Instructions For Report Of Medical Examination And Vaccination Record (Form I-693) (Page 5 of 12) in pdf

C. Ensure that the applicant is tested for gonorrhea and given therapy, if diagnosed.

D. Refer the applicant to a Hansen’s disease specialist for evaluation to confirm a suspected diagnosis of Hansen’s

disease (leprosy).

E. File a case report with the appropriate public health authorities if a case report is required by local laws or

regulations. You must also advise the applicant that a case report is being filed.

How Do I, as a Civil Surgeon, Fill Out My Portion of This Form I-693?

You, as the civil surgeon, are responsible for ensuring that Form I-693 is completed and signed as follows.

1. Part 4. Applicant’s Identification Information. You are responsible for verifying the identity of the applicant and

noting in Part 4., Applicant’s Identification Information, Item Numbers 1. - 2., the form of identification that the

applicant presents to you and the identification number, if applicable. You are also required to check the top of each

page of Form I-693 to make sure the name and A-Number (if any) are correct. Finally, you must require the applicant

to sign the Applicant’s Certification in Part 2. in your presence. The applicant should not sign Part 2. until the

medical examination is completed and all health-related follow-up requirements, if any, are met.

2. Part 5. Summary of Medical Examination. After the medical examination and any required follow-up, summarize

the results in Part 5.

3. Part 6. Civil Surgeon’s Contact Information, Certification, and Signature. You must sign the certification after

the medical examination is complete. Fill out your identifying information in this part before referring an applicant

for further tests or evaluation. Do not sign and date this part until the referral or follow-up evaluation (if required) is

completed and the applicant is medically cleared. Your signature must be original. Stamped signatures or typewritten

names are not acceptable.

In signing the Form I-693 in this part, you certify under penalty of perjury that you have a valid, unrestricted license

in the jurisdiction in the United States in which you are conducting immigration related medical examinations. You

also certify under penalty of perjury that no other jurisdiction in the United States in which you conduct immigration-

related medical examinations has revoked or placed restrictions on your license to practice medicine in that

jurisdiction.

For health departments performing the vaccination assessment for refugee adjustment applicants ONLY: You

must complete Part 6. Civil Surgeon’s Contact Information, Certification, and Signature of Form I-693. The

original or stamped signature of the physician on staff at the health department must be present in Part 6. USCIS

will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed

physicians. Health departments must also place either the official stamp or raised seal, whichever is customarily used,

in Part 6. where indicated.

Military physicians performing the medical examination for members and veterans of the U.S. Armed Forces

or U.S. Coast Guard and certain eligible dependents must also complete Part 6. The original or stamped signature

of the military physician operating under the blanket civil surgeon designation must appear in Part 6. USCIS will

reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed

physicians. Military treatment facilities must also place either their official stamp or raised seal in Part 6. where

indicated.

4. Part 7. Civil Surgeon Worksheet and Part 9. Vaccination Record. You must fill out this worksheet and provide

the results of each component of the medical examination relating to: communicable diseases of public health

significance, physical or mental disorders with associated harmful behavior, drug abuse or drug addiction, and

vaccinations. You must also include the results of any lab work or other studies required to determine whether the

applicant is inadmissible on health-related grounds. You must instruct applicants who have had a tuberculin skin test

(TST) to return to your office within 48 - 72 hours to have the TST read.

Form I-693 Instructions 10/19/17 N

Page 5 of 12

Instructions For Report Of Medical Examination And Vaccination Record (Form I-693) Page 5

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