Chapter 83.4 Designation and Revocation of Civil Surgeons.

(a) General Certification Procedures for Private Physicians Seeking Civil Surgeon Designation .

(1) Legal Authority .

The statutory authority relating to the designation of civil surgeons is found at section 232(b) of the Act. Refer to 8 CFR § 232.2(b) for further information about the selection of civil surgeons.

(2) Legal Requirements for Civil Surgeon Designation .

HHS regulations at 42 CFR § 34.2(c) define a civil surgeon as “[a] physician, with not less than 4 years’ professional experience, selected by the District Director of INS [now USCIS] to conduct medical examinations of aliens in the United States . . . .”

(A) Licensed physicians .

The implementing regulations at 8 CFR § 232.2(b) state that “[e]ach civil surgeon selected shall be a licensed physician with no less than 4 years’ professional experience.” (Emphasis added.) Thus, only licensed physicians may be designated as civil surgeons for medical examinations under section 232(b) of the Act. M.D.s (medical doctors) and D.O.s (Doctors of Osteopathy) are eligible to apply for civil surgeon designation, provided they are licensed to practice medicine in the state where they render medical services and have the requisite professional experience. Similarly, registered nurses, medical technicians, physical therapists, physician’s assistants, medical technicians, and other healthcare workers who are not licensed physicians may not be designated as civil surgeons. To resolve any doubts you may have about whether an applicant is in fact a licensed physician eligible for civil surgeon designation, you may call CDC, Division of Global Migration and Quarantine, at 404-498-1600. For information about the special designation of state and local health departments as civil surgeons for refugees seeking adjustment of st atus under section 209 of the Act and 8 CFR § 209.1, refer to Chapter 83.4(b).

(B) Professional Experience .

Based on consultations with CDC, USCIS has determined that internships and residencies are not counted towards the 4 years of professional experience required under section 232(b) of the Act for civil surgeon designation. For purposes of civil surgeon designation under section 232(b) of the Act, professional experience means experience obtained not in relationship to training. Both internship and residency are part of the training of physicians, as required of medical officers of the U.S. Public Health Service.

(3) Technical Instructions .

All designated civil surgeons must perform the medical exam according to the applicable HHS regulations at 42 CFR part 34 and the specific instructions published by the CDC entitled Technical Instructions for the Medical Examination of Aliens in the United States ( “Technical Instructions” ). See 42 CFR § 34.3(f). These Technical Instructions are binding on the civil surgeon, and they have the force of a regulation. The current Technical Instructions , along with important updates for civil surgeons, are available at CDC’s website:

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

(4) Application Procedures .

The current regulations do not specify an application process. USCIS is in the process of revising the regulations for the designation of civil surgeons. Until these revisions become effective, all USCIS offices should adhere to the following guidelines.

• Written Request . Require all physicians seeking civil surgeon designation to submit a written request.

• Evidence . Each request for civil surgeon designation must include, at a minimum, copies of the physician’s current medical license and curriculum vitae establishing 4 years of professional experience.

• Additional steps depending on time, staffing, and resources . Time and resources permitting, you may also call or visit the facility or physician before making a final decision on the request for civil surgeon designation. Under current regulations, you may also limit the number of civil surgeons designated for your district or sub-office; however, you must develop uniform standards for doing so and ensure that they are applied consistently throughout the entire district .

• Decision . Because the current regulations at 8 CFR § 232.2(b) state that the District Director may select as many civil surgeons as determined necessary to serve the needs of that district, you are not required to approve a request for civil surgeon designation if you have determined that the needs of the district are already met by the civil surgeons currently designated. If, however, a clinic or medical practice seeks to designate a new physician in place of another designated civil surgeon who has left, this nee d not be treated as a new request for civil surgeon designation. That physician must, however, meet the legal requirements for civil surgeon designation.

• Approval . Notify the physician in writing of the approval and forward a copy of your written notification to CDC at the following address:

Chief, Migration Health Assessment Section

Division of Global Migration and Quarantine (E03)

Centers for Disease Control and Prevention (CDC)

Atlanta, Georgia 30333.

Note that, while the current regulations state that district directors may also select clinics and local, county and state health departments, your approval and internal records should reflect only those individual physicians that have been designated on behalf of that clinic or practice. This is necessary to ensure that the legal requirements of section 232(b) of the Act, 8 CFR § 232.2(b), and 42 CFR § 34.2(b) relating to licensure and experience have been met.

• Updating the civil surgeon lists . Submit all civil surgeon deletions, additions, and corrections for districts and sub-offices to the Headquarters Immigration Services Division (ISD), ATTN: Customer Service Branch, through appropriate channels, within 24 hours of the date the change occurred, so that the local office profile may be updated. The information provided to Headquarters to be entered into the system must include the physician’s full name, name of medical practice, address, and telephone number. Specialty, subspecialty, and the date the license expires should also be included. In order to ensure the accuracy of the information in the database, it is critical to ensure that all the information entered into the local office profile is correct, especially the zip code and the civil surgeon’s telephone number. Applicants may obtain information about civil surgeons designated in their area by calling the National Customer Service Center at: 1-800-375-5283.

• Files . Create a separate file for each civil surgeon designated in your district or sub-office. If more than one physician is designated for a particular clinic or medical practice, one file may be retained to cover all physicians designated. However, the files should be maintained in such a way as to facilitate retrieval or review of information relating to the specific civil surgeon. The file should be retained for as long as the civil surgeon is designated and should include all relevant correspondence. In ad dition, the file should be retained for 5 years after the date the physician’s civil surgeon designation has been terminated (whether voluntarily or through the revocation process described in Chapter 83.4(c)).

