USCIS Policy Manual

VOLUME 8: ADMISSIBILITY

PART B: HEALTH RELATED GROUNDS OF INADMISSIBILITY

Chapter 1: Purpose and Background 


A. Purpose


The medical grounds of inadmissibility, the medical examination of foreign nationals, and the vaccinations administered to foreign nationals are designed to protect the health of the United States population. The immigration medical examination, the resulting medical examination report, and the vaccination record provide the information USCIS uses to determine if a foreign national meets the health-related standards for admissibility.


Four basic medical conditions may make an applicant inadmissible on health-related grounds:


  • Communicable disease of public health significance,

  • An immigrant’s failure to show proof of required vaccinations,

  • Physical or mental disorder with associated harmful behavior, and

  • Drug abuse or addiction.


B. Background


Public health concerns have been reflected in U.S. immigration law since the Immigration Act of 1882.[1] See Immigration Act of 1882, 22 Stat. 214. Among others, “persons suffering from a loathsome or a dangerous contagious disease” were not allowed to enter the United States.[2] See Immigration Act of 1891, 26 Stat. 1084.  In 1990, Congress revised and consolidated all of the grounds of inadmissibility. It narrowed health-related grounds of inadmissibility to include only applicants with communicable diseases, physical or mental disorders with associated harmful behavior, or those with drug abuse or addiction problems.[3] See Immigration Act of 1990 (IMMACT 90), Pub. L. 101-649. 


As of 1996, Congress requires all immigrant visa and adjustment of status applicants to establish that they have been vaccinated against certain vaccine-preventable diseases.[4] See Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208 and INA 212(a)(1)(A)(ii). 


C. Role of the Department of Health and Human Services (HHS)


Because medical knowledge and public health concerns can and do change over time, Congress gave the Department of Health and Human Services (HHS) the authority to designate by regulations which conditions make a person inadmissible on health-related grounds. 


The HHS component charged with defining these medical conditions is the Centers for Disease Control and Prevention (CDC). CDC’s responsibilities include:



D. Role of the Department of Homeland Security (DHS)


Congress authorizes the Department of Homeland Security (DHS) to determine a foreign national’s admissibility to the United States, which includes determinations based on health reasons.[7] See INA 212(a). DHS must follow HHS regulations and instructions when determining whether an applicant is inadmissible on health-related grounds.[8] See INA 212(a)(1)(A).


Congress also empowers DHS to designate qualified physicians as civil surgeons who conduct medical examinations of foreign nationals physically present in the United States.[9] See INA 232. 


E. Making a Medical Inadmissibility Determination


To make a medical inadmissibility determination, the officer should follow the steps outlined below: 


Overview of Process of Making a Medical Inadmissibility Determination

Step of Adjudication

Where can I find 

information 

on this step? 

Step 1: Is the applicant subject to health-related grounds of inadmissibility or is there another reason that requires the applicant to undergo a medical examination? 

Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html)]

Step 2: If required, has the applicant been medically examined by the appropriate physician and is the appropriate medical documentation in the file? 

Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html)]

Step 3: Was the medical documentation[10] Report of Medical Examination and Vaccination Record (Form I-693); Medical Examination for Immigrant or Refugee Applicant (1991 TB Technical Instructions) (Form DS-2053) or the Medical Examination for Immigrant or Refugee Applicant (2007 TB Technical Instructions) (Form DS-2054), and related worksheets. properly completed and is it still valid?

Chapter 4, Review of Medical Examination Documentation [8 USCIS-PM B.4(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html)] through Chapter 10, Other Medical Conditions [8 USCIS-PM B.10(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter10.html)]


Step 4: Is the applicant inadmissible based on health-related grounds?

Chapter 11, Inadmissibility Determination [8 USCIS-PM B.11(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html)]


Step 5: Is the applicant inadmissible based on grounds other than health-related grounds, as evidenced by the medical documentation?

Chapter 11, Inadmissibility Determination, Section D, Other Grounds of Inadmissibility [8 USCIS-PM B.11(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html#S-D)]


F. Legal Authorities


  • INA 212(a)(1)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2301)  Health-Related Grounds

  • INA 221(d)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-5118.html)  Physical Examination

  • INA 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-5339.html); 8 CFR 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-22375.html#0-0-0-8887a)  Detention of Aliens for Physical and Mental Examination

  • 42 U.S.C. 252(http://uscode.house.gov/view.xhtml?req=(title:42%20section:252%20edition:prelim)%20OR%20(granuleid:USC-prelim-title42-section252)&f=treesort&edition=prelim&num=0&jumpTo=true%20-%20sourcecredit%20) – Medical Examination of Aliens

  • 42 CFR 34(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html) – Medical Examination of Aliens

  • Technical Instructions for Civil Surgeons (Technical Instructions), and updates[11] Available online at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html. 


Chapter 2: Medical Examination and Vaccination Record


A. Purpose of the Medical Examination and Vaccination Report


The results of the medical examination and vaccination record determine whether an applicant is inadmissible on health-related grounds. The medical examination documentation indicates whether the applicant has either a Class A or Class B medical condition and the vaccination record shows whether the applicant has complied with all vaccination requirements.


B. Class A and B Conditions and Their Impact on Admissibility


Class A and B conditions are defined in HHS regulations.[12] See 42 CFR 34. 


Class A conditions are medical conditions that render a person inadmissible and ineligible for a visa or adjustment of status.[13] Class A conditions are medical conditions mentioned in INA 212(a)(1)(A). A Class A medical condition is a:


  • Communicable disease of public health significance per HHS regulation;

  • Present or past physical or mental disorder with associated harmful behavior or harmful behavior that is likely to recur; and

  • Drug abuse or addiction.


Class B conditions are defined as physical or mental abnormalities, diseases, or disabilities serious in degree or permanent in nature amounting to a substantial departure from normal well-being.[14] See 42 CFR 34.2(e). This may be a medical condition that, although not rendering an applicant inadmissible, represents a departure from normal health or well-being that may be significant enough to:


  • Interfere with the applicant’s ability to care for himself or herself, to attend school, or to work; or

  • Require extensive medical treatment or institutionalization in the future.


C. Completion of a Medical Examination


When a medical examination is required to determine the applicant’s admissibility, the person must be examined by a physician who is designated to perform this examination.


By statute, any medical officer in the U.S. Public Health Service may conduct the examination. However, this rarely occurs. Most medical examinations are conducted by a physician designated as a civil surgeon by USCIS[15] See INA 232 and 8 CFR 232. or designated as a panel physician abroad by the U.S. Department of State (DOS). Civil surgeons complete medical examinations for applicants in the United States, while panel physicians complete medical examinations for immigrant visa and refugee applicants seeking immigration benefits from outside the United States. 


Chapter 3: Applicability of Medical Examination and Vaccination Requirement


A. Requirements by Benefit Type


Medical examination and vaccination requirements vary depending on the immigration benefit the person is seeking. 


Most applicants subject to medical grounds of inadmissibility must undergo a medical examination to determine their admissibility. Some applicants, however, do not need to undergo a medical examination unless there is a specific concern. Nonimmigrants, for example, are in this category.


Even if the applicant is not subject to health-related grounds of inadmissibility, the officer may still order a medical examination as a matter of discretion if the evidence indicates that there may be a public health concern.[16] Based on the conditions listed in INA 212(a)(1). This could apply, for example, when an officer adjudicates a request for parole.[17] See INA 212(d)(5)(A). 


In general, an immigration officer may order a medical examination of an applicant at any time, if the officer is concerned that the applicant may be medically inadmissible.[18] See Matter of Arthur, 16 I&N Dec. 558 (BIA 1978) (The applicant has the burden of proof to establish his or her admissibility to the United States according to INA 291; the burden never shifts to the government). This rule applies regardless of the type of immigration benefit sought, or whether the applicant is applying for a visa, seeking entry at a U.S. port-of-entry, or already in the United States. 


A civil surgeon in the United States can only perform a medical examination for purposes of a benefits application processed within the United States. Similarly, a panel physician abroad can generally only perform a medical examination for purposes of a visa application processed outside the United States. There are limited exceptions where an applicant seeking a benefit application inside the United States does not have to repeat a medical examination performed by a panel physician. The following chart highlights the benefits that require a medical examination and vaccinations, and whether a civil surgeon or panel physician should conduct the medical examination.[19] Special considerations that apply to certain benefit types are noted in Section B, Special Considerations [8 USCIS-PM B.3(B)]. 


Medical Examination and Vaccination Requirements by Benefit Type

Benefit Type

Medical Examination

(Yes or No)

Vaccination

(Yes or No)

Panel Physician or 

Civil Surgeon

Immigrant Visa Applicants, applying with U.S. Department of State (DOS)

Yes

Yes

Panel Physician

Adjustment Applicants

Yes

Yes

Civil Surgeon

Nonimmigrant Visa Applicants, applying with DOS; and Nonimmigrants seeking change/extension of status while in the United States[20] See INA 248. See 8 CFR 214.1 and 8 CFR 248.

No (with some exceptions)[21] See Section B, Special Considerations [8 USCIS-PM B.3(B)].

No

N/A

Temporary Protected Status (TPS) Applicants[22] See INA 244.

No (with some exceptions)[23] See Section B, Special Considerations [8 USCIS-PM B.3(B)].

No

N/A

K or V Visa Applicants, applying with DOS[24] See INA 214. See 8 CFR 214.2(k) and 8 CFR 214.15.

Yes

No

Panel Physician

Nonimmigrant seeking change of status to V status[25] See INA 214(q) and 8 CFR 214.15. 

Yes

No

Civil Surgeon

K or V nonimmigrants applying for adjustment of status in the United States[26] See INA 245 and 8 CFR 245.

May be required[27] See Section B, Special Considerations [8 USCIS-PM B.3(B)]. 

