Form I-693 - Report Of Medical Examination And Vaccination Record

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Report of Medical Examination and Vaccination Record
USCIS
Form I-693
Department of Homeland Security
OMB No. 1615-0033
U.S. Citizenship and Immigration Services
Expires 02/28/2019
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 Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Physical Address
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
3.
Other Information
A.
B.
C. City/Town/Village of Birth
Sex
Date of Birth (mm/dd/yyyy)
Male
Female
D.
Country of Birth
E.
Alien Registration Number (A-Number) (if any)
A-
F. USCIS Online Account Number (if any)
Part 2. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-693 Instructions before completing this Part. You must submit
Form I-693 in a sealed envelope to USCIS as directed in the Form I-693 Instructions.
Applicant's Statement
Select the box for either Item A. or B. in Item Number 1.
NOTE:
Applicant's Statement Regarding the Interpreter
1.
A.
I can read and understand English, and I have read and understand every question and instruction on this form and my
answer to every question.
B.
The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question
in
, a language in which I am fluent, and I understood everything.
Applicant's Contact Information
2.
Applicant's Daytime Telephone Number
3.
Applicant's Mobile Telephone Number (if any)
4.
Applicant's Email Address (if any)
Form I-693 10/19/17 N
Page 1 of 13

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