Form I693 – Fill Out and Use This PDF

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 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 (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

Form I-693 Edition 09/13/21

Page 10 of 14

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

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