Yes

Panel Physician and/or Civil Surgeon

Refugee Applicants, including Principal and Derivative Applicants Overseas[28] See INA 207 and 8 CFR 207.7. See INA 208 and 8 CFR 208.21.

Yes

No

Panel Physician

Applicants seeking derivative refugee or derivative asylee status while in the United States[29] See INA 207 and 8 CFR 207.

No

No

N/A

Principal Asylum Applicants in the United States[30] See INA 208 and 8 CFR 208.

No

No

N/A

Applicants Seeking Derivative Asylee Status with DOS[31] See INA 208 and 8 CFR 208.21.

Yes

No

Panel Physician

Refugee-Based Adjustment Applicants[32] See INA 209 and 8 CFR 209.1.

May be required[33] See Section B, Special Considerations [8 USCIS-PM B.3(B)]. 

Yes

Civil Surgeon[34] Including State or local health department physicians, who are blanket designated by USCIS as civil surgeons for purposes of completing the vaccination record for refugees adjusting status only.

Asylees Applying for Adjustment of Status[35] See INA 209 and 8 CFR 209.2.

May be required[36] See Section B, Special Considerations [8 USCIS-PM B.3(B)]. 

Yes

Civil Surgeon

Kurdish asylees paroled under Operation Pacific Haven applying for adjustment of status

Yes

Yes

Panel Physician or Civil Surgeon

Registry Applicants

No

No

N/A

North American Indians entering the United States[37] See 8 CFR 289.1 and 8 CFR 289.2. American Indians born in Canada who meet the regulatory requirements may be regarded as having been admitted for lawful permanent residence. Because neither an immigrant visa nor an adjustment of status application is required, the applicant is not required to comply with the medical examination and vaccination requirements.

No

No

N/A

Children of returning residents entering the United States[38] See INA 101(a)(27)(A) and 22 CFR 42.22.  or Children of U.S. nationals

No

No

N/A

Internationally Adopted Orphans[39] See INA 101(b)(1)(F), including Hague Convention Adoptees.

Yes

Yes

(Exception available)

Panel Physician


B. Special Considerations


1. Nonimmigrants and TPS Applicants


In general, nonimmigrant visa applicants, nonimmigrants seeking change or extension of status, and Temporary Protected Status (TPS) applicants are only medically examined if the Consular Officer or immigration officer has concerns as to the applicant’s inadmissibility on health-related grounds. CBP Officers at ports-of-entry may also require a nonimmigrant arriving with or without a visa to submit to a medical examination to determine whether a medical ground of inadmissibility applies.


2. K or V Visa Applicants Applying with DOS[40] See INA 214. See 8 CFR 214.2(k) and 8 CFR 214.15. See 9 FAM 41.108 Note 1.2.


While the Consular Officer may encourage compliance, the Consular Officer cannot deny a K or V visa for lack of compliance with the vaccination requirements. 


Some panel physicians may perform the vaccination assessment in anticipation of the applicant’s later adjustment of status application.


3. Nonimmigrants Applying for Change of Status to V Status


For nonimmigrants applying for change of status to V status, the civil surgeon may perform the vaccination assessment in anticipation of the applicant’s later adjustment of status application.


4. K or V Nonimmigrants Applying for Adjustment[41] See INA 245 and 8 CFR 245.


K and V nonimmigrants applying for adjustment of status are not required to repeat the medical examination if the application was filed within one year of the date of the original medical examination, and:


  • The medical examination did not reveal a Class A medical condition; or 

  • The applicant received a conditional waiver in conjunction with the K or V nonimmigrant visa or the change of status to V and the applicant submits evidence of compliance with the waiver terms and conditions.[42] See 8 CFR 245.5.


If a new medical examination is required and reveals a Class A medical condition, a new waiver application will also be required. In such cases, the officer should determine whether the applicant complied with the terms and conditions of the first waiver, if applicable. Such determination should be given considerable weight in the adjudication of a subsequent waiver application.[43] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more information on medical waivers. 


Even if a new medical examination is not required, applicants must still comply with the vaccination requirements if the vaccination record was not included as part of the original medical examination report. If the vaccination report was properly completed at the time of the overseas examination, the officer may accept the vaccination assessment completed by the panel physician. 


An applicant’s overseas medical examination report completed by a panel physician should already be in the applicant’s A-file. If it is not in the A-file, the officer should request the medical examination report through a Request for Evidence (RFE).


If the applicant was granted a change of status to V in the United States,[44] Under INA 214(q). the medical examination report completed by the civil surgeon should be in the A-file created at the time that the change of status was initially granted. 


5. Refugees Applying for Adjustment[45] See INA 209 and 8 CFR 209.1.


By regulation, refugees applying for adjustment of status generally do not need to repeat the entire medical examination if the applicant was already examined by a panel physician for purposes of admission to the United States.[46] See 8 CFR 209.1(c). Refugees must undergo an additional medical examination only if the original examination by the panel physician revealed a Class A medical condition.


Family members granted refugee status in the United States must submit to a medical examination at the time they seek to adjust their status. 


All refugees must comply with the vaccination requirements at the time of adjustment of status by submitting the relevant parts of the Report of Medical Examination and Vaccination Record (Form I-693(http://www.uscis.gov/i-693)) completed by a designated civil surgeon. A prior vaccination assessment performed by the panel physician cannot be used for purposes of the adjustment of status application.[47] See 8 CFR 209.1(c).


USCIS granted a blanket civil surgeon designation to state and local health department physicians for the limited purpose of completing the vaccination record for refugees applying for adjustment of status. 


6. Asylees Applying for Adjustment


All asylees are required to undergo an immigration medical exam, including vaccination assessment, at time of adjustment.[48] See 8 CFR 209.2(d).


However, according to USCIS policy developed in consultation with CDC, an asylee dependent who had a medical examination conducted overseas is not required to undergo a new medical exam when applying for adjustment of status if:


  • The results of the overseas medical examination are contained in the A-file and no Class A condition was reported; 

  • The asylee has applied for adjustment of status within one year of eligibility to file; and

  • No evidence in the A-file or testimony given at the interview suggests that the asylee 

    has acquired a Class A condition after his or her entry into the United States.


Even if an asylee dependent may use the result of the previous examination, he or she must still establish compliance with the vaccination requirements and submit the vaccination assessment with his or her adjustment of status application. This requirement applies even if the applicant had a vaccination assessment completed overseas by a panel physician. To comply with the requirement, the applicant must have the relevant parts of Form I-693(http://www.uscis.gov/i-693) completed by the civil surgeon.

 

7. Children of Returning Residents Entering the United States[49] See INA 101(a)(27)(A) and 22 CFR 42.22. 


For children of returning residents entering the United States, as long as the parent’s visa is valid or the parent is a U.S. resident or U.S. national, there are no medical examination or vaccination requirements.


Children of returning residents entering the United States are: 


  • Children born abroad after the parent has been issued an immigrant visa and while the parent is applying for admission to the United States.

  • Children born abroad during the temporary visit abroad of a mother who is a national or permanent resident of the United States. 


8. Internationally Adopted Orphans[50] See INA 101(b)(1)(F). See Chapter 9, Vaccination Requirement, Section G, Exceptions for Certain Adopted Children [8 USCIS-PM B.9(G)] for more on this exception.


Children 10 years of age or younger who are classified as orphans and who are applying for IR-3 and IR-4 (orphans) and IH-3 and IH-4 (Hague Convention Adoptees) visas are not required to comply with the vaccination requirements before admission to the United States.[51] See INA 212(a)(1)(C), as amended by Section 2 of the International Adoption Simplification Act, Pub. L. 111-287, 124 Stat. 3058 (2010). 


Chapter 4: Review of Medical Examination Documentation


A. Results of the Medical Examination


The physician must annotate the results of the examination on the following forms: 


Panel Physicians


Panel physicians must annotate the results of the medical examination on the Medical Examination for Immigrant or Refugee Applicant (1991 TB Technical Instructions) (Form DS-2053) or the Medical Examination for Immigrant or Refugee Applicant (2007 TB Technical Instructions) (Form DS-2054), and related worksheets.[52] As of October 1, 2013, panel physicians only use DS-2054. The DS-2053 is no longer used after that date. 


Civil Surgeons


Civil surgeons must annotate the medical examination results on the Report of Medical Examination and Vaccination Record (Form I-693(http://www.uscis.gov/i-693)). 


B. Documentation Completed by Panel Physician 


Since a State Department Consular Officer reviews the medical documentation completed by a panel physician as part of the overseas visa process, a USCIS Officer may assume that the medical documentation is properly completed.[53] The Technical Instructions for Panel Physicians may differ from the Technical Instructions for Civil Surgeons. As long as the DS form is properly completed, the officer should accept the finding of the consular officer as correct.


If the USCIS Officer notices a significant irregularity such as an omission of a particular section, the officer may issue a Request for Evidence (RFE) to have a civil surgeon in the United States complete the missing part(s) of the medical examination. A civil surgeon should address any deficiency by completing the respective parts of a Form I-693(http://www.uscis.gov/i-693) according to the Technical Instructions for Civil Surgeons issued by CDC.[54] In this case, because the DS form was completed by a panel physician, the officer should retain the original document. The RFE must specify which sections of Form I-693 have to be completed by a civil surgeon. This should only happen in rare instances. 


Applicants who have already been examined abroad and are not required to repeat the medical examination in the United States may still have to show proof of the vaccination requirement.[55] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for specific information on who is required to be examined and to what extent. 


