Form I-693 - Report Of Medical Examination And Vaccination Record Page 5
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
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Part 6. Civil Surgeon's Contact Information, Certification, and Signature (continued)
Civil Surgeon's Certification
I certify under penalty of perjury under United States law that:
I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the United States OR a physician who
qualifies under a blanket designation specified by policy or law;
I have a currently valid and unrestricted license to practice medicine in the state where I am performing immigration-related medical
examinations, unless otherwise exempted;
I have not had my license to practice medicine revoked, and I am not subject to any restrictions on any license to practice medicine in
any other jurisdiction in the United States in which I conduct immigration-related medical examinations.
I performed an examination of the person identified in Part 1. of this Form I-693, after having made every reasonable effort to verify
that the person whom I examined is in fact the person identified in Part 1.;
I performed the examination in accordance with the Centers for Disease Control and Prevention's (CDC) Technical Instructions, as
well as all supplemental information or updates; and
All the information I provided on this Form I-693 is complete, true, and correct, based on the information provided to me by the
applicant.
Civil Surgeon's Signature
8.
Civil Surgeon's Signature
Date of Signature
(mm/dd/yyyy)
(Health departments and military treatment facilities MUST place their official stamp or seal here)
(official stamp or seal here)
Form I-693 10/19/17 N
Page 5 of 13
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