Form I-602 - Application By Refugee For Waiver Of Grounds Of Excludability Page 3

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C.
Endorsement by Local or State Health Officer
Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or
physician who signed in Section B is not in your health jurisdiction and is not familiar to you, you may wish to contact the health
officer responsible for the jurisdiction of the facility or physician prior to endorsing.
Signature:
Date:
Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis
Waiver, will be sent when the alien arrives in the United States.
Local Health Department Address
Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
15 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Products Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008,
Washington, DC 20529-2210. OMB No. 1615-0069. Do not mail your application to this address.
Form I-602 (Rev. 01/06/10)Y Page 3

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