• Denial . Notify the physician in writing of the denial. There is no appeal or review of a denied request for civil surgeon designation. However, if the request was denied because a sufficient number of civil surgeons is already designated, the physician is not precluded from reapplying at a later date.

(b) Special Designation of State and Local Health Departments as Civil Surgeons for Refugees Adjusting under Section 209 of the Act .

(1) Legal Authority .

When medical officers of the U.S. Public Health Service (PHS) are not available to examine individuals seeking admission to the United States, the Attorney General is authorized, in accordance with section 232(b) of the Act, to designate private physicians to serve as civil surgeons for this purpose. The corresponding regulations at 8 CFR § 232.2(b) state in part: "The district director shall select as many civil surgeons, including clinics and local, county and state health departments employing qualified civil surgeons, as he determines to be necessary to serve the needs of the Service in a locality under his jurisdiction." Therefore, USCIS has the authority to designate civil surgeons individually or en masse, provided they meet the legal requirements specified under section 232(b) of the Act, 8 CFR § 232.2(b), and 42 CFR § 34.2(b).

(2) Blanket Designation of Participating Health Departments .

By way of a memorandum dated July 30, 1998; HQ 70/21.1.1, 96 Act 074, HQOPRD designated all state and local health departments as civil surgeons for refugees applying for adjustment of status under section 209 of the Act. This designation:

• Is in addition to, not instead of, the civil surgeon designation described at 8 CFR § 232.2.

• Eases the difficulties encountered by refugee adjustment applicants in their efforts to obtain the vaccination sign-off;

• Relieves district offices of the need to continually update their civil surgeon lists of health departments to reflect the current physicians on staff; and

• Does not require district offices to maintain lists of individual health departments and the names of individual physicians employed by these health departments.

Participation in this HQOPRD blanket civil surgeon designation is entirely voluntary and at the discretion of the individual health department. In the past, CDC has provided each health department the vaccination supplement to Form I-693 and all the necessary instructions. New health departments wishing to participate in the blanket designation can obtain the technical instructions for the vaccination requirements and the vaccination supplement to Form I-693 from the CDC website at the following address:

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

(3) Aliens Eligible to Benefit from the Blanket Designation .

Pursuant to the understanding reached between USCIS , CDC, and HHS, this HQOPRD blanket civil surgeon designation of state and local health departments covers only the vaccination sign-off for those refugees applying for adjustment of status under section 209 of the Act. The small percentage of refugees who require the entire medical exam, as provided in 8 CFR § 209.1(b), will need to visit a private physician or health care facility designated in accordance with the standard procedures described in 8 CFR § 232.2(b) and Chapter 83.4(a). This blanket designat ion does not cover asylees seeking to adjust under section 209 of the Act.

(4) Certification by Participating Health Departments .

Health departments participating in the HQOPRD blanket civil surgeon designation will place either the official stamp or raised seal (whichever is customarily used by that specific health department) on the vaccination supplement, and the attending health department physician must sign it. In accordance with the agreements reached with CDC, the signature on the vaccination supplement may be the physician’s actual (original) or stamped signature. The health department nurse or other health care professional may, but is not required to , co-sign the vaccination supplement. A vaccination supplement that has been signed only by a registered nurse, physician's assistant, or other medical professional that is not a licensed physician is not sufficient to meet the requirements of section 232(b) of the Act as having been completed by a designated civil surgeon. The health department will place the signed vaccination supplement in a sealed envelope, according to the standard procedures all civil surgeons are required to follow.

If you encounter a vaccination supplement for a refugee that has been signed only by a medical professional employed by the health department (i.e., without an accompanying signature by a medical doctor), RFE the vaccination supplement to the applicant for corrective action. See also Chapter 83.4(b)(5), immediately below.

(5) Denied Applications Due to Improper Signature by the Health Department .

You may accept a Motion to Reopen, without fee, from a refugee whose application for adjustment of status under section 209 of the Act was denied solely because of an improper signature on the vaccination supplement. The Motion must be accompanied by a corrected vaccination supplement in an envelope sealed by the State or local health department.

(c) Procedures for Revoking a Physician’s Civil Surgeon Designation .

(1) Authority .

Current regulations do not contain specific revocation provisions; however, the law does not preclude revocation, especially when the physician no longer qualifies for civil surgeon designation or his or her professional conduct is egregious to the extent that it endangers public health or safety, including lack of license.

(2) Initiating the intended revocation .

The file should be well documented before you take any steps to revoke a physician’s civil surgeon designation. When the intended revocation is based on allegations of misconduct reported by an adjustment of status applicant, sworn statements should be taken from those applicants to support the allegations contained in the notice. Retain any other evidence of the alleged misconduct. Pending implementation of the revised civil surgeon regulations, refer the case to district counsel, UNLESS the intended revocation is based on evidence that the civil surgeon is no longer a licensed physician. Referrals to district counsel should include the reasons for the intended revocation and copies of the supporting evidence. Depending on the nature and severity of the allegations, it may also be necessary for you to consult with CDC and/or the local health department to obtain expert medical advice. Once the decision has been made to initiate the revocation, serve the physician with a notice of intent to revoke by Certified Mail/Return Receipt Requested. The notice must clearly state the exact reasons for the intended revocation. Allow 30 days from the date of the notice for the physician to respond with countervailing evidence. The physician may be represented by counsel at his or her own cost.

(3) Decision .

Advise the physician in writing of the decision to uphold or reverse the notice of intent to revoke the civil surgeon designation. Update the local office profile, accordingly, and notify the regional POC, per the instructions in Chapter 83.4(a)(4).