Form I-602 - Application By Refugee For Waiver Of Grounds Of Excludability Page 2
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3PART 3.
To be completed for appplicants with active or suspected tuberculosis or who have or have had a physical or
mental disorder and behavior associated with the disorder.
A.
Statement by Applicant
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in Part B below; and
2. Present copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and
3. Submit to counseling and such examinations, treatment, and medical regimen as may be required; and
4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until I am
discharged.
Signature
Date:
NOTE to Applicant's Sponsor in United States: Arrange for medical care of the applicant and have the physician complete
Section B below
B.
Statement by Physician and/or Health Facility
This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or
military hospital. NOTE: Upon arrival of the alien in the United States, Form CDC 75.18, Report on Alien With Tuberculosis
Waiver, will be sent to the address given below.
I agree to supply any treatment or observation necessary for the proper management of the alien's tuberculosis condition.
I agree to submit Form CDC 75.18 to the health officer named below (Section C) either (a) within 30 days of the alien's
reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the alien; or (b) 30 days after
receiving Form CDC 75.18, if the alien has not reported. (NOTE: Military Hospitals should submit this form directly to the
Centers for Disease Control, Atlanta, GA 30333.)
Satisfactory financial arrangements have been made. (NOTE: This statement does not relieve the alien of submitting such
evidence as the U.S. Consulate may require to establish that the alien is not likely to become a public charge.)
I represent: (Check the appropriate box and give the complete name and address of the facility.)
1.
Local Health Department Outpatient Clinic
2.
Military Hospital
3.
Other Public or Private Health Facility
4.
Private Practice
Signature of Physician:
Date:
Address: (If military, enter name and address of receiving hospital)
NOTE to Applicant's Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in Section
B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant plans to
reside in the United States. Provide the health officer with the address where the applicant plans to reside in the United States.
Form I-602 (Rev. 01/06/10)Y Page 2
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