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Questions and Answers: 2009 Update to the Tuberculosis Screening Required for Adjustment of Status
These Questions and Answers only provide information about the assessment by the civil surgeon to determine whether an applicant has been infected with TB and address the most recent updates to the Tuberculin (TB) Component of the Technical Instructions for the Medical Examination of Aliens in the United States.
On November 1, 2009, the Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC) updated the Tuberculosis Component of the Technical Instructions for the Medical Examination of Aliens in the United States (May 2008) (available on CDC's website at www.cdc.gov/ncidod/dq/civil.htm). This update makes the traditional Tuberculin Skin Test (TST), and as of November 1, 2009, the QuantiFERON®-TB Gold (QFT-G) Test, the QuantiFERON®- TB Gold in Tube (QFT-G IT) test, and the T-Spot TB test available for TB testing. USCIS anticipated this change and made the necessary amendments to Form I-693, Report of Medical Examination and Vaccination Record.
The civil surgeon is required to comply with the Technical Instructions for the Medical Examination of Aliens in the United States (Technical Instructions), and any updates, issued by the CDC. The update to the TB Component of the Technical Instructions is effective and applies to the completion of any medical assessment made on or after November 1, 2009. The update supplements the Tuberculosis Component of the Technical Instructions for the Medical Examination of Aliens (May 2008) (TB Component of the Technical Instructions); it does NOT replace it.
The screening for TB is one part of the medical examination only; the civil surgeon has to screen an applicant for other conditions that render an applicant inadmissible to the United States. These conditions include other communicable diseases of public health significance, as defined in the Department of Health and Human Service's (HHS) regulations at 42 CFR part 34; mental and physical disorders with associated harmful behaviors; and drug abuse or drug addiction. The civil surgeon also has to assess whether the individual has received vaccinations against vaccine preventable diseases, and administer appropriate vaccines, as required by HHS.
More information on immigration medical exams and civil surgeons is available on our website at www.uscis.gov. For more information about the medical examination, please visit Immigration Medical Examinations. For more information about civil surgeons, please visit Designated Civil Surgeons.
Questions and Answers
Q. What is Tuberculosis?
TB is spread through the air from one person to another. The bacteria are put into the air when a person with active TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected.
However, not everyone infected with TB bacteria becomes sick. People who are infected but not sick have what is called latent TB infection. People who have latent TB infection do not feel sick, do not have any symptoms, and cannot spread TB to others. However, some people with latent TB infection go on to get TB disease. People with active TB disease can be treated if they seek medical help. Most people with latent TB infection can take medicine so that they will not develop active TB disease. For more information on TB infection, visit www.cdc.gov.
Q. Why are TB and TB control an issue in the United States?
TB continues to be a problem. For example, while the number of TB cases is still declining, the speed of decline has slowed since 2003. Multidrug-resistant TB (MDR TB) remains a concern, and extensively drug-resistant TB (XDR TB) has become an important issue. Finally, racial and ethnic minority populations and foreign-born individuals continue to account for a large number of TB cases in the United States. This is why the initial screening for TB and the appropriate treatment of TB for individuals coming to the United States and living here permanently is an important tool to help eradicate the disease in the United States and worldwide.
For more information on TB, please consult CDC's website at www.cdc.gov.
Q. Why am I, as an applicant for adjustment of status, screened for TB?
Therefore, every immigrant, including an adjustment of status applicant, has to be screened for health-related grounds of inadmissibility, such as communicable diseases of public health significance. Adjustment of status applicants are screened by going to a civil surgeon (a physician that is designated by USCIS) and having a medical examination which includes a screening for communicable diseases of public health significance (such as TB) and other physical or mental conditions. The civil surgeon also assesses vaccination status and administers required vaccines. If the civil surgeon encounters an individual with a significant health-related condition, the civil surgeon will be able, for most conditions, to prescribe the necessary treatment so that the inadmissibility no longer exists and the danger to the public is eliminated or diminished.
Q. Are all adjustment of status applicants screened for TB?
Before November 1, 2009, screening for TB had to be done through the administration of a tuberculin skin test (TST). As of November 1, 2009, the civil surgeon may use an interferon gamma release assay (IGRA) in place of TST testing. If evidence of TB infection is found, a chest x-ray is required.
For more information, please visit the CDC's website at http://www.cdc.gov/ncidod/dq/civil.htm.
Q. What is a tuberculin skin test (TST)?
There are certain exceptions that do not require you to undergo another TST if you had one previously. If possible, you should bring written documentation of any previous TB screening to your appointment with the civil surgeon so that the civil surgeon is able to determine whether you are required to have another one.
Q. What is initial testing with interferon gamma release assay (in place of TST)?
If you choose an IGRA (in place of a TST), the civil surgeon will take a blood sample from you during the medical examination. The blood is used to perform the TB initial screening test. Unlike with the TST, you will not have to return to the civil surgeon's office to have the test result read.
