A. Medical Exception Requirements​

In 1994, Congress enacted legislation providing an exception to the naturalization educational requirements for applicants who cannot meet the educational requirements because of a physical or developmental disability or mental impairment.​ [1] See Immigration and Nationality Technical Corrections Act of 1994, Pub. L. 103-416 (October 25, 1994). See INA 312(b). The “55/15” and “50/20” exceptions, as well as the “65/20” special consideration provisions were also added by the same legislation.

T​he English ​and ​civics requirements do not apply to naturalization applicants who are unable to comply due to a “medically determinable” physical or developmental disability or mental impairment that has lasted, or is expected to last, at least 12 months. The regulations define “medically determinable” as a determination made by acceptable clinical or laboratory techniques.​ [2] See INA 312(b). See 8 CFR 312.1(b)(3) and 8 CFR 312.2(b).

The applicant must demonstrate a disability or impairment that affects the functioning of the individual such that, even with reasonable accommodations, he or she is unable to demonstrate the educational requirements for naturalization. Illiteracy alone is not a valid reason to seek an exception to the educational requirements. In addition, advanced ag​e​, in and of itself, is not a medically determinable physical or developmental disability or mental impairment.​

An applicant seeking an exception to the educational requirements submits a Medical Certification for Disability Exceptions (​Form N-648​) as an attachment to the naturalization ​application.​ [3] See 8 CFR 312.2(b)(2). The first edition of Form N-648 was made available to the public as an attachment to the final rule. See 62 FR 12915-12928 (March 19, 1997). See 74 Interpreter Releases 512-15 (March 24, 1997). A licensed medical professional must complete the form. The medical professional must certify that the applicant’s medical condition prevents the applicant from meeting the English requirement, the civics requirement, or both requirements. ​

USCIS recognizes that certain circumstances may prevent concurrent filing of the naturalization application and the disability exception form. ​Accordingly, an applicant may file the disability exception form during any part of the naturalization process, including after the application is filed but before the first ​examination​, during the first ​examination​, during the re​-​examination if the applicant’s first ​examination ​was rescheduled, and during the rehearing on a denied naturalization application. ​

B. Medical Exception Versus Accommodation​

Requesting an exception to the English and civics requirements is different from requesting an accommodation to the naturalization examination process.​ [4] See Part C, Accommodations [12 USCIS-PM C].An exception to the English and civics requirements exempts the applicant from the educational requirements completely. An accommodation, on the other hand, simply modifies the manner in which an applicant meets the educational requirements; it does not exempt the applicant from the educational requirements.​

Reasonable accommodations include, but are not limited to, sign language interpreters, extended time for testing, and off-site testing. A disability exception requires an applicant to show that his or her medical condition ​prevents him or her from ​comply​ing​ with the English and civics requirements even with reasonable accommodations. ​

C. Authorized Medical Professionals​

USCIS only authorizes the following licensed medical professionals to certify the disability exception form:​

Medical doctors;​

Doctors of osteopathy; and​

Clinical psychologists.​ [5] See 8 CFR 312.2(b)(2).

These medical professionals must be licensed to practice in any state of the United States, Washington, D.C., Guam, Puerto Rico, the Virgin Islands, or the Commonwealth of the Northern Mariana Islands.​ [6] Initially, the corresponding Notice of Proposed Rulemaking (NPRM) issued by legacy INS to address this legislation proposed that all exception eligibility determinations be based on individual assessments by civil surgeons or qualified individuals or entities designated by the Attorney General. The proposed rule suggested that the civil surgeon (or “authorized entity”) provide their assessment in a one-page document. The assessment would attest to the origin, nature, and extent of the applicant's medical condition. INS removed the requirement for a civil surgeon determination in the final rule. See NPRM at 61 FR 44227-44230 (August 28, 1996).

The medical professional must:​

Conduct an in-person examination of the applicant;​

Explain the nature and extent of the medical condition on ​Form N-648​;​

Explain how the medical condition relates to the applicant’s inability to comply with the English and civics requirements;​

Attest that the medical condition has lasted or is expected to last at least 12 months; and​

Attest​ that the cause of the medical condition ​is not related​ to the illegal use of drugs.​

The medical professional must complete the disability exception form using common terminology that a person without medical training can understand. While staff associated with the medical professional may assist in completing the form, the medical professional alone is responsible for verifying the accuracy of the form’s content. The medical professional certifying the form may attach supporting documents, such as medical diagnostic reports and records. The attachments must not replace written responses to each question or item on the form. ​

