Supplement 1,
Applicants With a Class A Tuberculosis Condition
(As Defined by Health and Human Services Regulations)
USCIS
Form I-690
Department of Homeland Security
OMB No. 1615-0032
U.S. Citizenship and Immigration Services
Expires 12/31/2018
Applicant's Name
Given Name (First Name)
Middle Name (if applicable)
Family Name (Last Name)
Alien Registration Number (A-Number) (if any)
USCIS Online Account Number (if any)
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A-
Section A. Applicant's Sponsor in the United States
1.
Make arrangements for the applicant's medical care and have the attending physician or facility complete Section C.
2.
Obtain the necessary endorsements.
A.
Treatment is being provided by a local health department. If a local health department will provide the necessary care
and/or treatment to the applicant, that facility should select Item A. in Item Number 4. under Section C.
B.
Treatment is being provided by a private physician or by any other private or public facility. If a private physician, a
private medical facility or a public medical facility (other than a local health department) will provide the applicant's medical
care and/or treatment, that facility should select block (B.) or (C.) in Item Number 4. of Section C., as applicable.
C.
Endorsement of State Health Department Official.
3.
Physical Address in the United States where the applicant plans to reside:
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Section B. Applicant's Statement
Upon admission to the United States, I will:
1.
Go directly to the physician or health facility named in Item Number 6. of Section C.;
2.
Present copies of diagnostic tests used during my visa examination to verify my diagnosis;
3.
Attend counseling and examinations, treatment and medical regimen as required; and
4.
Remain under prescribed treatment or observation, regardless of whether I am on an inpatient or an outpatient basis, until I
am discharged.
5.
Applicant's Signature
Date of Signature (mm/dd/yyyy)
Form I-690 Supplement 1 12/23/16 N
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