Form I693 PDF Details

The Form I-693, also known as the Report of Medical Examination and Vaccination Record, is a crucial document for individuals seeking certain immigration benefits under United States Citizenship and Immigration Services (USCIS). This form, part of the Department of Homeland Security, serves as a comprehensive record of one's medical examination and vaccination status, which is essential for determining eligibility for U.S. immigration. The process begins with the individual, referred to as the applicant, providing detailed personal information including full name, physical address, and other pertinent details such as gender, date of birth, and if applicable, Alien Registration Number (A-Number) and USCIS Online Account Number. This form further captures the applicant's acknowledgement regarding the interpreter's assistance or the services of a preparer in the completion of the form, emphasizing the importance of the authenticity and accuracy of the information provided. The applicant is required to submit this form in a sealed envelope as directed by the instructions, which underscores the form's critical role in the immigration process. Moreover, the form includes sections that must be completed by the civil surgeon after conducting the medical examination, ensuring that the applicant meets the health-related criteria for immigration. It outlines the need for thorough completion and accurate reporting to prevent potential denial of the associated immigration benefit, aligning with the broader regulatory framework that governs immigration to the United States.

QuestionAnswer
Form NameForm I693
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namesi693 693 form, form i 693 medical examination, i 693 form, 693

Form Preview Example

 

Report of Medical Examination and Vaccination Record

USCIS

 

Department of Homeland Security

Form I-693

 

OMB No. 1615-0033

 

 

 

U.S. Citizenship and Immigration Services

Expires 03/31/2022

 

 

 

 

 

 

 

 

 

 

 

 

►START HERE - Type or print in black ink.

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon)

1.Your Full Name

Family Name (Last Name)

Given Name (First Name)

Middle Name

 

 

 

 

 

2. Physical Address

 

 

 

 

 

Street Number and Name

 

Apt. Ste. Flr.

Number

 

 

 

 

 

 

 

City or Town

 

State

ZIP Code

 

 

 

 

 

 

3.Other Information

A.Gender Male

B. Date of Birth (mm/dd/yyyy)

C. City/Town/Village of Birth

Female

D.

Country of Birth

E. Alien Registration Number (A-Number) (if any)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

► A-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F.

USCIS Online Account Number (if any)

 

 

 

 

 

 

 

 

 

 

 

 

►

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

NOTE: Read the Penalties section of the Form I-693 Instructions before completing this section. You must submit Form I-693 in a sealed envelope to USCIS as directed in the Form I-693 Instructions.

Applicant's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

1.Applicant's Statement Regarding the Interpreter

A.

I can read and understand English, and I have read and understand every question and instruction on this form and my answer to every question.

B.

The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question

in

 

, a language in which I am fluent, and I understood everything.

 

 

 

2.Applicant's Statement Regarding the Preparer

At my request, the preparer named in Part 4.,

prepared this application for me based only upon information I provided or authorized.

,

Form I-693 Edition 09/13/21

Page 1 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

► A-

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

Applicant's Contact Information

3. Applicant's Daytime Telephone Number

4. Applicant's Mobile Telephone Number (if any)

 

 

 

 

5.Applicant's Email Address (if any)

Applicant's Certification

I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

I furthermore authorize release of information contained in this form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:

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.

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.

Applicant's Signature

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

 

6. Applicant's Signature

Date of Signature (mm/dd/yyyy)

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.

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

Provide the following information about the interpreter, if you used one.

Interpreter's Full Name

1. Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

 

 

 

 

2.Interpreter's Business or Organization Name (if any)

Form I-693 Edition 09/13/21

Page 2 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

► A-

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

Interpreter's Mailing Address

3. Street Number and Name

 

 

 

 

 

Apt. Ste. Flr.

Number

 

 

 

 

 

 

 

 

 

 

 

City or Town

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number

5. Interpreter's Mobile Telephone Number (if any)

 

 

 

 

6.Interpreter's Email Address (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluent in English and

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

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.

Interpreter's Signature

7. Interpreter's Signature

 

Date of Signature (mm/dd/yyyy)

 

 

 

 

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

1. Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

 

 

 

 

2.Preparer's Business or Organization Name (if any)

Form I-693 Edition 09/13/21

Page 3 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

► A-

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant (continued)

Preparer's Mailing Address

3. Street Number and Name

 

 

 

 

 

Apt. Ste. Flr.

