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A-Number (if any)

(mm/dd/yyyy)

Part 2.  Applicant's Statement, Contact Information, Certification, and Signature (continued)

I certify, under penalty of perjury that I am the person who is identified in Part 1. of this Form I-693, and that the information in Part 1. of this form is complete, true, and correct.  I understand the purpose of this medical examination, and I authorize the required tests and procedures to be completed.  If it is determined that I willfully misrepresented a material fact or provided false or altered information or documents with regard to my medical examination, I understand that any immigration benefit I derived from this medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties.

1)  I reviewed and provided or authorized all of the information in my form;

2)  I understood all of the information contained in, and submitted with, my form; and

3)  All of this information was complete, true, and correct at the time of filing.

NOTE:  Do not sign or date Form I-693 until instructed to do so by the civil surgeon.

NOTE TO ALL APPLICANTS AND CIVIL SURGEONS:  If you or the civil surgeon do not completely fill out this form according to the instructions USCIS may deny your immigration benefit.

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A-Number (if any)

I am fluent in English and                                                    

in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this form and his or her answer to every question.  The applicant informed me that he or she understands every instruction, question, and answer on the form, including the Applicant's Certification, and has verified the accuracy of every answer.

, which is the same language specified in Part 2., Item B.

Part 3.  Interpreter's Contact Information, Certification, and Signature (continued)

(mm/dd/yyyy)   

Part 4.  Applicant's Identification Information  (To be completed by the civil surgeon) 

Part 5.  Summary of Medical Examination (To be completed by the civil surgeon)

Summary of Overall Findings:

Class B Conditions (See Item Numbers 1. - 4. in Part 7. Civil Surgeon Worksheet) 

Dates of Follow-up Examinations, if required:

Date of First Examination 

Date of Examination

Date of Examination 

Date of Examination 

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

Family Name (Last Name)

Name of Medical Practice, Facility, or Health Department

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A-Number (if any)

Class A Conditions (See Item Numbers 1. - 3. in Part 7. Civil Surgeon Worksheet)

Part 6.  Civil Surgeon's Contact Information, Certification, and Signature  

NOTE:  Do not sign Form I-693 and do not have the applicant sign in Part 2. until all health-related follow-up requirements are met.

I am a civil surgeon designated to examine applicants seeking certain immigration benefits in the United States OR a physician who qualifies under a blanket designation specified by policy or law;

I have a currently valid and unrestricted license to practice medicine in the state where I am performing immigration-related medical examinations, unless otherwise exempted;

I performed an examination of the person identified in Part 1. of this Form I-693, after having made every reasonable effort to verify that the person whom I examined is in fact the person identified in Part 1.;

I performed the examination in accordance with the Centers for Disease Control and Prevention's (CDC) Technical Instructions, as well as all supplemental information or updates; and

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A-Number (if any)

Part 6.  Civil Surgeon's Contact Information, Certification, and Signature (continued) 

(mm/dd/yyyy)   

(official stamp or seal here)

I have not had my license to practice medicine revoked, and I am not subject to any restrictions on any license to practice medicine in any other jurisdiction in the United States in which I conduct immigration-related medical examinations.

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A-Number (if any)

(To be completed by the civil surgeon, according to the Technical Instructions at

www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)

Interferon Gamma Release Assay (for acceptable IGRA's, consult the Technical Instructions and any updates posted on the CDC's website):

Select only one box.

Negative (including indeterminate, or borderline/equivocal) (no chest X-ray required)

Positive (chest X-ray required)

Chest X-ray not required (medically cleared for TB for USCIS)

Chest X-ray required due to initial screening test results

Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)

Chest X-ray required due to TST or IGRA exception (Clearly specify the TST or IGRA exception in the Remarks section below.)

Chest X-Ray:  Required based on TST or IGRA result, or if specific TST or IGRA exceptions apply, or for an applicant with TB signs or symptoms or immunosuppression (such as HIV).

Date Chest X-Ray Read (mm/dd/yyyy)

Normal

Abnormal (describe results in Remarks section below.)

Tuberculosis (TB):  An initial screening test, either a tuberculin skin test (TST) or an interferon gamma release assay (IGRA), is required for all applicants 2 years of age and older; for children under 2 years of age, see the Technical Instructions.  The civil surgeon should perform only one type of initial screening test, followed by further evaluation if needed (chest X-ray).

Not administered (TST exception; please explain in Remarks section below)

Date TST Applied (mm/dd/yyyy)

Date TST Read (mm/dd/yyyy)

Size of Reaction (mm)

Not administered (IGRA exception; please explain in Remarks section below)

Part 7.  Civil Surgeon Worksheet 

Negative (4mm or less of induration)

Positive (> 5mm; chest X-ray required)

Date Blood Sample Drawn (mm/dd/yyyy)

Date Blood Sample Drawn (mm/dd/yyyy)

No Class A or Class B TB 

Class A Pulmonary TB Disease

Was applicant referred for treatment (not required to complete Form I-693)?

Class B2 Pulmonary TB

Class B, Latent TB Infection (Answer the following question.)

Class B, Other Chest Condition (non-TB)

Class B1 Pulmonary TB

Class B1 Extra Pulmonary TB

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A-Number (if any)

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.)

Date Confirmation Run (mm/dd/yyyy)

Serologic Test for Syphilis (Required for applicants 15 years of age and older)

Date Screening Run (mm/dd/yyyy)

Confirmation Nonreactive 

Remarks:  (Include any therapy given with doses and dates)

Screening Nonreactive (mm/dd/yyyy)

Screening Reactive, Titer 1:

Part 7.  Civil Surgeon Worksheet (continued)

Name of Screening Test

Drug:

Dosage:

Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Date Specimen Reported (mm/dd/yyyy)

Screening Test Name

Positive

Negative