Form I-693 - Report Of Medical Examination And Vaccination Record Page 11
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
►
Part 9. Vaccination Record
NOTE: See Technical Instructions at
for list of required vaccines.
Please make sure to mark every row. Reserve all comments for the Remarks section below. NOTE: For purposes of the influenza
vaccine, the flu season is October 1 through March 31. For applicants who only require a vaccination assessment: Submit only
this page with Part 1., Part 2., Part 3., Part 4., and Part 6. of Form I-693. (If you need an interpreter, complete Part 3.
Interpreter's Contact Information, Certification, and Signature.) For more information, see Form I-693 Instructions, Frequently
Asked Questions.
Vaccine History Transferred From A Written Record
Vaccine
Complete
Blanket Waivers to be
Given
Series
Requested from USCIS
(Not Medically Appropriate)
Vaccine
Date Given
Not Age -
Contra-
Not
Date
Date
Date
Date
Mark an X if
Insufficient
by
Appropriate
indication
Flu
Received
Received
Received
Received
complete; write date
Time
Civil Surgeon
Season
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
of lab test if immune
Interval
(mm/dd/yyyy)
or "VH" if varicella
history
Specify Vaccine:
Text
DT
DTaP
DTP
Specify Vaccine:
Text
Td
Tdap
Specify Vaccine:
Text
OPV
IPV
MMR (measles,
mumps-rubella) or
if monovalent or
Text
other combination
of the vaccines are
given, specify
vaccines
Text
Hib
Text
Hepatitis B
Text
Varicella
Text
Pneumococcal
Influenza
Text
Rotavirus
Text
Hepatitis A
Text
Meningococcal
NOTE: Give a copy to the applicant.
Form I-693 10/19/17 N
Page 11 of 13
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