C. Documentation Completed by Civil Surgeon

 

1. Civil Surgeon Designation


Except for physicians who are Public Health Service Officers, only physicians designated by USCIS to act as civil surgeons may conduct an immigration medical examination in the United States and complete Form I-693(http://www.uscis.gov/i-693).[56] Form I-693 can only be used for immigration benefits that are granted in the United States. Only doctors of medicine (M.D.) and doctors of osteopathy (D.O.) who are currently licensed to practice as physicians may be designated.[57] See INA 232 and 8 CFR 232. The physician must be designated as a civil surgeon at the time of the completion of the medical examination.


To determine whether the physician is designated as a civil surgeon, the officer should consult the designated civil surgeon list through the civil surgeon locator on uscis.gov.


If the officer has questions as to the past designation of a civil surgeon, the officer should contact the appropriate civil surgeon POC(s). 


2. Complete Form


The following requirements must always be met regarding any Form I-693(http://www.uscis.gov/i-693) submitted to USCIS:


  • The form must be completed legibly;

 






  • The form must be in a sealed envelope as detailed in the form’s instructions. 


If the above requirements are not met, or if there is evidence that the envelope has been tampered with, the officer must return the original Form I-693(http://www.uscis.gov/i-693) to the applicant for corrective action. Whenever an original is returned to the applicant, the officer should retain a copy. 


A response to an RFE is acceptable if it is completed by a civil surgeon in one of the following ways:


  • The civil surgeon annotates the original medical examination in the deficient part(s), and both the applicant and the civil surgeon re-sign and re-date their respective certifications.

 

  • The civil surgeon re-completes an entirely new Form I-693(http://www.uscis.gov/i-693), and corrects for the original deficiency.



The applicant may return to the original civil surgeon who performed the immigration medical exam or a new civil surgeon to correct the form.


The civil surgeon must place the corrected form[64] Along with the original Form I-693, if separate from the corrected form.  in a sealed envelope. The applicant must then return the sealed envelope to USCIS.


3. Signatures


The applicant, the civil surgeon, and any other health care provider who evaluated the applicant as part of the immigration medical examination should sign the form, to verify that the content of their representations is truthful.


Signature of the Civil Surgeon 


The civil surgeon’s signature must be an original signature. There is no exception to this requirement. Stamps of the physician’s signature or other substitutes, or copies of the civil surgeon’s original signature, are not acceptable.


As outlined in CDC’s Technical Instructions, the civil surgeon is only permitted to sign the Form I-693(http://www.uscis.gov/i-693) after he or she has completed the entire medical examination. An examination is not completed until any prescribed treatment for a Class A condition has been administered. 


There may be circumstances when an applicant refuses to undergo one part of the examination, but the civil surgeon certifies the form with a notation that part of the exam is not complete. In these cases, the officer should issue an RFE to the applicant for corrective action.


The civil surgeon might also diagnose a Class A condition for which the applicant refuses treatment. The civil surgeon might then annotate the Class A condition but still certify and sign the form. In this case, the officer should not return the form for corrective action. The officer should determine that the applicant is inadmissible and ask the applicant to request a waiver, if available.[65] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more on waivers. 


Signature of the Health Department 


In agreement with CDC, USCIS granted blanket civil surgeon designation to local and state health departments in the United States. This blanket designation allows health departments to complete the vaccination portion of Form I-693(http://www.uscis.gov/i-693) for refugees seeking adjustment if they have a physician who meets the professional qualifications for a civil surgeon. If a refugee only requires the vaccination assessment, the only parts of the form that need to be completed are the applicant’s information, the vaccination assessment, and the certifications. The other parts are irrelevant and do not have to be submitted. 


If the health department physician is completing only a vaccination assessment for refugees seeking adjustment, the physician’s signature may be either an original (handwritten) or a stamped signature, as long as it is the signature of the health department physician. The attending nurse may, but does not have to, co-sign with the physician. The signature of the physician must be accompanied by the health department’s stamp or raised seal, whichever is customarily used. 


If the health department does not properly sign, the officer should return the medical documentation to the applicant for corrective action.[66] See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C] for more information on the blanket civil surgeon designation for health departments. 


Signature of a Military Physician designated as a Civil Surgeon for Members and Veterans of the Armed Forces


To ease the difficulties encountered by physicians and applicants in the military, USCIS issued a blanket civil surgeon designation to qualifying military physicians to permit them to perform the immigration medical examination and complete the Form I-693(http://www.uscis.gov/i-693) for eligible members and veterans of the U.S. armed forces and their dependents.[67] See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C] for more information on the blanket civil surgeon designation for military physicians. 


Pursuant to the understanding reached between USCIS and the CDC, military physicians who qualify under this blanket civil surgeon designation may perform the entire immigration medical examination as long as the exam is conducted in the United States on the premises of a Military Treatment Facility (MTF) and conducted for a U.S. armed forces member, veteran, or dependent who is eligible to receive medical care at the MTF.


If operating under the blanket civil surgeon designation for military physicians, a physician’s signature may be either an original (handwritten) or stamped signature, as long as it is the signature of a qualifying military physician. Nurses and other health care professionals may, but are not required to, co-sign the form. The signature of the physician must be accompanied by the official stamp or raised seal of the MTF, whichever is customarily used.


If the military physician does not properly sign, the officer should return the medical documentation to the applicant for corrective action.


Signature of the Applicant


The applicant or the civil surgeon may complete the section about the applicant’s information. The civil surgeon must always verify the applicant’s identity by requiring a government-issued ID, as stated in CDC’s Technical Instructions. 


The applicant must sign the certification only when instructed by the civil surgeon. By signing the form, the applicant attests that he or she consented to the medical examination and that any information provided in relation to the medical examination is truthful. 


Whenever the civil surgeon orders a test that he or she does not perform personally, the civil surgeon must ensure that the physician or staff to whom the applicant is referred checks the identity of the applicant by requesting a government-issued ID.[68] By signing the form, the civil surgeon certifies that he or she has examined the applicant according to the procedures and requirements outlined in the Technical Instructions, Form I-693, and form instructions. Officers do not need to verify whether the civil surgeon instructed the referring physician to check the applicant’s identity.


An officer should follow the chart below to determine whether the applicant or a legal guardian must sign the form.[69] See 8 CFR 103.2(a)(2). 


Signature of the Applicant

Age of Applicant

Signature Requirement


Age 14 or Older

The applicant must sign Form I-693(http://www.uscis.gov/i-693). However, a legal guardian may sign for a mentally incompetent person.


Under Age 14

Either the applicant, a parent, or legal guardian may sign the Form I-693(http://www.uscis.gov/i-693). The officer should not reject the form as improperly completed if only the applicant, parent, or guardian signs.



Signature of Physicians Receiving Referrals for Evaluation


If the civil surgeon is unable to perform a particular medical assessment, he or she is required to refer the applicant to another physician. The physician receiving the referral is required to complete the appropriate section on Form I-693(http://www.uscis.gov/i-693) after he or she has completed the evaluation of the applicant’s condition. The civil surgeon may not sign the civil surgeon’s certification on the form until the civil surgeon has received and reviewed the report of the physician who received the referral. If the referring physician ordered treatment, the civil surgeon may not sign the certification until the treatment has been completed.


Contracted services used by the civil surgeon to complete a step in the medical examination are not considered referrals. Therefore, the referral section can be blank in such cases.[70] Civil surgeons are, however, still responsible for ensuring that the contractor properly checks the applicant’s ID.  For example, if the civil surgeon uses a contractor to draw blood, the referral section does not have to be completed. However, if the Technical Instructions require a referral to the Health Department because the applicant has TB, the officer must make sure that the referral section is completed.


4. Validity Period of Form I-693(http://www.uscis.gov/i-693) (Including Use of Prior Versions)



Evidentiary Value


A person seeking an immigration benefit and who is subject to medical grounds of inadmissibility must establish that he or she is not inadmissible on medical grounds.[71] See INA 212(a)(1). In general, those applying for immigration benefits while in the United States must use Form I-693(http://www.uscis.gov/i-693) to show they are free from any conditions that would render them inadmissible. 


An officer may determine that the applicant has met the burden of proof required to establish that he or she is free from a medical condition that would render the applicant inadmissible if all of the following criteria are met:



In general, if any one of the above criteria is not met, the applicant has not met the burden of proof required to establish that he or she is free of a medical condition that would render him or her inadmissible to the United States. In this case, the officer should follow standard operating procedures regarding issuance of an RFE or Notice of Intent to Deny (NOID) to address the deficiency. 


Special rules may apply to certain foreign nationals who were examined overseas, including certain nonimmigrant fiancé(e)s or spouses of U.S. citizens (K visa), spouses of lawful permanent residents (V visa), refugees, and asylee dependents. Such foreign nationals usually do not need to repeat the full medical exam in the United States for purposes of adjustment of status.[77] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for more information on these special considerations. 


Generally, the only acceptable version of Form I-693(http://www.uscis.gov/i-693) is the version in use at the time of the medical examination. Prior versions of Form I-693(http://www.uscis.gov/i-693) are generally not acceptable because they may lack necessary information.[78] See http://www.uscis.gov/i-693 for the current and accepted version(s) of the form.


Timing of the Submission of the Medical Examination Report


The medical examination report may be submitted to USCIS:


  • Concurrently with the immigration benefit application; or


 

Place of Submission of the Medical Examination Report


The medical examination report should be submitted to the appropriate location.[80] See http://www.uscis.gov/i-693 for location information.


Chapter 5: Review of Overall Findings


A. Overall Finding of Admissibility


The civil surgeon should properly complete the part addressing when the medical examinations and any follow-up examinations took place. The civil surgeon should also mark the appropriate boxes in the “Summary of Overall Findings” section. 


If the summary indicates a Class A condition, the officer should ensure that the findings in the other form sections correspond. If they do correspond, the applicant is inadmissible. If there is conflicting information, the officer should return the form to the applicant for corrective action. 

