Instructions For Report Of Medical Examination And Vaccination Record (Form I-693) (Page 4 of 12) in pdf

Part 2. Applicant’s Statement, Contact Information, Certification, and Signature

Item Numbers 1. - 5. Select the appropriate box to indicate that you either read this form yourself or whether you had

an interpreter assist you. Further, you must sign and date your Form I-693 in front of the civil surgeon, and provide your

daytime telephone number, mobile telephone number (if any), and email address (if any). Every Form I-693 MUST

contain the signature of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place

of a signature is not acceptable.

Note Regarding Applicant’s Signature: The civil surgeon must witness you signing Form I-693. The civil surgeon

will type or print the form of applicant identification document presented, and the identification number from your

identification document.

Part 3. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1. - 7. If you used anyone as an interpreter to read the Instructions and questions on this form to you in a

language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address

of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number

(if any), and his or her email address (if any). The interpreter must sign and date Form I-693.

Civil Surgeon’s Instructions

What Are My Responsibilities as a Designated Civil Surgeon?

1. Truthfully and accurately report the results. You are responsible for reporting the results of the medical

examination and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon’s certification

provided on the form.

You must take reasonable steps to ensure that the person appearing for the medical examination is the same

person applying for the requested immigration benefit. All applicants must present a valid government-issued

photo identification or another form of government-recognized identity documentation. You must note in Part 4.,

Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification presented and identification

number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a

material fact or using any false documents in connection with this medical examination.

You should direct the applicant to complete and sign in Part 2., Item Numbers 1. - 5., in your presence. You should

also ensure that the applicant’s name and A-Number (if any) are at the top of each page of the Form I-693 and match

the information provided in Part 1.

2. Follow U. S. Department of Health and Human Services (HHS) regulations and Centers for Disease Control

and Prevention (CDC) guidelines. As a USCIS-designated civil surgeon, you are required to perform the medical

examination according to HHS regulations. These regulations include the specific guidelines found in the Technical

Instructions for the Medical Examination of Aliens in the United States, published by the CDC. The Technical

Instructions (including periodic updates posted by the CDC) are available at

exams/ti/civil/technical-instructions-civil-surgeons.html.

3. Make referrals and file case reports, as required. According to the CDC’s Technical Instructions, you are required

to:

A. Refer the applicant to the local health department if a chest X-ray suggests TB or other circumstances described

in the CDC’s Technical Instructions.

B. Ensure that any applicant diagnosed with syphilis is treated with the standard treatment regimen described in the

CDC’s Technical Instructions.

Form I-693 Instructions 10/19/17 N

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Instructions For Report Of Medical Examination And Vaccination Record (Form I-693) Page 4