Form I-693 - Report Of Medical Examination And Vaccination Record Page 6
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13Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any)
A-
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Part 7. Civil Surgeon Worksheet
(To be completed by the civil surgeon, according to the Technical Instructions at
civil/technical-instructions-civil-surgeons.html)
1.
Communicable Disease of Public Health Significance
A.
Tuberculosis (TB): An initial screening test, either a tuberculin skin test (TST) or an interferon gamma release assay (IGRA),
is required for all applicants 2 years of age and older; for children under 2 years of age, see the Technical Instructions. The civil
surgeon should perform only one type of initial screening test, followed by further evaluation if needed (chest X-ray).
(1) Tuberculin Skin Test:
Not administered (TST exception; please explain in Remarks section below)
Date TST Applied (mm/dd/yyyy)
Date TST Read (mm/dd/yyyy)
Size of Reaction (mm)
Negative (4mm or less of induration)
Positive (> 5mm; chest X-ray required)
Result:
(2)
Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted
on the CDC's website):
Not administered (IGRA exception; please explain in Remarks section below)
Select only one box.
QuantiFERON
T-Spot
Date Blood Sample Drawn (mm/dd/yyyy)
Date Blood Sample Drawn (mm/dd/yyyy)
Result:
Negative (including indeterminate, or borderline/equivocal) (no chest X-ray required)
Positive (chest X-ray required)
Indeterminate, borderline, or equivocal) (no chest X-ray required)
(3)
Initial Screening Test Result and Chest X-Ray Determinations:
Chest X-ray not required (medically cleared for TB for USCIS)
Chest X-ray required due to initial screening test results
Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)
Chest X-ray required due to TST or IGRA exception (Clearly specify the TST or IGRA exception in the Remarks
section below.)
(4)
Chest X-Ray: Required based on TST or IGRA result, or if specific TST or IGRA exceptions apply, or for an applicant
with TB signs or symptoms or immunosuppression (such as HIV).
Date Chest X-Ray Taken (mm/dd/yyyy)
Date Chest X-Ray Read (mm/dd/yyyy)
Result:
Normal
Abnormal (describe results in Remarks section below.)
TB Classification/Findings (Select only if chest X-ray was performed):
No Class A or Class B TB
Class B2 Pulmonary TB
Class A Pulmonary TB Disease
Class B, Other Chest Condition (non-TB)
Class B1 Extra Pulmonary TB
Class B, Latent TB Infection (Answer the following question.)
Class B1 Pulmonary TB
Was applicant referred for treatment (not required to complete Form
I-693)?
Yes
No
Form I-693 10/19/17 N
Page 6 of 13
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