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

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 7. Civil Surgeon's Contact Information, Certification, and Signature (continued)

Civil Surgeon's Certification

I certify under penalty of perjury under United States law that:

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 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.

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

All the information I provided on this Form I-693 is complete, true, and correct, based on the information provided to me by the applicant.

Civil Surgeon's Signature

8. Civil Surgeon's Signature

 

Date of Signature (mm/dd/yyyy)

 

 

 

 

(Health departments and military treatment facilities MUST place their official stamp or seal here)

(official stamp or seal here)

Form I-693 Edition 09/13/21

Page 6 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 8. Civil Surgeon Worksheet

(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)

1.Communicable Disease of Public Health Significance

A.Tuberculosis (TB): An initial screening test, 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 will perform further evaluation if needed (chest X-ray).

(1)Interferon Gamma Release Assay (for acceptable IGRAs, consult the TECHNICAL INSTRUCTIONS and any updates posted on the CDC's website):

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

Select only one box.

QuantiFERON

Date Blood Sample Drawn (mm/dd/yyyy)

T-Spot

Date Blood Sample Drawn (mm/dd/yyyy)

Result:

Negative (no chest X-ray required)

Positive (chest X-ray required)

Indeterminate (including borderline/equivocal) (no chest X-ray required)

(2) Initial Screening Test Result and Chest X-Ray Determinations:

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

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 IGRA exception (Clearly specify the IGRA exception in the Remarks section below.)

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

Date Chest X-Ray Taken (mm/dd/yyyy)

 

Date Chest X-Ray Read (mm/dd/yyyy)

 

 

 

 

 

 

Result:

Normal

Abnormal (describe results in Remarks section below.)

TB Classification/Findings (Select only if chest X-ray was performed):

No Class A or Class B TB

Class A Pulmonary TB Disease

Class B2 Pulmonary TB

Class B, Other Chest Condition (non-TB)

Class B1 Extra Pulmonary TB

Class B, Latent TB Infection

Class B1 Pulmonary TB

Class B0 Pulmonary TB

(4)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 IGRA, give the reason why an exception applies.)

Form I-693 Edition 09/13/21

Page 7 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 8. Civil Surgeon Worksheet (continued)

B.Syphilis

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

(a)Name of Screening Test

(b) Date Screening Run (mm/dd/yyyy)

(c) Screening Nonreactive (mm/dd/yyyy)

Screening Reactive, Titer 1:

(d)If Reactive, Name of Confirmatory Test

(e) Date Confirmation Run (mm/dd/yyyy)

 

(f)

Confirmation Nonreactive

Confirmation Reactive

(2) Findings:

No Class A or Class B Syphilis

Syphilis, Class A (untreated)

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

Syphilis, Class B (treated in the last year)

Drug:

Start Date (mm/dd/yyyy)

C. Gonorrhea

Dosage:

End Date (mm/dd/yyyy)

(1)Laboratory Test for Gonorrhea (Required for applicants 15 years of age and older)

(a)Screening Test Name

(b) Date Specimen Reported (mm/dd/yyyy)

(c)

Positive

Negative

(2) Findings:

 

No Class A or Class B Gonorrhea

Gonorrhea, Class A (untreated)

Gonorrhea, Class B (treated in the last year)

(3)Remarks: (Include any treatment given with doses and dates)

Drug:

Start Date (mm/dd/yyyy)

Dosage:

End Date (mm/dd/yyyy)

Form I-693 Edition 09/13/21

Page 8 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 8. Civil Surgeon Worksheet (continued)

D.Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance

(1)Findings:

(a)

(b)

(c)

No Class A/B Condition

Hansen's Disease (leprosy, any classification) untreated, Class A

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

Hansen's Disease (leprosy, any classification) treated or partially treated, Class B

Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)

Mid-borderline, borderline lepromatous, lepromatous (multibacillary)

(2)Remarks: (Include any therapy given and any counseling or referrals) If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

2.Physical or Mental Disorders With Associated Harmful Behavior

Include here any physical or mental disorders with current associated harmful behavior or history of associated harmful behavior judged likely to recur. This category of physical or mental disorders includes any diagnosis of substance-related disorders that involve any substance that is not listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act (for example, diagnosis of an alcohol-related disorder). Diagnose mental disorders according to the diagnostic criteria in the most recent edition of the Diagnostic and Statistical Manual (DSM) or another authoritative source, as determined by the director of the CDC. Diagnose physical disorders according to the diagnostic criteria in the most recent edition of the World Health Organization's Manual of the International Classification of Diseases, Injuries, and Causes of Death (ICD) or another authoritative source as determined by the director of the CDC. See the CDC's Technical Instructions for more information.

