Form N-648 - Medical Certification For Disability Exceptions - U.s. Department And Immigration Services

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OMB No. 1615-0060; Expires 03/31/2019
Form N-648, Medical Certification for
Department of Homeland Security
Disability Exceptions
U.S. Citizenship and Immigration Services
ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a
licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must
conduct an in-person examination of the applicant. (See instructions for Form N-648 for additional information which is also located in the
"FORMS" section at )
Reminder About Eligibility Requirements
Completing and Certifying This Form
This form is intended for an applicant who seeks an exception to the
All questions or items must be answered fully and accurately.
English and/or civics requirements due to a physical or
Responses should utilize common terminology, without
developmental disability or mental impairment that has lasted, or is
abbreviations, that a person without medical training can understand.
expected to last, 12 months or more. An applicant who with
U.S. Citizenship and Immigration Services (USCIS) recommends
reasonable accommodations provided under the Rehabilitation Act of
that the certifying medical professional use the electronic Form
1973 can satisfy the English and civics requirements does not need to
N-648 located in the "FORMS" section If the
submit this form. Reasonable accommodations include, but are not
medical professional completes the form by hand, then responses
limited to, sign language interpreters, extended time for testing, and
must be legible and appear in black ink.
off-site testing.
Type or print clearly in black ink.
I certify that I have examined:
This N-648 is:
Last Name
First Name
Middle Name
USCIS A-Number
Address (Street Number and Name)
U.S. Social Security Number
State or Province
Zip Code or Postal Code
Location & Date
Telephone Number
E-Mail Address (if any)
Date of Birth
Type or print clearly in black ink. If you need more space to complete an answer, use a separate sheet of paper. Type or print the applicant's name
and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer
refers. You must sign and date each continuation sheet. You must answer and complete each question since USCIS will not accept an incomplete
Form N-648. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant.
NOTE: Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S. territories
of Guam, Puerto Rico, and the Virgin Islands) are authorized to certify the form. While staff of the medical practice associated with the medical
professional certifying the form may assist in its completion, the medical professional is responsible for the accuracy of the form's content.
Last Name
First Name
Middle Name
Business Address (Street Number and Name)
State or Province
Zip Code or Postal Code
Telephone Number
License Number
Licensing State
E-Mail Address (if any)
1. Currently licensed as a (Check all that apply):
Medical Doctor
Doctor of Osteopathy
Clinical Psychologist
2. Medical practice type:
Form N-648 03/21/17 Y Page 1


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