If the civil surgeon omits the summary finding entirely, the officer should check the findings in the other form sections to determine whether the applicant has a Class A condition. If all sections are properly completed, and no Class A condition has been indicated by the civil surgeon, the officer should not issue a Request for Evidence (RFE) and instead proceed with the adjudication.


If the officer is unable to determine whether the applicant has a Class A condition based on the other form sections, the officer should return the form to the applicant for corrective action. The RFE should be sent to the applicant directing him or her to return to the civil surgeon to correct the form. 


B. Changes to the Summary Findings


The Technical Instructions direct civil surgeons to treat Class A communicable diseases of public health significance or refer the applicant for treatment. Generally, the civil surgeon can only sign off upon completion of the treatment. This is why the officer may encounter a summary finding that has been reclassified from a “Class A condition” to a “Class B” or “No Class A or Class B” condition.


The officer should not reject the form because of the reclassification as long as the information is consistent with the information otherwise provided in the medical examination documentation. In such cases, the applicant is not inadmissible on health-related grounds.


For example, a civil surgeon may initially annotate the summary section with a Class A condition but, following treatment, change the annotation to a Class B condition. In this instance, the summary section may indicate an earlier Class A condition, followed by a later Class B determination. Since the civil surgeon indicated on the Form I-693(http://www.uscis.gov/i-693) that a former Class A condition is now a Class B condition, the applicant is not inadmissible on health-related grounds. 


Chapter 6: Communicable Diseases of Public Health Significance


A. Communicable Diseases


Applicants who have communicable diseases of public health significance are inadmissible.[81] See INA 212(a)(1)(A)(i). HHS has designated the following conditions as communicable diseases of public health significance that apply to immigration medical examinations conducted in the United States:[82] See 42 CFR 34.2(b).

 

  • Chancroid 


  • Gonorrhea


  • Granuloma inguinale


  • Leprosy, infectious


  • Lymphogranuloma venereum


  • Syphilis, infectious stage 


  • Tuberculosis (TB), Active—Only a Class A TB diagnosis renders an applicant inadmissible to the United States. Under current CDC guidelines, Class A TB means TB that is clinically active and communicable. 


1. Additional Communicable Diseases for Applicants Abroad


HHS regulations also list two additional general categories of communicable diseases of public health significance.[83] See 42 CFR 34.2(b)(2) and 42 CFR 34.2(b)(3).  Currently, these provisions only apply to applicants outside the United States who have to be examined by panel physicians:[84] An officer will not encounter such annotations on Form I-693, but may on the DS-2053/DS-2054. 



  • Communicable diseases that may pose a public health emergency of international concern if they meet one or more of the factors listed in 42 CFR 34.3(d)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html) and for which the Director of the CDC has determined that (A) a threat exists for importation into the United States, and (B) such disease may potentially affect the health of the American public. The determination will be made consistent with criteria established in Annex 2 of the revised International Health Regulations. HHS/CDC's determinations will be announced by notice in the Federal Register.


2. Human Immunodeficiency Virus (HIV) 


As of January 4, 2010, HIV infection is no longer defined as a communicable disease of public health significance according to HHS regulations.[86] See Pub. L. 110-293 and 42 CFR 34.2(b) as amended by 74 FR 56547 (November 2, 2009). Therefore, HIV infection does not make the applicant inadmissible on health-related grounds for any immigration benefit adjudicated on or after January 4, 2010, even if the applicant filed the immigration benefit application before January 4, 2010. 


The officer should disregard a diagnosis of HIV infection when determining whether an applicant is inadmissible on health-related grounds. The officer should administratively close any HIV waiver application filed before January 4, 2010. 


B. Parts of Form I-693(http://www.uscis.gov/i-693) Addressing Communicable Diseases 


1. Tuberculosis 


An initial screening test, either a Tuberculin Skin Test (TST) or an Interferon Gamma Release Assay (IGRA), is required for all applicants 2 years of age or older. According to the Technical Instructions, applicants under 2 years of age are required to undergo an initial screening test if there is evidence of contact with an applicant known to have TB or there is another reason to suspect TB. For more information, please see the TB Component of the Technical Instructions. 


The “testing age” is the applicant’s age on the date the civil surgeon completed the medical examination by signing the form, not the age at the time of the adjudication. An officer should not send a Request for Evidence (RFE) for testing if the applicant was properly exempt from the testing requirement due to age at the time of the medical examination. The officer, however, may always require testing if evidence indicates the applicant may have been exposed to TB since the examination.


The initial screening test results must be recorded. If the initial screening test was not administered, the exceptions should be clearly annotated in the remarks portion after the “not administered” box in the testing section. The officer should be aware that anyone who previously received the Bacille Calmette-Guérin vaccine[87] Often referred to as the “BCG” vaccine. BCG vaccine is a tuberculosis vaccination that is administered in many countries outside of the United States, especially those with a high TB rate. For more information, please see CDC’s website at www.cdc.gov.  must still undergo an initial TB screening test. These applicants are not exempt from the initial screening test. 


The civil surgeon must also annotate the “Initial Screening Test Result and Chest X-Ray Determination” section. If the section indicates that the applicant is medically cleared relating to TB, then no further TB tests are required. In this case, the X-ray section should be left blank.


If a chest X-ray is required, the chest X-ray section must be completed. If the chest X-ray is suggestive of active TB disease, the applicant must be referred to the health department for further assessment and possible treatment.[88] Under the new Technical Instructions, among other assessments, sputum cultures are required for applicants with chest X-ray findings suggestive of active TB diseases. Drug susceptibility testing is required for positive cultures results. These tests can take months to complete. Also, a referral to the health department and the TB treatment can take months. Officers, applicants, and their representatives should be aware that it can take a long time, and that the civil surgeon is not permitted to sign the Form I-693 until after follow-up assessments and treatment have been completed. The civil surgeon cannot sign off on the Form I-693(http://www.uscis.gov/i-693) until any required steps relating to TB have been completed.


Under the Technical Instructions, a pregnant applicant can defer the chest X-ray until after pregnancy but the civil surgeon may not submit the form until the chest X-ray has been performed, interpreted, and the appropriate follow-up, if required under the Technical Instructions, is completed. If the officer receives an incomplete medical examination for a pregnant applicant, the officer should return the original form to the applicant for corrective action according to established local procedures. 


Class A TB requires a referral to the TB Control Program of the Health Department for evaluation and the completion of TB treatment before the civil surgeon can sign off on the form. In this case, the referral evaluation section must be completed and evidence of treatment must accompany the form. If not, the officer should RFE for corrective action.


All Class B TB (other than Class B, latent TB) requires a referral to the Health Department for follow-up assessment before the civil surgeon can sign off on the form. In this case, the referral evaluation section must be completed. If not, the officer should RFE for corrective action.


For applicants identified with Class B, latent TB, a referral to the Health Department is only recommended under the Technical Instructions. A referral is not required and that section does not have to be completed in this case. Therefore, the officer may accept Form I-693(http://www.uscis.gov/i-693) without the referral evaluation section being completed and should not RFE.

 

Determining whether a referral is required is detailed in the TB Technical Instructions.[89] Available online at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/tuberculosis-civil-technical-instructions.html.  


2. Syphilis and Other Communicable Diseases


Serological testing for syphilis is required for applicants 15 years of age or older. Applicants under 15 years may be tested by the civil surgeon if illness is suspected. The testing age is the age on the date the civil surgeon completed the medical examination and signed the form, not the age at the time of the adjudication of the adjustment application. 


The civil surgeon must complete all “Findings” boxes for all categories. The civil surgeon may add explanatory remarks; however, the officer should not RFE simply because there are no remarks. Note that versions of Form I-693(http://www.uscis.gov/i-693) prior to the October 14, 2009 version may not have had boxes for “No Class A or B Condition” for some of these entries. In this case, the adjudicator should accept the finding reflected in the Summary Findings section of the form for the admissibility determination. 


Chapter 7: Physical or Mental Disorder with Associated Harmful Behavior


A. Physical or Mental Disorders with Associated Harmful Behavior


Applicants who have physical or mental disorders and harmful behavior associated with those disorders are inadmissible.[90] See INA 212(a)(2)(A)(iii). The inadmissibility ground is divided into two subcategories:


  • Current physical or mental disorders, with associated harmful behavior. 

  • Past physical or mental disorders, with associated harmful behavior that is likely to recur or lead to other harmful behavior. 


There must be both a physical or mental disorder and harmful behavior to make an applicant inadmissible based on this ground. Neither harmful behavior nor a physical/mental disorder alone renders an applicant inadmissible on this ground. Harmful behavior is defined as behavior that may pose, or has posed, a threat to the property, safety, or welfare of the applicant or others.


Physical or mental disorders with associated harmful behaviors are diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). Officers should consult the Technical Instructions for additional information, if needed.


Under the Technical Instructions, a diagnosis of substance abuse/addiction for a substance that is not listed in Section 202 of the Controlled Substance Act (with current associated harmful behavior or a history of associated harmful behavior judged likely to recur) is classified as a mental disorder.


Under prior Technical Instructions and the July 20, 2010 or older versions of the form, these conditions were summarized under the drug abuse/addiction part of the form. An officer, however, should not find an applicant inadmissible for “drug abuse/addiction” if a non-controlled substance is involved.


B. Relevance of Alcohol-Related Driving Arrests or Convictions


1. Alcohol Use and Driving


Alcohol is not listed in Section 202 of the Controlled Substances Act. Therefore, alcohol use disorders are treated as a physical or mental disorder for purposes of determining inadmissibility. As a result, an applicant with an alcohol use disorder will not be deemed inadmissible unless there is current associated harmful behavior or past associated harmful behavior likely to recur. The harmful behavior must be such that it poses, has posed, or is likely to pose a threat to the property, safety, or welfare of the applicant or others. 