D. Guidelines for Officer’s Review​

1. General Guidelines for Review​

An officer must review the disability exception form to determine whether the applicant is eligible for the exception. The officer may reach one of the following outcomes after his or her review:​

The form sufficiently establishes that the applicant is eligible for the exception; or​

The form is insufficient in establishing that the applicant is eligible for the exception.​

The tables below provide general guidelines on what an officer should and should not do when reviewing a disability exception form.​

General Guidelines for Officer’s Review of Form N-648​

When reviewing the form, an officer SHOULD:​

Determine whether the form has been properly completed, certified, and signed (the medical professional must have certified the form within six months of its submission). Once certified, the form is valid for the duration of the application.​

Ensure that the form relates to the applicant and that there are no discrepancies ​between the form and other information, including ​biographic data, testimony during ​the interview​, or ​information contained in the applicant’s ​A-file​

Determine whether the form fully addresses the underlying medical condition and its causal connection with the applicant’s inability to comply with the requirements​

Determine whether the form contains sufficient information to establish that the applicant is eligible for the exception by a preponderance of the evidence (“more likely than not”)​

When reviewing the form, an officer SHOULD NOT:​

Assume responsibility or authority to determine the validity of the medical diagnosis or opinion on the applicant’s ability to comply with the English and civics requirements​

Refer an applicant to another medical professional solely because the applicant sought care from a professional who shares the same language, culture, ethnicity, or nationality​

Conclude that the applicant does not have the medical condition because it was not previously recorded in other immigration related medical examinations or documents ​

Question an applicant about the applicant’s ability to complete a certain activity if the form does not discuss that particular activity​

Require that an applicant complete specific medical, clinical, or laboratory diagnostic techniques, tests, or methods​

Develop and substitute his or her own diagnosis of the applicant’s medical condition in lieu of the medical professional’s diagnosis​

Use questionnaires or tests to challenge each applicant’s diagnosed medical condition​

Question the applicant about his or her medical care, job duties, community and civic affairs, or daily living activities unless facts in the form or during the examination directly contradict facts in the A-file​

Request to see an applicant’s medical records or prescription medication solely to question whether there was a proper basis for the medical professional’s diagnosis​

Infer that the applicant is able to comply with all portions of the English and civics requirements in cases where an applicant only seeks an exception from certain portions​

2. Review for Completeness of Form​

An officer must verify that the submitted disability exception form is complete. The officer should verify that the medical professional has answered all of the required questions and has certified the form along with the applicant. If a question has not been answered completely or the medical professional or applicant does not sign the form, the officer must proceed with the examination in English as if the applicant had not submitted the form. The officer provides the applicant with an opportunity to take each portion of the English and civics test.​

A complete form​ [7] See Medical Certification for Disability Exceptions (Form N-648). must contain all of the information requested on the form, to include the information listed in the table below.​

Properly Completed Form N-648​

All forms must contain the information requested on the form, to include:​

Clinical diagnosis of the applicant’s medical condition and its DSM code (if applicable) ​

Description of the medical condition forming the basis for the disability exception​

Date the medical professional examined the applicant​

Description of the doctor-patient relationship indicating whether the medical professional regularly treats the applicant for the cited conditions or an explanation of why he or she is certifying the disability form instead of the regularly treating medical professional​

Statement that the medical condition has lasted, or is expected to last, at least 12 months​

Statement whether the medical condition is the result of the illegal use of drugs​

Explanation of what caused the medical condition, if known​

Description of the clinical methods used to diagnose the medical condition​

Description of the medical condition’s effect on the applicant’s ability to successfully complete the educational requirements for naturalization​

Statement whether the medical professional used an interpreter to examine the applicant​

The medical professional is not required to address the severity of the effects of the medical condition on the applicant’s daily life.​

3. Medical Examination and Nexus​

In reviewing the request for the medical exception, the officer must focus on whether the medical professional has explained that the applicant has a disability or impairment and that there is a nexus (causal connection) between the disability or the impairment and the applicant’s inability to demonstrate the educational requirements for naturalization. The medical professional must specifically explain how the applicant's disability or impairment prohibits the applicant from being unable to demonstrate the educational requirements.​

4. Missing Interpreter Certification​

There may be instances where the interpreter certification on the disability exception form may not have been completed. In this instance, the officer should ask the applicant whether the medical professional used an interpreter during the medical examination that formed the basis of the medical exception form.​

The officer should not draw a negative inference if the medical professional did not use an interpreter if he or she examined the applicant in the applicant’s native language.​

