Class A
Remarks: (Include any therapy given, rehabilitation, counseling, or referrals.)
Prior Substance (Drug) Use in Remission, Class B
Chancroid, Class A
Lymphogranuloma Venereum, Class A
Granuloma Inguinale, Class A
Gonorrhea, Class A
Physical/Mental Disorder, Without Associated Harmful Behavior, Class B
Hansen's Disease (Leprosy, Noninfectious), Class B
Hansen's Disease (Leprosy, Infectious), Class A
Serologic Test for Syphilis (Required for applicants 15 years and older)
Screening Indeterminate
Part 2. Medical examination (Continued)
5. Vaccinations (See Technical Instructions at http://www.cdc.gov/ncidod/dq/civil.htm for list of required vaccines.)
Form I-693 (Rev. 06/05/08)N Page 3
Applicant may be eligible for blanket waiver(s) as indicated above.
Applicant will request an individual waiver based on religious or moral convictions.
Applicant does not meet immunization requirements.
Vaccine history complete for each vaccine, all requirements met.
Results:
Give Copy to Applicant
Vaccine History Transferred From a Written Record
Waiver(s) to Be Requested From USCIS
Completed Series
Vaccine Given
Mark an X if
completed; write
date of lab test if
immune or "VH"
if varicella history
Date Given
by Civil
Surgeon
mm/dd/yyyy
Date
Received
mm/dd/yyyy
Date
Received
mm/dd/yyyy
Date
Received
mm/dd/yyyy
Vaccine
Blanket
Not Medically Appropriate
Not Flu
Season
Insufficient
Time Interval
Contra-
indication
Not Age
Appropriate
Hib
Hepatitis B
Varicella
Pneumococcal
Influenza
MMR (Measles
Mumps-Rubella) or if
monovalent or other
combination of the
vaccines are given,
specify vaccine(s):
Specify
Vaccine:
DT
DTP
DTaP
Specify
Vaccine:
Td
Tdap
OPV
IPV
Specify
Vaccine:
Rotavirus
Hepatitis A
Human Papillomavirus
Zoster
Meningococcal
A-number (if any)
Name (Type or print your name)
Part 3. Referral to health department or other doctor/facility (To be completed by Civil Surgeon, if referral was made)
Remarks: (Include name of medical condition and reasons for referral.)
Type or Print Name of Doctor or Health Department
Date of Referral (mm/dd/yyyy)
Address: (Street Number and Name, City, State and Zip Code)
Daytime Phone # (Include Area Code) no dashes or ( )
Part 4. To Be Completed by Physician or Health Department Performing Referral Evaluation
Type or Print Full Name of Evaluating Physician or Health Department
Signature
Address: (Street Number and Name, City, State and Zip Code)
The applicant identified on this form was referred to me by the civil surgeon named in Part 5 of this form. I have provided appropriate
evaluation/treatment.
Remarks: (Attach a separate sheet of paper, if needed.)
Name of Medical Practice or Health Department
Daytime Phone # (Include Area Code) no dashes or ( )
Date (mm/dd/yyyy)
Form I-693 (Rev. 06/05/08)N Page 4
Part 2. Medical examination (Continued)
6. List other medical conditions, Class B other (e.g. hypertension, diabetes)
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signature
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Part 6. Health department identifying information. (If completed by State or local health department on behalf of a
refugee, place a stamp or seal where indicated.)
Type or Print Name
Date (mm/dd/yyyy)
Signature
Daytime Phone # (Include Area Code) no dashes or ( )
(Place State or local health
department stamp/seal below.)
Form I-693 (Rev. 06/05/08)N Page 5
Part 5. 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 in current status designated to examine applicants
seeking certain immigration benefits in the United States; I have a currently valid and unrestricted license to practice medicine in the
state where I am performing medical examinations; 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 person whom I examined is 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 provided to me; and that all information provided by me on this form is true and correct to the
best of my information, knowledge, and belief.
Name of Medical Practice or Health Department
E-Mail Address
Type or Print Full Name (First, Middle, Last)
Signature
Address (Street Number and Name, City, State and Zip Code)
Date (mm/dd/yyyy)
Daytime Phone # (Include Area Code) no dashes or ( )
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I-693, Report of Medical Examination and Vaccination Record (ILW.COM)

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Completed 9 January 2021

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