Form N-648 - Medical Certification For Disability Exceptions - U.s. Department And Immigration Services Page 2

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Applicant's Name
USCIS A-Number
A-
Part 3. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S)
1. Provide the clinical diagnosis of the applicant's disability and/or impairment, that form the basis for seeking an exception to the English
and/or civics requirements. If applicable, please provide the relevant medical code as accepted by the Department of Health and Human
Services (HHS). This includes the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of
Diseases (ICD). For example, DSM-V 318.1 Intellectual Disability (Severe) or 2015/16 ICD-10-CM F72 Severe intellectual disabilities.
2. Provide a basic description of the disability and/or impairments, for example, Intellectual Disability (Severe) is a genetic disorder that
causes lifelong intellectual disability, developmental delays, and other problems.
3. Date you first examined the applicant regarding the conditions listed in number 1.
Date (mm/dd/yyyy)
Location (if different from business address on Page 1; otherwise type or print "same as business address")
4. Date you last examined the applicant regarding the conditions listed in number 1, if different from above.
Date (mm/dd/yyyy)
Location (if different from business address on Page 1; otherwise type or print "same as business address")
5. Are you the medical professional regularly treating this applicant for the conditions listed in Item Number 1?
Yes (If "Yes," indicate duration of treatment.)
Years
Months
No (If "No," provide the name of the applicant's regularly treating medical professional on the next page and explain why you are certifying
this form instead of the regularly treating medical professional.)
Form N-648 03/21/17 Y Page 2

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