The officer may question the applicant about the applicant’s visits with the medical professional and the nature of their relationship​ if the interpreter certification is not complete and the medical professional did not conduct the examination in the applicant’s native language​.​

The officer should question the applicant under oath in the applicant’s language of choice with use of an interpreter to address the issues of concern​ related to the medical exception form​.​

5. Requesting a Supplemental Disability Determination​

In general, an officer should not request a supplemental disability determination and should evaluate the original form on its own merits. If an officer questions the veracity of the information on the disability exception form, the officer should exercise caution when requesting an applicant to obtain a supplemental disability determination from another authorized medical professional.​ [8] See 8 CFR 312.2(b)(2). The officer must:​

Explain the reasons for doubting the veracity of the information on the original disability exception form;​

Consult with his or her supervisor and receive approval before requesting the applicant to undergo a supplemental disability determination; and​

Provide the applicant with the relevant state medical board contact information to facilitate the applicant’s ability to find another medical professional.​

E. Establishing Eligibility for the Exception​

An officer determines a request for a medical exception is sufficient if:​

The medical exception form is properly completed; and​

The medical professional explains how the applicant’s medical condition prohibits the applicant from meeting the English requirement, the civics requirement, or both requirements.​

The table below provides the general procedures for cases where an applicant qualifies for a disability exception. The procedures apply to any phase of the naturalization examination, to include the initial or re​-​examination, or hearing on a denial.​

General Procedures if Form N-648 Establishes Eligibility​

If form is deemed sufficient at any naturalization examination or hearing:​

The officer must proceed with the ​interview​ without administering the test​, in the applicant’s language of choice with the use of an interpreter, if the medical professional indicated on the form that the applicant was unable to comply with ​any of ​the educational requirements​.​

T​he officer must administer ​the tests for the other requirements, if the medical professional indicated on the form that the applicant was unable to comply with only some of the educational requirements. If the medical professional indicated that the applicant was unable to comply with the English speaking requirement, the interview can proceed in the applicant’s language of choice with the use of an interpreter.​

The officer must determine whether the applicant meets the rest of the applicable naturalization requirements and make a decision on the naturalization application.​

F. Failing to Establish Eligibility for the Exception​

An officer determines that a request for a medical exception is insufficient if:​

The ​N-648​form ​is not properly completed;​

The medical professional fails to explain how the applicant’s medical condition prohibits the applicant from meeting the English requirement, the civics requirement, or both requirements; or​

The officer finds that the applicant listed on the form was not examined by the certifying medical professional or is not the same person as the naturalization applicant.​

The table below provides the general procedures for cases where an applicant is ineligible for the disability exception. The procedures apply to any phase of the naturalization examination, to include the initial or ​re-​examination or hearing on a denial.​

General Procedures if Form N-648 Fails to Establish Eligibility​

If form is deemed insufficient at any naturalization examination or hearing:​

The officer must proceed with the initial or re​-​examination, or hearing, in English as if the applicant had not submitted a disability exception form.​

The officer must provide the applicant with an opportunity to take all portions of the English and civics testing.​

1. Insufficient Request for Medical Exception at Initial Interview​

Passing the English and Civics Tests​

If an applicant fails to qualify for a disability exception but subsequently meets the English and civics requirements in the same ​examination​:​

The officer should proceed with the naturalization examination to determine whether the applicant meets the rest of the applicable eligibility requirements for naturalization.​

The officer should not determine that the applicant engaged in fraud or lacks good moral character (GMC) for the sole reason that the applicant met the English and civics requirements after submitting a disability exception form.​

The officer may question the applicant further, however, on the reasons for submitting the form and the applicant’s relationship to the medical professional.​

Failing the English and Civics Tests​

If an applicant fails to qualify for the disability exception and fails to meet the English and civics requirements:​

The officer must issue the applicant a request for evidence addressing the issues with the medical disability exception form.​ [9] The officer should issue a request for evidence on Form N-14.

The USCIS office must reschedule the applicant to appear for a ​re-​examination, to include a second opportunity to meet the English and civics requirements, between 60 and 90 days after the initial examination.​

2. Insufficient Request for Medical Exception at Re​-​examination​

If an officer determined that an applicant’s disability exception form was insufficient at the initial examination, the officer should have issued a request for evidence addressing the deficiencies of the form. An officer conducting the re​-​examination should review the evidence submitted in response to the request for evidence issued at the initial examination.​

The reexamining officer may review an applicant’s disability exception form for the first time if the applicant is submitting the form for the first time at the re​-​examination.​