In the course of adjudicating benefit applications, officers frequently encounter criminal histories that include arrests and/or convictions for alcohol-related driving incidents, such as DUI (driving under the influence) and DWI (driving while intoxicated). These histories may or may not rise to the level of a criminal ground of inadmissibility.[91] See INA 212(a)(2). A record of criminal arrests and/or convictions for alcohol-related driving incidents may constitute evidence of a health-related inadmissibility as a physical or mental disorder with associated harmful behavior.


Operating a motor vehicle under the influence of alcohol is clearly an associated harmful behavior that poses a threat to the property, safety, or welfare of the applicant or others. Where a civil surgeon’s mental status evaluation diagnoses the presence of an alcohol use disorder (abuse or dependence), and where there is evidence of harmful behavior associated with the disorder, a Class A medical condition should be certified on Form I-693(http://www.uscis.gov/i-693). 


2. Re-Examinations 


Requesting Re-Examinations


Some applicants may fail to report, or may underreport, alcohol-related driving incidents in response to the civil surgeon’s queries. Where these incidents resulted in an arrest, they may be subsequently revealed in the criminal history record resulting from a routine fingerprint check. Consequently, a criminal record printout revealing a significant history of alcohol-related driving arrests may conflict with the medical examination report that indicates no alcohol-related driving incidents were reported to or evaluated by the civil surgeon.


In such an instance, an officer may require the applicant to be re-examined. The re-examination would be limited to a mental status evaluation specifically considering the record of alcohol-related driving incidents. On the Request for Evidence (RFE), officers should use the following language: “Please return to the civil surgeon for purposes of conducting a mental status evaluation specifically considering the record of alcohol-related driving incidents.”


Upon re-examination, the civil surgeon may refer the applicant for further evaluation to a psychiatrist or to a specialist in substance-abuse disorders as provided for under the Technical Instructions. After such referral, the civil surgeon will determine whether a Class A medical condition exists and amend the Form I-693(http://www.uscis.gov/i-693) accordingly. The determination of a Class A condition is wholly dependent on the medical diagnosis of a designated civil surgeon. 


Re-Examination for Significant Criminal Record of Alcohol-Related Driving Incidents


Only applicants with a significant criminal record of alcohol-related driving incidents that were not considered by the civil surgeon during the original medical examination should be referred for re-examination. 


The actual criminal charges for alcohol-related driving incidents vary among the different states. A significant criminal record of alcohol-related driving incidents includes:


  • One or more arrests/convictions for alcohol-related driving incidents (DUI/DWI) while the driver’s license was suspended, revoked, or restricted at the time of the arrest due to a previous alcohol-related driving incident(s).


  • One or more arrests/convictions for alcohol-related driving incidents where personal injury or death resulted from the incident(s).


  • One or more convictions for alcohol-related driving incidents where the conviction was a felony in the jurisdiction in which it occurred or where a sentence of incarceration was actually imposed.




If the officer finds that the criminal record appears to contradict the civil surgeon’s finding in the medical examination report, then the officer should request a re-examination.


Example: An applicant’s criminal record shows that she was convicted for DWI-related vehicular manslaughter. However, the medical examination report reflects that no Class A or B physical or mental disorder was found. In this case, the officer should request a re-examination because the medical examination report finding should have reflected that the applicant has a history relating to an alcohol-related driving incident that could indicate a physical or mental disorder with associated harmful behavior. 


3. Determination Based on Re-Examination


Upon completion of the re-examination, the officer should determine whether the applicant is inadmissible. If the civil surgeon annotated a Class A condition, the applicant is inadmissible. If no Class A condition is certified by the civil surgeon, the officer may not determine that the applicant is inadmissible. In exceptional cases, the officer may seek review of the civil surgeon’s determination from CDC. 


If the applicant is inadmissible, he or she may file an application for waiver of inadmissibility.[94] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more on waivers. 


C. Relevance of Other Evidence


The guidance relating to alcohol-related driving arrests or convictions described above applies to any similar scenario where the record of proceeding contains evidence that may indicate inadmissibility due to a mental or physical disorder with associated harmful behavior that was not considered by the civil surgeon in the original medical examination. Such evidence includes, but is not limited to: 


  • A prior finding of inadmissibility due to a mental disorder. 


  • A history of institutionalization for a mental disorder. 


  • A criminal history other than drunk driving arrests/convictions, such as assaults and domestic violence, in which alcohol or a psychoactive substance was a contributing factor. 


  • Any other evidence that suggests an alcohol problem.


  • Other criminal arrests where there is a reasonable possibility of a mental disorder as a contributing factor. 


Accordingly, where the record of proceeding available to the officer contains evidence suggestive of a mental disorder, and the Form I-693(http://www.uscis.gov/i-693) medical report does not reflect that the evidence was considered by the civil surgeon, the applicant must be required to undergo a mental status re-examination by a civil surgeon specifically addressing the adverse evidence that may not have initially been revealed to the civil surgeon.


D. Parts of Form I-693(http://www.uscis.gov/i-693) Addressing Physical or Mental Disorders


The civil surgeon must check the appropriate findings box on the medical examination report. The civil surgeon should also either annotate the findings in the remarks section or attach a report, if the space provided is not sufficient. However, the officer should not RFE simply because the civil surgeon has omitted the remarks or failed to attach a report. 


Chapter 8: Drug Abuse or Drug Addiction 


A. Drug Abuse or Drug Addiction


Applicants who are found to be drug abusers or addicts are inadmissible.[95] See INA 212(a)(1)(A)(iv). Drug abuse and drug addiction are defined as the non-medical use of a controlled substance listed in Section 202 of the Controlled Substance Act. 


In 2010, CDC changed the Technical Instructions on how a civil surgeon determines whether an applicant is a drug abuser or drug addict.[96] See CDC’s Technical Instructions for Physical or Mental Disorders with Associated Harmful Behaviors and Substance-Related Disorders, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html.  The civil surgeon must now make this determination according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) as specified in the Technical Instructions.[97] The DSM is a publication of the American Psychiatric Association. Considerations that were relevant under previous Technical Instructions, such as a pattern of abuse or a history of experimental use of drugs, no longer play a direct role in the admissibility determination; they are now only considered as one of the elements under the DSM assessment. The assessment under the DSM is complicated. For more information, please see the Technical Instructions. 


If the applicant is classified as a drug abuser or addict, the applicant can apply again for an immigration benefit if his or her drug abuse or addiction is in remission. Remission is now defined by DSM criteria, and no longer by a set timeframe as it was under previous Technical Instructions.[98] Under the pre-2010 Technical Instructions, an applicant’s substance abuse or addiction was in remission if the applicant had not engaged in non-medical use of a controlled substance within the past three years, or non-medical use of a non-controlled substance within the past two years. In order for an applicant’s drug abuse or addiction to be classified as in remission, the applicant must return to a civil surgeon for a new assessment. 


If the officer has reason to question the completeness or accuracy of the medical examination report, the officer should ask CDC to review the medical report before sending a Request for Evidence (RFE).


Most applicants who are found to be drug abusers or addicts are ineligible for a waiver; the availability depends, however, on the immigration benefit the applicant seeks.[99] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more on waivers. 


B. Part of Form I-693(http://www.uscis.gov/i-693) Addressing Drug Abuse or Drug Addiction


The civil surgeon must check the appropriate findings box on the medical examination report. The civil surgeon should also either annotate the findings in the remarks section or attach a report, if the space provided is not sufficient. However, the officer should not RFE simply because the civil surgeon has omitted the remarks or failed to attach a report. 


C. Request for CDC Advisory Opinion

If an officer has a case where there is a question concerning the diagnosis and/or classification made by the civil surgeon or panel physician, the officer may forward the pertinent documents to CDC and request an advisory opinion. 

The request should include a cover letter indicating the request and reason(s) for the request.

The request should include the following documents: 

  • A copy of the medical examination documentation (Form I-693(http://www.uscis.gov/i-693) or Form DS-2053/DS-2054, and its related worksheets); 

  • A copy of the provided medical report(s) detailing the medical condition for which the advisory opinion is being requested; and 

  • Copies of all other relevant medical reports, laboratory results, and evaluations connected to the medical condition. 


The documents should be mailed to the following address: 


Centers for Disease Control and Prevention

Division of Global Migration and Quarantine

1600 Clifton Road, Mailstop E 03

Atlanta, GA 30333

Attention: Quality Assessment Program (QAP)/Advisory Opinion 

 

If the officer determines that a waiver case warrants expeditious review by CDC, the case may be faxed to (404) 639-4441 or emailed to cdcqap@cdc.gov(mailto:cdcqap@cdc.gov)Attention: Quality Assessment Program (QAP)/Advisory Opinion, Urgent. If sent via email, the documents should be sent in password protected file(s). If sent via fax, the fax cover sheet should request that the case be reviewed expeditiously and that CDC’s response be sent via fax. The officer should also email CDC a cdcqap@cdc.gov(mailto:cdcqap@cdc.gov), advising that an expedited request was sent via fax.


Once the documents are received by CDC, the documents are reviewed and CDC will forward a response letter with results of the review to the requesting USCIS office. Only CDC’s response is provided to the requesting USCIS office. 


CDC’s usual processing time for review and response back to the requesting USCIS office is approximately 4 weeks. 


Upon receipt, the officer should review CDC’s response letter to determine next steps. 


Chapter 9: Vaccination Requirement 


A. Vaccination Requirements for Immigrants


Some vaccines are expressly required by statute. Others are required because CDC has determined they are in the interest of public health.[100] Effective December 14, 2009, CDC changed its methods on how to assess which vaccines should be required for immigration purposes. This led to changes in the list of required vaccines; some that were required prior to 2009 are no longer required since December 14, 2009. 