A. Findings:

(1)

No Class A or B Physical or Mental Disorder

(2)

Current Physical/Mental Disorder with Associated Harmful Behavior, Class A

(3)

History of Physical/Mental Disorder with Associated Harmful Behavior Likely to Recur, Class A

(4)

Current Physical/Mental Disorder without Associated Harmful Behavior, Class B

(5)

History of Physical/Mental Disorder with Associated Harmful Behavior Unlikely to Recur, Class B

B.Remarks: (Include diagnosis, likelihood of recurrence of the harmful behavior, therapy given, and any counseling or referrals. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

Form I-693 Edition 09/13/21

Page 9 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 8. Civil Surgeon Worksheet (continued)

3.Drug Abuse/Drug Addiction

The U.S. Department of Health and Human Services (DHHS) sets the medical guidelines for determining drug abuse and drug addiction. The terms are defined at 42 CFR 34.2(h) and (i).

Include here any diagnosis of drug abuse or drug addiction.

"Drug abuse" is "current substance use disorder or substance-induced disorder, mild,” but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. Make the diagnosis according to the diagnostic criteria in the most current edition of the DSM, or by another authoritative source as determined by the director of the CDC.

"Drug addiction" is "current substance use disorder or substance-induced disorder, moderate or severe," but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. Make the diagnosis according to the diagnostic criteria in the most current edition of the DSM.

You may also make a diagnosis of full remission, according to the diagnostic criteria in the most current edition of the DSM or another authoritative source as determined by the director of the CDC. See the CDC's Technical Instructions for more information.

A. Findings:

(1)

No Class A or B Substance (Drug) Abuse/Addiction

(2)

Substance (Drug) Abuse, Listed in section 202 of the Controlled Substances Act, Class A

(3)

Substance (Drug) Addiction, Listed in section 202 of the Controlled Substances Act, Class A

(4)

Substance (Drug) Abuse in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B

(5)

Substance (Drug) Addiction in Full Remission, Listed in section 202 of the Controlled Substances Act, Class B

B.Remarks: (Include any therapy given, rehabilitation, counseling or referrals. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

4.Other Medical Conditions (List any other Class B conditions, such as hypertension or diabetes, and all required evaluation components as found in HHS's Technical Instructions for Medical Examinations of Aliens in the United States.)

5.Required Referral to Health Department or Other Doctor (To be completed by civil surgeon, if a referral is medically required.)

A.Type or Print Name of Doctor or Health Department Receiving Required Referral

B.Address

 

Street Number and Name

 

Apt. Ste. Flr.

Number

 

 

 

 

 

 

 

City or Town

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

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Page 10 of 14

Apt. Ste. Flr. Number

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 8. Civil Surgeon Worksheet (continued)

C.Date of Referral (mm/dd/yyyy)

D.Remarks: (Include the name of medical condition and the reasons for referral. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

Part 9. Referral Evaluation (To be completed by the health department or other doctor performing the referral evaluation)

The applicant identified on this Form I-693 was referred to me by the civil surgeon named in Part 7. of this Form I-693. I have provided appropriate evaluation/treatment, having made every reasonable effort to verify that the person whom I have evaluated/ treated is the person identified in Part 1.

1.Evaluating Physician or Health Department's Full Name

A. Family Name (Last Name)

Given Name (First Name)

 

Middle Name

 

 

 

 

 

 

B. Health Department 's Name

2.Address

Street Number and Name

City or Town

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

3.Signature of Health Department Individual or Other Doctor Performing Referral Evaluation

 

Signature

 

 

 

Date Signed (mm/dd/yyyy)

 

 

 

 

 

 

4. Name of Medical Practice or Health Department

5. Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If you need extra space to complete this section, use the space provided in Part 11. Additional Information.

Form I-693 Edition 09/13/21

Page 11 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 10. Vaccination Record

NOTE: See TECHNICAL INSTRUCTIONS at www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical- instructions.html for list of required vaccines, including COVID-19 vaccine guidance.

