Form I-693 - Report Of Medical Examination And Vaccination Record Page 7
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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 (continued)
(5)
Remarks: (Include any signs or symptoms of TB, additional tests and therapy given, with start and stop dates and any
changes. If you did not perform TST or IGRA, give the reason why an exception applies.)
B.
Syphilis
(1)
Serologic Test for Syphilis (Required for applicants 15 years of age and older)
(a)
Name of Screening Test
(b)
Date Screening Run (mm/dd/yyyy)
(c)
Screening Nonreactive (mm/dd/yyyy)
Screening Reactive, Titer 1:
(d)
If Reactive, Name of Confirmatory Test
(e) Date Confirmation Run (mm/dd/yyyy)
(f)
Confirmation Nonreactive
Confirmation Reactive
(2)
Findings:
No Class A or Class B Syphilis
Syphilis, Class A (untreated)
Syphilis, Class B (treated in the last year)
(3)
Remarks: (Include any therapy given with doses and dates)
Drug:
Dosage:
Start Date (mm/dd/yyyy)
End Date (mm/dd/yyyy)
C.
Gonorrhea
(1) Laboratory Test for Gonorrhea (Required for applicants 15 years of age and older)
(a)
Screening Test Name
(b)
Date Specimen Reported (mm/dd/yyyy)
(c)
Positive
Negative
Form I-693 10/19/17 N
Page 7 of 13
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