The INA[101] See INA 212(a)(1)(A)(ii). specifies the following vaccinations:

 

  • Mumps, measles, rubella 


  • Polio 



  • Pertussis 


  • Haemophilius influenza type B 


  • Hepatitis B 


CDC requires the following additional vaccines for immigration purposes:


  • Varicella 

  • Influenza 

  • Pneumococcal pneumonia

  • Rotavirus 

  • Hepatitis A 

  • Meningococcal 


If any of the listed vaccinations are not received and the vaccinations are age appropriate and medically appropriate, the applicant is inadmissible. Generally, all age appropriate vaccine rows of the vaccination assessment must have at least one entry before the assessment can be considered to have been properly completed.


B. Blanket Waiver if Vaccine is “Not Medically Appropriate”


1. Definition of “Not Medically Appropriate”


The term “not medically appropriate” applies to: 



  • Vaccinations that cannot be administered on account of a medical contraindication (“contraindication”);

    • A contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine is given.

    • Examples of contraindications include a severe allergic reaction to a vaccination that was previously given, or pregnancy.



  • The influenza vaccine if it is not the flu season, or if the vaccine for the specific flu strain missing is no longer available (“not flu season”). 


If receiving the vaccine is not medically appropriate, the civil surgeon should indicate this medical finding on the Form I-693(http://www.uscis.gov/i-693) in the appropriate boxes. USCIS will then waive that vaccine(s).[105] See INA 212(g)(2)(B). A separate waiver application is not required for an officer to grant a waiver of the vaccination requirement as “not medically appropriate.” 


The officer should generally accept a finding by the civil surgeon that a vaccine is not medically appropriate unless that finding is clearly wrong. For example, if a vaccine was age appropriate at the time of the medical exam based on the vaccination chart,[106] See Section D, Vaccination Chart. [8 USCIS-PM B.9(D)]. but the civil surgeon marked that the vaccine is not medically appropriate because it is not age appropriate, then it is clear that the civil surgeon’s mark is incorrect. The same is true for a finding that a vaccine is not medically appropriate because it is not flu season; the officer should be able to clearly see whether the finding is correct based on the date of the medical examination. 


An officer, however, should usually defer to a civil surgeon’s finding that a vaccine is not medically appropriate because of a contraindication. This is because such a finding involves medical judgment. 


As indicated in the previous section, generally all age appropriate vaccine rows of the vaccination assessment must have at least one entry before the assessment can be considered to have been properly completed. However, if the officer can see from the record that the age appropriate vaccine was not required because, for instance, “it is not the flu season” but the civil surgeon failed to mark this on the vaccination assessment, then the officer may grant a blanket waiver despite the omission. In such cases, the officer should annotate in the “For USCIS Use Only” Remarks box in the vaccination record that a blanket waiver was granted. 


2. Pregnancy or an Immuno-Compromised Condition[107] Immuno-compromised condition refers to a medical state that does not allow the body to fight off infection. 


Some vaccines are, in general, not medically appropriate during pregnancy. These vaccines will likely be marked as contraindicated on Form I-693(http://www.uscis.gov/i-693) if the applicant was pregnant at the time of the medical examination.[108] See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate during pregnancy, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html. 


The civil surgeon may annotate in the remarks section that the applicant did not receive one or more vaccines because of a contraindication that is based on pregnancy or a condition other than pregnancy. The reason for the contraindication may be annotated by the civil surgeon on the Form I-693(http://www.uscis.gov/i-693); however, if it is omitted, the officer does not need to issue a Request for Evidence (RFE) solely for that omission as long as the contraindication is marked in the vaccine chart. 


An officer should also never issue an RFE for additional vaccines if the applicant is no longer pregnant at the time of the adjudication of the adjustment of status. As long as the vaccination assessment was properly completed by the civil surgeon at the time of the examination, the vaccination assessment can be accepted. In other words, if a woman did not receive certain required vaccines because she was pregnant at the time of the medical examination, and the contraindication box is marked by the civil surgeon, the applicant is not required to get those vaccines later at the time of the adjudication.


Likewise, some vaccines are not medically appropriate for applicants who have an immuno-compromised condition (such as HIV/AIDS or a weakened immune system because of taking certain medications) and may be marked by the civil surgeon as contraindicated.[109] See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate for immuno-compromised persons, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html. 


In the case of an immuno-compromised person, the officer should never issue an RFE for additional vaccines even if, at the time of the adjudication of adjustment of status, the applicant is no longer immuno-compromised. As long as the vaccination assessment was properly completed at the time of the examination by the civil surgeon, the vaccination assessment can be accepted. The applicant should not be required to get the missing vaccines later at the time of the adjudication.


3. Blanket Waiver due to Nationwide Vaccination Shortage


USCIS will grant a blanket waiver only in the case of a vaccination shortage if CDC recommends that USCIS should do so based on CDC’s assessment that there is a nationwide shortage. 


An officer may only grant a blanket waiver for a vaccine based on a vaccination shortage if the following circumstances are met: 


  • CDC declares that there is a nationwide vaccination shortage, and issues the appropriate statement on its website for civil surgeons; 

  • USCIS issues the appropriate statement on uscis.gov; and 

  • The civil surgeon annotates the medical examination form in compliance with any additional requirements specified by CDC or USCIS.


The grant of this blanket waiver does not differ from the grant of other blanket waivers.


4. Vaccines Not Routinely Available Abroad


“National vaccination shortage” principles do not apply overseas. In the context of overseas vaccinations, the term panel physicians use to indicate the unavailability of a vaccine is “not routinely available.” Therefore, if the adjustment applicant is permitted to use the vaccination assessment completed overseas,[110] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for more information on applicants who may use the vaccination assessment completed overseas for adjustment purposes. then officers should not find the applicant inadmissible solely based on the lack of the vaccine(s) that is “not routinely available.” Officers should also not issue an RFE for corrective action. USCIS will grant a blanket waiver in these cases.


C. Adjudication Steps 


Vaccination Requirement: Adjudication Steps

Step 1

Determine which vaccination(s) were age appropriate for the applicant to receive based on the applicant’s age on the date the medical exam was completed.[111] See Section D, Vaccination Chart [8 USCIS-PM B.9(D)] for a chart of vaccine requirements by age.  


Step 2

Verify that any vaccine that was required (age appropriate)[112] Since the applicant was not required to receive non-age appropriate vaccines at the time of the medical exam, the officer does not need to review these vaccine rows at the time of adjudication. as of the date of the medical exam is marked as:


  • Received by the applicant; or 


  • “Not medically appropriate” because of contraindication, inappropriate time interval, or not flu season.


Step 3

If the required (age appropriate) vaccinations were not received or not marked as “not medically appropriate” as of the date the medical exam was completed, determine whether the missing vaccinations would still be required as of the date of adjudication. 


Vaccinations missing at the time of the medical exam may no longer be required as of the date of adjudication if, for example, the applicant has aged out, or it is not the flu season, or a vaccine is no longer required by law.


Step 4

If the missing vaccinations are no longer required as of the date of the adjudication, the vaccination requirements have been met. 


Step 5

If the missing vaccinations would still be required, the officer should send an RFE for an updated Form I-693(http://www.uscis.gov/i-693) showing the applicant has received those vaccinations.



D. Vaccination Chart 


CDC’s most updated vaccination table for civil surgeons can be located through the following link: Vaccination Chart in Technical Instructions(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html#tbl1).


USCIS officers should rely on the following chart to determine inadmissibility based on failure to meet the vaccination requirements. This chart is specifically made for USCIS and is updated as of January 28, 2014. 


The chart is not intended to be used by civil surgeons. 


Vaccination Chart

Age of Applicant

Age Appropriate Vaccinations 

(Required for Immigration Purposes)

Birth through 5 weeks

  • Hepatitis B

6 weeks through 7 weeks

  • Hepatitis B

  • Rotavirus

2 months through 5 months

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • Hib

  • Hepatitis B

  • Pneumococcal (for PCV)

  • Rotavirus

6 months through 7 months

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • Hib

  • Hepatitis B

  • Pneumococcal (for PCV)

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

  • Rotavirus

8 months through 11 months

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • Hib

  • Hepatitis B

  • Pneumococcal (for PCV)

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

12 months through 23 months

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • MMR

  • Hib

  • Hepatitis B

  • Varicella

  • Pneumococcal (for PCV)

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

  • Hepatitis A

2 years through 4 years

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • MMR

  • Hib

  • Hepatitis B

  • Varicella

  • Pneumococcal (for PCV)

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

5 years through 6 years

  • DT, DTP, or DTaP

  • IPV or OPV (Note: OPV not administered in U.S.)

  • MMR

  • Hepatitis B

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

7 years through 10 years

  • Td or Tdap 

  • IPV or OPV (Note: OPV not administered in U.S.)

  • MMR

  • Hepatitis B

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

11 years through 17 years

  • Td or Tdap 

  • IPV or OPV (Note: OPV not administered in U.S.)

  • MMR

  • Hepatitis B

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

  • Meningococcal

18 years

  • Td or Tdap 

  • MMR

  • Hepatitis B

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

  • Meningococcal

19 years through 49 years

  • Td or Tdap 

  • MMR

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

50 years through 59 years

  • Td or Tdap 

  • MMR (if born in 1957 or later)

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

60 years through 64 years

  • Td or Tdap 

  • Varicella

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)

65 years and older

  • Td 

  • Varicella

  • Pneumococcal (for PPV)

  • Influenza (during flu season only; Oct. 1 thru Mar. 31)


E. Special Vaccination Considerations


Additionally, officers should pay special attention to the following developments.


