Form I-690 - Supplement 1 - Applicants With A Class A Tuberculosis Condition Page 2
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3Section C. Statement by Physician or Health Facility
1.
I agree to supply counseling and any treatment or observation necessary for the proper management and continued care of the
applicant's tuberculosis condition.
2.
I agree to submit a summary of my initial evaluation of the applicant's condition, indicating presumptive diagnosis, test results,
and plans for the applicant's future care, to:
The Division of Global Migration and Quarantine (E03)
Centers for Disease Control and Prevention
Atlanta, Georgia 30333
A.
I will submit the summary referenced above within 30 days of the date the applicant is required to appear for evaluation
and/or care; and
B.
If at the end of the 30-day period the applicant fails to appear for evaluation and/or care as required, I will submit a report to
notify the Center for Disease Control and Prevention (CDC) and the health official indicated in Section D. of the applicant's
failure to appear.
3.
Satisfactory financial arrangements have been made for the applicant's medical care and treatment. (The applicant must still
submit evidence, as required by the consular officer or USCIS, to establish that he or she is unlikely to become a public charge
(another ground of inadmissibility under Immigration and Nationality Act (INA) section 212(a)(4)).
4.
I represent: (Select the appropriate box and provide the information requested below.)
A.
Local Health Department
B.
Other Public Health Facility
C.
Private Medical Practice
5.
I agree to submit a copy of my evaluation to the health official indicated in Section D.
6.
Name of Physician
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
Name of Facility
7.
Address of Physician or Facility
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
8.
Signature of Physician
Date of Signature (mm/dd/yyyy)
Form I-690 Supplement 1 12/23/16 N
Page 2 of 3
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