Number

 

 

 

 

 

 

 

 

 

 

 

City or Town

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

Preparer's Contact Information

4. Preparer's Daytime Telephone Number

5. Preparer's Mobile Telephone Number (if any)

 

 

 

 

6.Preparer's Email Address (if any)

Preparer's Statement

7.A.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case

extends

does not extend beyond the preparation of this application.

NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Preparer's Signature

8. Preparer's Signature

 

Date of Signature (mm/dd/yyyy)

 

 

 

 

Parts 5. - 10. of this form must be completed by the civil surgeon.

Part 5. Applicant's Identification Information (To be completed by the civil surgeon) (continued)

Please complete the following about the applicant:

1.Form of identification presented by applicant (for example, passport or driver's license)

2.Document Identification Number

Form I-693 Edition 09/13/21

Page 4 of 14
No Class A or Class B Condition
Class B Conditions (See Item Numbers 1. - 4. in Part 8. Civil Surgeon Worksheet) Class A Conditions (See Item Numbers 1. - 3. in Part 8. Civil Surgeon Worksheet)

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

► A-

Part 6. Summary of Medical Examination (To be completed by the civil surgeon)

1.Summary of Overall Findings:

A.

B.

C.

2.Date of First Examination (mm/dd/yyyy)

3.Dates of Follow-up Examinations, if required:

Date of Examination (mm/dd/yyyy) Date of Examination (mm/dd/yyyy) Date of Examination (mm/dd/yyyy)

Part 7. 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.

Civil Surgeon's Information

1. Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

 

 

 

 

 

 

2.Name of Medical Practice, Facility, or Health Department

Physical Address

3. Street Number and Name

 

Apt. Ste. Flr.

Number

 

 

 

 

 

 

 

City or Town

 

State

ZIP Code

 

 

 

 

 

 

Mailing Address

4. Street Number and Name (PO Box)

 

Apt. Ste. Flr.

Number (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

City or Town

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

Contact Information

5. Daytime Telephone Number

6. Mobile Telephone Number (if any)

 

 

 

 

 

 

 

 

7.Email Address (if any)

Form I-693 Edition 09/13/21

Page 5 of 14

How to Edit Form I693 Online for Free

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1. Firstly, once completing the form i 693, start in the part that contains the following blanks:

Step # 1 of submitting i693 uscis

2. After the previous part is completed, it is time to add the essential particulars in Applicants Statement Regarding the, I can read and understand English, The interpreter named in Part, a language in which I am fluent, Applicants Statement Regarding the, At my request the preparer named, prepared this application for me, Form I Edition, and Page of allowing you to move forward further.

Step # 2 of completing i693 uscis

3. This part is usually hassle-free - fill out every one of the blanks in Family Name Last Name, Given Name First Name, Middle Name, ANumber if any, Part Applicants Statement Contact, Applicants Contact Information, Applicants Daytime Telephone Number, Applicants Mobile Telephone Number, Applicants Email Address if any, Applicants Certification, I authorize the release of any, I furthermore authorize release of, and I understand that USCIS may in order to complete this process.

i693 uscis writing process outlined (portion 3)

Always be very careful while completing I furthermore authorize release of and Applicants Certification, as this is where most users make errors.

4. Filling in Applicants Signature, Date of Signature mmddyyyy, NOTE TO ALL APPLICANTS AND CIVIL, Part Interpreters Contact, Provide the following information, Interpreters Full Name, Interpreters Family Name Last Name, Interpreters Given Name First Name, Interpreters Business or, Form I Edition, and Page of is essential in the fourth stage - make sure you spend some time and be attentive with each and every blank!

Writing section 4 of i693 uscis

5. To finish your form, this last subsection involves several additional fields. Filling in Family Name Last Name, Given Name First Name, Middle Name, ANumber if any, Part Interpreters Contact, Interpreters Mailing Address, Street Number and Name, City or Town, Apt, Ste, Flr Number, State, ZIP Code, Province, and Postal Code will finalize everything and you're going to be done in the blink of an eye!

Find out how to fill out i693 uscis part 5

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