1. Human Papillomavirus (HPV) Vaccination


From August 1, 2008 through December 13, 2009, HPV vaccination was required for female applicants ages 11 years through 26 years. The requirement was eliminated on December 14, 2009, and affects any admissibility determination under INA 212(a)(1)(A)(ii)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2309) on that date or thereafter. Therefore, for adjudications taking place on or after December 14, 2009, officers should disregard any annotation of the HPV vaccine, or the lack thereof, on Form I-693(http://www.uscis.gov/i-693) or U.S. Department of State’s Vaccination Documentation Worksheet (Form DS-3025), when determining whether the vaccination requirements are met. 

2. Zoster Vaccination


From August 1, 2008 through December 13, 2009, the zoster vaccination was required for applicants ages 60 years or older unless the applicant had received the varicella vaccine.


The zoster vaccine, however, was not available in the United States due to a nationwide shortage from the time it became mandatory. Therefore, even though the vaccine was missing, the Form I-693(http://www.uscis.gov/i-693) could be accepted if the physician was unable to obtain the vaccine. 


On December 14, 2009, the zoster vaccine was removed from the list of required vaccines for immigration purposes, and the change affects any admissibility determination made on or after that date. Therefore, officers should disregard any annotation of the zoster vaccine, or the lack thereof, on any Form I-693(http://www.uscis.gov/i-693) or U.S Department of State’s Vaccination Documentation Worksheet (Form DS-3025), when determining whether the vaccination requirements are met. 

3. Influenza Vaccination


The flu vaccination is only available during the flu season. For purposes of Form I-693(http://www.uscis.gov/i-693), the flu season commences annually on October 1 and runs through March 31.


Over time, CDC has changed the age category of applicants required to obtain the flu vaccine for immigration purposes. As of November 16, 2010, CDC’s Technical Instructions require that all applicants 6 months of age or older receive the flu vaccine during the flu season.


If an applicant was required to obtain the flu vaccine at the time of the medical examination (the date of the civil surgeon’s certification governs) but a flu vaccine annotation is missing, the officer should only issue an RFE if it is still the same flu season and if it is reasonable to expect that the applicant will be able to obtain the flu vaccine within the time frame of the RFE.


This accounts for the fact that the flu vaccine is strain-specific and only available for a limited time each year. The officer should not issue an RFE if the applicant will not be able to obtain the strain-specific flu vaccine that had been required at the time of the medical examination because:


  • It is no longer the same flu season; or

  • It is not the flu season at all.


4. Vaccination Requirements Prior to August 1, 2008


The following vaccines were NOT required prior to August 1, 2008: Hepatitis A, meningococcal, rotavirus, human papillomavirus (HPV), and zoster.[113] Please see information immediately above for the zoster and the HPV vaccine, since these vaccines have not been required since December 2009. 


F. Completion of the Results Section by the Civil Surgeon


According to the Vaccination Component of the Technical Instructions, the civil surgeon should mark the appropriate results box at the bottom of the vaccination assessment chart. The Technical Instructions direct the civil surgeon to only check one appropriate box. 


The officer should be aware that civil surgeons may improperly mark the boxes because they may misunderstand the meaning of these boxes. Therefore, the officer should determine, from the vaccination assessment completed by the civil surgeon, whether the applicant received all vaccines, which blanket waivers should be granted, and whether the applicant requires any other waivers. The officer should exercise discretion in reviewing the vaccination chart and when evaluating the results boxes at the bottom of the vaccination assessment chart. 


If the civil surgeon did not check any result boxes, the officer should only return the form for corrective action if he or she is unable to ascertain whether the applicant is admissible. The officer should never alter or complete sections on the medical examination report that are the responsibility of the civil surgeon, such as the results boxes.


The results boxes and their meanings are described below (according to the Vaccination Component of the Technical Instructions).


Vaccination Record: Explanation of Results

Applicant may be eligible for blanket waiver(s) as indicated above 

This box will usually be checked because some vaccines may not be age appropriate for the applicant, a vaccination series could not be completed, there was a contraindication, or because of any other condition noted in the “Not Medically Appropriate” heading.

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


If an applicant objects to one of the vaccines based on religious or moral convictions, the "Applicant will request an individual waiver based on religious or moral convictions" box must be checked. 

This is not a blanket waiver, and the applicant will have to submit a waiver request on Form I-601(http://www.uscis.gov/i-601)

Even if the applicant otherwise requires a blanket waiver(s), the civil surgeon must check this box, and not the box titled “Applicants may be eligible for blanket waivers.” It may be, however, that the civil surgeon checks both boxes, in which case, the officer should just request the waiver documentation that establishes the religious or moral conviction.

Vaccine history complete for each vaccine, all requirements met 

If the applicant has met the vaccination requirements, i.e., completed the series for all required vaccines, the "Vaccine history complete for each vaccine, all requirements met" box must be checked.

Applicant does not meet immunization requirements 


If an applicant's vaccine history is incomplete and the applicant refuses administration of a single dose of any required vaccine that is medically appropriate for the applicant, the "Applicant does not meet immunization requirements" box must be checked.

If this box is checked, the applicant may be inadmissible. Depending on the case, the officer should ask for the reason through an RFE, Notice of Intent to Deny (NOID), or an interview. 

If the applicant refused to be vaccinated on account of a religious or moral conviction, the officer should direct the applicant to file a waiver. If the applicant had no religious or moral reason for refusal, the applicant is inadmissible. 

The officer should not return the assessment to the civil surgeon if he or she has enough information to determine health-related inadmissibility.


G. Exception for Certain Adopted Children


Some children are not subject to the vaccination requirement[114] Under INA 212(a)(1)(C), as amended by Section 2 of the International Adoption Simplification Act, Pub. L. 111-287, 124 Stat. 3058 (2010). if all of the following conditions are met: 



For the child to benefit from this exception, the adopting parent(s) must sign an affidavit prior to the immigrant visa issuance, affirming that the child will receive the required vaccination within 30 days of admission to the United States or at the earliest time that is medically appropriate. However, noncompliance with the vaccination requirements following the child's admission to the United States is not a ground for removal. 


The Department of State has developed a standard affidavit form, Affidavit Concerning Exemption from Immigrant Vaccination Requirements for a Foreign Adopted Child (Form DS-1981), to ensure that adopting parents are aware of the possibility of an exception from the vaccination requirements and of their obligation to ensure that the child is vaccinated following admission.[117] The affidavit is made under oath or affirmation in the presence of either the consular officer or a notary public. The completed form must be submitted to the consulate as part of the immigrant visa application.


Only orphans or Convention adoptees whose adoptive or prospective adoptive parents have signed an affidavit will be exempt from the vaccination requirement. If the adopting parent(s) prefers that the child meet the vaccination requirement as part of the visa application process, the child may benefit from the waiver(s) for those vaccinations which the panel physician determines are medically inappropriate.[118] See INA 212(g)(2)(B). This waiver authority has been delegated to the Department of State and a consular officer can grant the waiver. Neither a form nor a fee is required.


When the adoptive or prospective adoptive parent cannot sign the affidavit in good faith because of religious or moral objections to vaccinations, the child will require a waiver.[119] When the waiver application is for a child, the child’s parent must satisfy the waiver requirements under INA 212(g)(2)(C). The waiver is filed by submitting an Application For Waiver of Grounds of Inadmissibility (Form I-601), along with the required fee. See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility, Chapter 3, Waiver of Immigrant Vaccination Requirement [9 USCIS-PM C.3] for more information on the requirements for vaccination waivers based on religious beliefs or moral objections.  


Chapter 10: Other Medical Conditions 


The civil surgeon should annotate any other medical condition the applicant may have, as directed by the Technical Instructions. A condition annotated in this section does not render the applicant inadmissible on health-related grounds of inadmissibility. However, it may impact other inadmissibility determinations. 


Chapter 11: Inadmissibility Determination


A. Civil Surgeon or Panel Physician Documentation


If a “Class A condition” is noted on the medical form, it is conclusive evidence that the applicant is inadmissible. The Class A annotation may also indicate that an applicant could be inadmissible on other grounds of inadmissibility. For example, “harmful behavior” associated with a physical or mental disorder, or illegal drug use, may have resulted in criminal convictions that make an applicant inadmissible under INA 212(a)(2)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-1203). However, a criminal conviction should be supported by conviction records or similar evidence, and not just the medical examination report.[120] See Section D, Other Grounds of Inadmissibility [8 USCIS-PM B.11(D)] for more information. 

 

If a civil surgeon or panel physician only annotates a “Class B condition” (per HHS regulations), the applicant is never inadmissible on health-related grounds. The officer should remember that if the civil surgeon or panel physician indicates on the Form I-693(http://www.uscis.gov/i-693) that a former Class A condition is now a Class B condition, the applicant is no longer inadmissible. However, a Class B condition may indicate that the applicant could be inadmissible on other grounds because of the condition, such as public charge.[121] See Section D, Other Grounds of Inadmissibility [8 USCIS-PM B.11(D)] for more information. 


The officer may encounter medical documentation that is not fully completed. In this case, the officer should issue a Request for Evidence (RFE). If the physician fails to properly complete the form in response to the RFE, the applicant has not established that he or she is clearly admissible to the United States.[122] See INA 291.  


B. Applicant’s Declaration


If the applicant indicates that he or she may be inadmissible based on a medical reason, the officer must order a medical examination of the applicant. Based on the results of that medical exam, the officer should ascertain whether the applicant actually has a Class A, Class B, or no condition at all that is relevant to the applicant’s admissibility. The applicant should not be found inadmissible unless the medical examination confirms the presence of a Class A medical condition.

 

C. Other Information 


Even if the civil surgeon or panel physician did not annotate a Class A or B condition in the medical documentation, or if the applicant was not required to undergo a medical examination, the officer may order or reorder an immigration medical examination at any time if he or she has concerns as to an applicant’s inadmissibility on health-related grounds. 


The concern should be based on information in the A-file, information that is revealed by the applicant or another applicant during an interview, or information revealed during a background investigation. 