Please make sure to mark every row. Reserve all comments for the Remarks section below. NOTE: For purposes of the influenza

vaccine, the flu season is October 1 through March 31. For applicants who only require a vaccination assessment: Submit only this Part with Parts 1. - 5., and Part 7. of Form I-693. (If you need an interpreter, complete Part 3. Interpreter's Contact Information, Certification, and Signature.) For more information, see Form I-693 Instructions, Frequently Asked Questions.

Vaccine History Transferred From A Written Record

Vaccine

Complete

Blanket Waiver(s) to be

 

 

 

 

 

 

Given

Series

Requested from USCIS (Not

 

 

 

 

 

 

 

 

Medically Appropriate)

 

 

 

 

 

 

 

 

 

 

 

Vaccine

Date

Date

Date

Date

Date Given

Mark an X if

Not Age -

Contra-

Insufficient

*See

 

 

Received

Received

Received

Received

by

complete; write date

Appropriate

indication

Time

Below

 

 

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

Civil Surgeon

of lab test if immune

 

 

Interval

Table

 

 

 

 

 

 

(mm/dd/yyyy)

or "VH" if varicella

 

 

 

 

 

 

 

 

 

 

 

history

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify Vaccine:

 

 

 

 

 

 

 

 

 

 

DT

DTaP

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

DTP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify Vaccine:

 

 

 

 

 

 

 

 

 

 

Td

Tdap

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify Vaccine:

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

OPV

IPV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (measles,

 

 

 

 

 

 

 

 

 

 

mumps-rubella) or

 

 

 

 

 

 

 

 

 

 

if monovalent or

 

 

 

 

 

 

 

 

 

 

other combination

 

 

 

 

 

 

 

 

 

TEXT

of the vaccines are

 

 

 

 

 

 

 

 

 

 

given, specify

 

 

 

 

 

 

 

 

 

 

vaccines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib

 

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis B

 

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

 

Varicella

 

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

Pneumococcal

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rotavirus

 

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis A

 

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

Meningococcal

 

 

 

 

 

 

 

 

 

TEXT

 

 

 

 

 

 

 

 

 

 

 

COVID-19 (In

 

 

 

 

 

 

 

 

 

 

“Remarks” section,

 

 

 

 

 

 

 

 

 

 

write “COVID-19”

 

 

 

 

 

 

 

 

 

 

and specify vaccine

 

 

 

 

 

 

 

 

 

 

brand)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: Give a copy to the applicant.

*For Influenza vaccine, check the box in this column only if vaccine is not medically appropriate because it is not flu season.

*For COVID-19 vaccine, check the box in this column only if vaccine is not routinely available in the state where the civil surgeon practices according to the TECHNICAL INSTRUCTIONS blanket waivers for this vaccine.

Form I-693 Edition 09/13/21

Page 12 of 14

Family Name (Last Name)

Given Name (First Name)

Middle Name

A-Number (if any)

A-

Part 10. Vaccination Record (continued)

Results:

Applicant completed vaccination requirements or may be eligible for blanket waivers as indicated above

Applicant will request an individual waiver based on religious or moral convictions

Applicant does not meet immunization requirements

Remarks: (If needed, provide any comments, such as the reason for contraindication.)

FOR USCIS USE ONLY

Remarks (if any)

Form I-693 Edition 09/13/21

Page 13 of 14

Part 11. Additional Information

If you (the applicant or the civil surgeon) need extra space to provide any additional information within this form use the space below. If you (the applicant or civil surgeon) need more space than what is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print the applicant's name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

1. Family Name (Last Name)

 

Given Name (First Name)

 

Middle Name

 

 

 

 

 

 

 

 

 

 

 

 

2. A-Number (if any) A-

3. A. Page Number

B. Part Number

C. Item Number

 

 

 

 

 

 

 

 

 

 

 

 

D.

4. A. Page Number

B. Part Number

C. Item Number

 

 

 

 

 

 

 

 

 

 

 

 

D.

5. A. Page Number

B. Part Number

C. Item Number

 

 

 

 

 

 

 

 

 

 

 

 

D.

6. A. Page Number

B. Part Number

C. Item Number

 

 

 

 

 

 

 

 

 

 

 

 

D.

Form I-693 Edition 09/13/21

Page 14 of 14

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Step # 1 of submitting i693 uscis

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Step # 2 of completing i693 uscis

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i693 uscis writing process outlined (portion 3)

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Writing section 4 of i693 uscis

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Find out how to fill out i693 uscis part 5

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