The results of the IGRA test are generally available within 24 hours of your office visit. If the result is negative, you will probably not need any further testing for TB. If the result is positive, you will be required to have a chest x-ray as a means of additional screening for TB. You may not have a TST or other initial screening test; the administration of more than one initial screening test is a violation of the Technical Instructions.
There are certain exceptions to the IGRA testing requirement. For the civil surgeon to make the best determination of what is required, you should bring, at the time of your appointment with the civil surgeon, written documentation of any IGRA testing you previously had.
Q. Which initial testing method is better, the TST or the IGRA blood tests?
Q. Does a civil surgeon have to offer all three tests to me?
The ability to perform the IGRA blood tests varies in different parts of the United States. In order to perform the blood tests correctly, the civil surgeon must ensure that the test is timely initiated and processed. The civil surgeon may not have the necessary equipment or a laboratory nearby to perform the test correctly. This may be one of the reasons that a civil surgeon chooses to use the traditional TST as an initial TB testing method.
If the civil surgeon does not offer the test that you prefer, you can try to find a civil surgeon who does.
Q. Who pays for the initial TB test?
Q. What happens if I choose a TST and the TST is "positive"? Can I choose another, alternative test instead of a chest X-ray?
Q: What happens if I choose an IGRA test and the result is indeterminate or borderline/equivocal? Do I need to repeat the IGRA test?
Q. When can a civil surgeon start to use the IGRA tests in place of the TST?
If a Form I-693 is completed prior to November 1, 2009 by using other methods than the TST, the form will be rejected.
Q. Are there any exceptions to the initial TB testing requirement?
• Applicants providing written documentation (with a health care provider's signature) of a TST reaction of 5 mm or greater of induration. For this TST exception to apply, the written documentation must include:
• Applicants who have a history of a severe reaction with blistering to a prior TST.
• Applicants providing written documentation (with the health care provider's signature) of a prior positive IGRA. If more than one IGRA has previously been performed, the most recent result should be used by the civil surgeon. The written documentation must include:
If one of these exceptions applies, the civil surgeon is directed to annotate the Form I-693 accordingly and to have the applicant undergo a chest x-ray.
Q. When is a chest x-ray required?
• The applicant has a TST reaction of 5mm or greater of induration (including pregnant or possibly pregnant individuals)
Q. If a chest x-ray is required, will USCIS accept Form I-693 without the full and formal chest x-ray report?
The chest x-ray should be interpreted by a radiologist or other qualified physician who is trained and experienced in reading chest radiographs demonstrating TB or other diseases of the lungs. After interpreting the results, the radiologist or other qualified physician should create and sign the full and formal report on official hospital or medical office letterhead. USCIS will accept the original or a copy of the report. USCIS cannot accept any preliminary or incomplete evaluation, whether handwritten or not, that does not describe the full evaluation or findings. In most cases, the civil surgeon will have to wait a day or two before this report has been sent by the reviewing medical office and cannot not sign off on the Form I-693 until this report has been received.
The instructions of Form I-693 direct the civil surgeon to the applicant a copy of the results of any testing conducted in relation to Form I-693 and a copy of the Form I-693, as submitted to USCIS.
Q. Will USCIS accept a Form I-693 if the civil surgeon performed a chest x-ray without the initial TB test (either TST or IGRA)?
Q: I am pregnant (or possibly pregnant) and I have a positive initial screening result. Do I still need a chest x-ray or will USCIS accept Form I-693 without an x-ray?
If you are pregnant (or possibly pregnant) and your initial TB test reveals that you are infected with TB, you are required to undergo a chest x-ray, pursuant to the TB Component of the Technical Instructions for the Medical Examination of Aliens in the United States (May 2008) and its update.
However, you may choose to defer the chest x-ray until later in pregnancy or after delivery but the civil surgeon cannot sign the medical examination form until the radiograph is performed and interpreted, and treatment of Class A pulmonary TB disease, if needed, is completed.
Therefore, if you choose to defer the chest x-ray, the civil surgeon cannot sign the Form I-693.
Q. I have an abnormal chest x-ray, and the referral to the local health department determines that I don't have Class A TB but a Class B TB condition. Am I cleared for immigration purposes and can the civil surgeon immediately sign Form I-693 and give it to me in a sealed envelope?
Q. What is my skin test is positive and my chest x-ray is normal?
Q: Where can I find more information about TB and how it affects the completion of Form I-693?
If you want to look at the Technical Instructions for the Medical Examination of Aliens in the United States, including the TB Component of these Technical Instructions, please visit CDC's website at www.cdc.gov or click on the following link: www.cdc.gov/ncidod/dq/civil.htm.
If you have any questions about the civil surgeon program or the completion of Form I-693, or the adjustment of status application, please visit USCIS' website at www.uscis.gov or call the USCIS National Customer Service Center at 1-800-375-5283 (TTY 1-800-767-1833).
Last Reviewed/Updated: 06/18/2013