Form I-693 - Report Of Medical Examination And Vaccination Record Page 4
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
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Part 5. Summary of Medical Examination (To be completed by the civil surgeon)
1.
Summary of Overall Findings:
A.
No Class A or Class B Condition
B.
Class B Conditions (See Item Numbers 1. - 4. in Part 7. Civil Surgeon Worksheet)
C.
Class A Conditions (See Item Numbers 1. - 3. in Part 7. Civil Surgeon Worksheet)
2.
Date of First Examination
(mm/dd/yyyy)
3.
Dates of Follow-up Examinations, if required:
Date of Examination
Date of Examination
Date of Examination
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Part 6. Civil Surgeon's Contact Information, Certification, and Signature
NOTE: Do not sign Form I-693 and do not have the applicant sign in Part 2. until all health-related follow-up requirements are met.
Civil Surgeon's Information
1.
Family Name (Last Name)
Given Name (First Name)
Middle Name (if applicable)
2.
Name of Medical Practice, Facility, or Health Department
Physical Address
3.
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
Mailing Address
4.
Street Number and Name (PO Box)
Apt.
Ste.
Flr.
Number (if applicable)
City or Town
State
ZIP Code
Contact Information
5.
6.
Daytime Telephone Number
Mobile Telephone Number (if any)
7.
Email Address (if any)
Form I-693 10/19/17 N
Page 4 of 13
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