Report of Immigration Medical Examination and Vaccination Record
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-693
OMB No. 1615-0033
Expires 09/30/2027
► 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. Your Full Legal Name (Do not provide a nickname)
First Name
Middle Initial
Last Name
2. Current Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3. Other Information
A. Sex
Male
Female
B. Date of Birth (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
C. City/Town/Village of Birth
D. Country of Birth
E. Alien Registration Number (A-Number) (if any)
F. USCIS Online Account Number (if any)
4. Immigration Medical Examination Requirement
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 01/20/25
Page 1 of 14
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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
Format: (000) 000-0000.
2. Applicant's Mobile Telephone Number (if any)
Format: (000) 000-0000.
3. Applicant's Email Address (if any)
example@example.com
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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Part 3. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
Interpreter's Name
First Name
Last Name
2. Interpreter's Business or Organization Name
Interpreter's Contact Information
3. Interpreter's Daytime Telephone Number
Format: (000) 000-0000.
4. Interpreter's Mobile Telephone Number (if any)
Format: (000) 000-0000.
5. Interpreter's Email Address (if any)
example@example.com
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Rows
Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-Number (if any)
1
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 [language], 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 he or she understood every instruction, question, and answer on the application.
6. Interpreter's Signature
Date of Signature (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant
Preparer's Full Name
Preparer's Full Name
First Name
Last Name
2. Preparer's Business or Organization Name
Preparer's Contact Information
3. Preparer's Daytime Telephone Number
Format: (000) 000-0000.
4. Preparer's Mobile Telephone Number (if any)
Format: (000) 000-0000.
5. Preparer's Email Address (if any)
example@example.com
Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this application for the applicant at his or her 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 he or she understands the responses and information in or submitted with the application.
6. Preparer's Signature
Date of Signature (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
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Name and A-Number
First Name
Middle Initial
Last Name
A-Number (if any)
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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Examination (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Examination (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Examination (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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)
First Name
Middle Initial
Last Name
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. Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
4. Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Information
5. Daytime Telephone Number
Format: (000) 000-0000.
6. Mobile Telephone Number (if any)
Format: (000) 000-0000.
7. Email Address (if any)
example@example.com
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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;
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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(Health departments and military treatment facilities MUST place their official stamp or seal here.)
(official stamp or seal here)
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Applicant Name
First Name
Middle Initial
Last Name
A-Number (if any)
Part 8. Civil Surgeon Worksheet
(To be completed by the civil surgeon, according to the
Technical Instructions for Civil Surgeons
at
www.cdc.gov/immigrant-refugee-health/hcp/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).
Not Administered (IGRA exception; please explain in Remarks section below)
Select only one box.
QuantiFERON
T-Spot
Date Blood Sample Drawn (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Blood Sample Drawn (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
Date Chest X-Ray Taken (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Chest X-Ray Read (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Normal
Abnormal findings suggestive of TB that require smears and cultures:
Abnormal findings suggestive of TB that require smears and cultures:
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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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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.
Sputum Smear Results
Rows
Date Specimen Obtained (mm/dd/yyyy)
Date Smear Result Reported (mm/dd/yyyy)
Positive
Negative
1.
2.
3.
Sputum Culture Results
Rows
Date Specimen Obtained (mm/dd/yyyy)
Date Culture Result Reported (mm/dd/yyyy)
Positive
Negative
NTM
Contaminated
1.
2.
3.
(6) TB Classification/Findings (Select only if chest X-ray was performed.):
No Class A or Class B TB
Class A Pulmonary TB Disease
Class B0 Pulmonary TB
Class B1 Pulmonary TB
Class B1 Extrapulmonary TB
Class B2 TB, Latent TB Infection
Class B, Other Chest Condition (non-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
www.cdc.gov/immigrant-refugee-health/hcp/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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Nontreponemal Test Nonreactive Date Reported (mm/dd/yyyy)
Screening Reactive, Titer 1:
Other
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
Part 8. Civil Surgeon Worksheet (continued)
(d) Name of Treponemal Test
(e) Date Treponemal Test Reported (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(f)
Treponemal 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)
(h) Date Repeat Treponemal Test Reported (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(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, congenital] and any therapy given with doses and dates of administration.)
Drug:
Dosage:
Start Date (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
www.cdc.gov/immigrant-refugee-health/hcp/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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(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)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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
www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/hansens-disease.html
.
(1) Findings:
(a) No Class A/B Condition
(b) Hansen's Disease (leprosy, any classification) untreated, Class A
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
www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/other-physical-or-mental-abnormality-disease.html
for more information.
A. Findings:
(1) No Class A or B Physical or Mental Disorder
(2) Physical/Mental Disorder with Associated Harmful Behavior, Class A
(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
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.)
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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.
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
www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/mental-health.html
for more information.
A. Findings:
(1) No Class A or B Substance (Drug) Abuse/Addiction
(2) Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A
(3) Substance (Drug) Abuse in Full Remission, listed in section 202 of the Controlled Substances Act, Class B
(4) 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 www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/medical-history-physical-examination.html.)
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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
First Name
Last Name
B. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
C. Date of Referral (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
First Name
Middle Initial
Last Name
B. Health Department 's Name
2. Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Signature of Health Department Individual or Other Doctor Performing Referral Evaluation
Date Signed (mm/dd/yyyy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
4. Name of Medical Practice or Health Department
5. Daytime Telephone Number
Format: (000) 000-0000.
NOTE:
If you need extra space to complete this section, use the space provided in
Part 11. Additional Information.
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
Part 10. Vaccination Record
NOTE:
See
Technical Instructions for Civil Surgeons
at
www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/index.html
for a list of required vaccines, and
www.cdc.gov/immigrant-refugee-health/hcp/civil-surgeons/vaccination.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.
Rows
Date Received (mm/dd/yyyy)
Date Received (mm/dd/yyyy)
Date Received (mm/dd/yyyy)
Date Received (mm/dd/yyyy)
Date Given by Civil Surgeon (mm/dd/yyyy)
Mark "X" if complete; write date of lab test if immune or "VH" if varicella history
Not Age Appropriate
Contra- indication
Insufficient Time Interval
*See Below Table
Specify Vaccine: DT DTaP DTP
Specify Vaccine: Td Tdap
Specify Vaccine: OPV IPV
MMR (measles, mumps, rubella) or, if monovalent or other combination of the vaccines are given, specify vaccines
Hib
Hepatitis B
Varicella
Pneumococcal
Influenza
Rotavirus
Hepatitis A
Meningococcal
COVID-19 (In "Remarks" section, write "COVID-19" and specify vaccine brand)
NOTE: Give a copy to the applicant.
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Name
First Name
Middle Initial
Last Name
A-Number (if any)
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:
Applicant completed vaccination requirements or may be eligible for blanket waivers as indicated above.
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.)
FOR USCIS USE ONLY
Remarks (if any)
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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) / Given Name (First Name) / Middle Name (if applicable)
First Name
Middle Initial
Last Name
2. A-Number (if any)
3. A. Page Number
3. B. Part Number
3. C. Item Number
3. D.
4. A. Page Number
4. B. Part Number
4. C. Item Number
4. D.
5. A. Page Number
5. B. Part Number
5. C. Item Number
5. D.
6. A. Page Number
6. B. Part Number
6. C. Item Number
6. D.
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