If an applicant submits a medical exception form for the first time during the re​-​examination, the officer determines if the form is sufficient or insufficient. If the officer determines that the form is sufficient to establish eligibility for the disability exception, the officer must proceed with the naturalization examination with the use of an interpreter, exempting the applicant from the educational requirements.​

If the officer determines that the form is insufficient, the officer must afford the applicant a second opportunity to take the English and civics tests. If the applicant fails any portion of the test or refuses to respond to test questions during the re​-​examination, the officer must deny the naturalization application based on the applicant’s failure to meet the educational requirements for naturalization. In the denial notice, the officer must provide a detailed explanation for finding the medical exception form insufficient.​

If an officer determines that the evidence submitted in response to the request for evidence is insufficient:​

The officer must proceed with the re​-​examination in English as if the applicant had not submitted a disability exception form.​

The officer must provide the applicant with a second opportunity to take any portion of the English and civics tests that the applicant previously failed. ​

The officer must not provide the applicant a third opportunity to submit a disability exception form or to take the English and civics tests.​

If the applicant fails any portion of the testing, to include a refusal to be tested or to respond, the officer must deny the naturalization application based on the applicant’s failure to meet the educational requirements for naturalization. ​

The officer must provide a detailed explanation of the disability exception form’s deficiencies in the naturalization application denial notice. ​

3. Insufficient Request for Medical Exception at Hearing on Denial​

An officer may conduct a full ​de novo​ hearing on a denied naturalization application, including review of a previously submitted disability exception form during the hearing on the naturalization denial.​ [10] See 8 CFR 336.2.An applicant may submit additional documentation for review at the hearing, to include a new disability exception form. ​

If the applicant submits a new or initial form at the hearing, the hearing officer determines whether the form is sufficient for the medical exception. If the form is insufficient, the officer should retest the applicant on any portion of the English and civics tests previously failed by the applicant.​ [11] See Part B, Naturalization Examination, Chapter 6, USCIS Hearing and Judicial Review, Section B, Review of Timely Filed Hearing Request [12 USCIS-PM B.6(B)].

4. Discrepancies and Misrepresentation​

Some cases may present questions about whether the certifying medical professional actually examined the applicant. An officer should find a disability exception form insufficient if the officer identifies any discrepancies or misrepresentations indicating:​

The applicant on the form was not examined by the certifying medical professional; or​

The applicant on the form is not the same person as the naturalization applicant.​

G. Fraud Referrals​

There may be cases where an officer suspects or determines that an applicant or medical professional has committed fraud in the process of seeking a medical disability exception. The officer should consult with his or her supervisor to determine whether to refer such a case to Fraud Detection and National Securi​ty (FDNS).​

If an officer or the local FDNS office determines that an applicant or medical professional has committed fraud, the officer must explain the findings of fraud in the denial notice.​


Footnotes


1. [^] 

See Immigration and Nationality Technical Corrections Act of 1994, Pub. ​L. 103-416 (October 25, 1994).​ See ​INA 312(b)​. The “55/15” and “50/20” exceptions, as well as the “65/20” special consideration provisions ​were also added​ by the same legislation.​

3. [^] 

See ​8 CFR 312.2(b​)(​2)​. The first edition of ​Form N-648​was made​ available to the public as an attachment to the final rule. See ​62 FR 12915-12928​ (March 19, 1997). ​See 74 Interpreter Releases 512-15 (March 24, 1997).​

4. [^] 

See Part C, Accommodations [​12​ USCIS-PM C​].​

5. [^] 

See ​8 CFR 312.2(b​)(​2)​. ​

6. [^] 

Initially, the corresponding Notice of Proposed Rulemaking (NPRM) issued by legacy INS to address this legislation proposed that all exception eligibility determinations ​be based​ on individual assessments by civil surgeons or qualified individuals or entities designated by the Attorney General. The proposed rule suggested that the civil surgeon (or “authorized entity”) provide their assessment in a one-page document. The assessment would attest to the origin, nature, and extent of the applicant's medical condition. INS removed the requirement for a civil surgeon determination in the final rule. See NPRM at 61 FR 44227-44230 (August 28, 1996).​

7. [^] 

See Medical Certification for Disability Exceptions (​Form N-648​).​

8. [^] 

See ​8 CFR 312.2(b​)(​2)​.​

9. [^] 

The officer should issue a request for evidence on Form N-14.​

10. [^] 

See ​8​ CFR 336.2​.​

11. [^] 

See Part B, Naturalization Examination, Chapter 6, USCIS Hearing and Judicial Review, Section B, Review of Timely Filed Hearing Request [​12 USCIS-PM ​B.6(​B)​].​