D. Other Grounds of Inadmissibility


1. General Considerations


Where relevant, the information contained in the medical examination can be used to determine whether other grounds of inadmissibility may apply. For instance, health is one factor to consider when determining if someone is inadmissible on public charge grounds. This factor must, however, be considered in light of all other factors specified by law[123] See INA 212(a)(4)(B). and in standard public charge guidance.[124] Whether the person is likely to become a public charge is determined according to standard public charge guidance: Is it likely that the person will become primarily dependent on the Government for subsistence, as shown by (a) receipt of public cash assistance for income maintained or (b) long-term institutionalization at public expense? See 64 FR 28689 (1999).   


2. Criminal Grounds

 

An applicant may be inadmissible on criminal grounds if he or she has admitted to committing certain controlled substance violations.[125] See INA 212(a)(2)(A). An applicant may acknowledge to a civil surgeon or a panel physician that he or she has used a controlled substance, which the physician then may annotate on the medical documentation. 


USCIS does not consider this acknowledgement, in and of itself, a valid admission that would make an applicant inadmissible on criminal grounds.[126] A valid admission (absent a conviction) for purposes of criminal inadmissibility grounds “requires that the [foreign national] be given an adequate definition of the crime, including all essential elements, and that it be explained in understandable terms.” See Matter of K-, 7 I&N Dec. 594 (BIA 1957).  However such an acknowledgment of drug use may open a line of questioning to determine criminal inadmissibility. USCIS Officers should find that an applicant has made a valid “admission” of a crime only when the admission is made in accordance with the requirements outlined by the Board of Immigration Appeals (BIA).[127] See Matter of K-, 7 I&N Dec. 594 (BIA 1957). Even in the Ninth Circuit, USCIS officers should continue to follow Matter of K-, rather than Pazcoguin v. Radcliffe, 292 F.3d 1209 (9th Cir. 2002). Following Matter of K- will ensure that any admission the person may make is a fully informed one.    

 

E. Privacy Concerns


An officer should take great care to regard the privacy of the applicant. The officer should generally not discuss the applicant’s medical issues with applicants other than the applicant, his or her counsel, immigration officers, or other government officials[128] Such as CDC. who clearly have a need to know the information.


The officer should not directly contact a civil surgeon to discuss an applicant’s inadmissibility or medical issues. If the officer has any concerns that cannot be resolved by reviewing the evidence in the record, the officer should issue an RFE.


Chapter 12: Waiver Authority


USCIS may provide waivers for some medical grounds of inadmissibility under INA 212(g)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006/0-0-0-2364.html#0-0-0-2813) and other provisions governing the specific immigration benefit the applicant is seeking. In certain cases, applicants must file a waiver application[129] See Application for Waiver of Grounds of Inadmissibility (Form I-601), Application By Refugee for Waiver of Grounds of Exludability (Form I-602), or Application for Waiver of Grounds of Inadmissibility Under Section 245A or 210 of the Immigration and Nationality Act (Form I-690). either along with their Application to Register Permanent Residence or Adjust Status (Form I-485(http://www.uscis.gov/i-485)) and Report of Medical Examination and Vaccination Record (Form I-693(http://www.uscis.gov/i-693)) or in response to a Request for Evidence (RFE).[130] See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C] for more information on waivers of medical grounds of inadmissibility. 





Footnotes


1. [^] 

 See Immigration Act of 1882, 22 Stat. 214.

2. [^] 

 See Immigration Act of 1891, 26 Stat. 1084. 

3. [^] 

 See Immigration Act of 1990 (IMMACT 90), Pub. L. 101-649.

4. [^] 

 See Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104-208 and INA 212(a)(1)(A)(ii)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2309).

5. [^] 

 Officers and designated physicians must obtain the Technical Instructions from CDC’s website at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/index.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/index.html). Updates to the Technical Instructions must also be followed.

6. [^] 

 CDC can be reached at cdcqap@cdc.gov(mailto:cdcqap@cdc.gov). Officers should identify themselves as an immigration officer in the e-mail. This e-mail address is not for inquiries from the public. It is only for inquiries from immigration officers and civil surgeons. Inquiries from the public should be submitted to CDC INFO at http://www.cdc.gov/cdc-info/requestform.html(http://www.cdc.gov/cdc-info/requestform.html)

7. [^] 

 See INA 212(a)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-1201).

8. [^] 

 See INA 212(a)(1)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2303).

9. [^] 

 See INA 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-5339.html).

10. [^] 

 Report of Medical Examination and Vaccination Record (Form I-693(http://www.uscis.gov/i-693)); Medical Examination for Immigrant or Refugee Applicant (1991 TB Technical Instructions) (Form DS-2053) or the Medical Examination for Immigrant or Refugee Applicant (2007 TB Technical Instructions) (Form DS-2054), and related worksheets.

11. [^] 

 Available online at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html)

12. [^] 

 See 42 CFR 34(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html).

13. [^] 

 Class A conditions are medical conditions mentioned in INA 212(a)(1)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2303).

14. [^] 

 See 42 CFR 34.2(e)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html).

15. [^] 

 See INA 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-5339.html) and 8 CFR 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-22375.html#0-0-0-8887a).

16. [^] 

 Based on the conditions listed in INA 212(a)(1)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2301).

17. [^] 

 See INA 212(d)(5)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006/0-0-0-2364.html#0-0-0-2759).

18. [^] 

 See Matter of Arthur, 16 I&N Dec. 558 (BIA 1978) (The applicant has the burden of proof to establish his or her admissibility to the United States according to INA 291(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-9611.html); the burden never shifts to the government).

19. [^] 

 Special considerations that apply to certain benefit types are noted in Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

20. [^] 

 See INA 248(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-8006.html). See 8 CFR 214.1(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-17205.html#0-0-0-9207) and 8 CFR 248(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-27672.html#0-0-0-8921a).

21. [^] 

 See Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

22. [^] 

 See INA 244(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-7238.html).

23. [^] 

 See Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

24. [^] 

 See INA 214(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-3422/0-0-0-3594.html). See 8 CFR 214.2(k)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-18881.html#0-0-0-12701) and 8 CFR 214.15(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-21812.html#0-0-0-12739).

25. [^] 

 See INA 214(q)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-3422/0-0-0-3827.html#0-0-0-3559) and 8 CFR 214.15(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-21812.html#0-0-0-12739). 

26. [^] 

 See INA 245(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-7418.html) and 8 CFR 245(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-24520.html#0-0-0-8913a).

27. [^] 

 See Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

28. [^] 

 See INA 207(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1625.html) and 8 CFR 207.7(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-14843.html#0-0-0-8853a). See INA 208(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1687.html) and 8 CFR 208.21(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-14927/0-0-0-15394.html#0-0-0-11375).

29. [^] 

 See INA 207(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1625.html) and 8 CFR 207(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-14843.html#0-0-0-8853a).

30. [^] 

 See INA 208(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1687.html) and 8 CFR 208(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-14927.html#0-0-0-8855a).

31. [^] 

 See INA 208(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1687.html) and 8 CFR 208.21(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-14927/0-0-0-15394.html#0-0-0-11375).

32. [^] 

 See INA 209(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1825.html) and 8 CFR 209.1(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15531.html#0-0-0-11769).

33. [^] 

 See Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

34. [^] 

 Including State or local health department physicians, who are blanket designated by USCIS as civil surgeons for purposes of completing the vaccination record for refugees adjusting status only.

35. [^] 

 See INA 209(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1825.html) and 8 CFR 209.2(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15551.html#0-0-0-11771).

36. [^] 

 See Section B, Special Considerations [8 USCIS-PM B.3(B)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html#S-B)].

37. [^] 

 See 8 CFR 289.1(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-30277/0-0-0-30282.html#0-0-0-19241) and 8 CFR 289.2(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-30277/0-0-0-30287.html#0-0-0-19243). American Indians born in Canada who meet the regulatory requirements may be regarded as having been admitted for lawful permanent residence. Because neither an immigrant visa nor an adjustment of status application is required, the applicant is not required to comply with the medical examination and vaccination requirements.

38. [^] 

 See INA 101(a)(27)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-195.html#0-0-0-845) and 22 CFR 42.22(http://www.uscis.gov/ilink/docView/22CFR/HTML/22CFR/0-0-0-1/0-0-0-1978/0-0-0-2091.html#0-0-0-443). 

39. [^] 

 See INA 101(b)(1)(F)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-434.html#0-0-0-1153), including Hague Convention Adoptees.

40. [^] 

 See INA 214(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-3422/0-0-0-3594.html). See 8 CFR 214.2(k)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-18881.html#0-0-0-12701) and 8 CFR 214.15(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-17197/0-0-0-21812.html#0-0-0-12739). See 9 FAM 41.108 Note 1.2(http://www.state.gov/documents/organization/87492.pdf).

41. [^] 

 See INA 245(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-7418.html) and 8 CFR 245(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-24520.html#0-0-0-8913a).

42. [^] 

 See 8 CFR 245.5(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-24520/0-0-0-24763.html#0-0-0-16053).

43. [^] 

 See Volume 9, WaiversPart C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC.html)] for more information on medical waivers.

44. [^] 

 Under INA 214(q)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-3422/0-0-0-3827.html#0-0-0-3559).

45. [^] 

 See INA 209(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-1825.html) and 8 CFR 209.1(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15531.html#0-0-0-11769).

46. [^] 

 See 8 CFR 209.1(c)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15531.html#0-0-0-11781).

47. [^] 

 See 8 CFR 209.1(c)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15531.html#0-0-0-11781).

48. [^] 

 See 8 CFR 209.2(d)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-15524/0-0-0-15551.html#0-0-0-11809).

49. [^] 

 See INA 101(a)(27)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-195.html#0-0-0-845) and 22 CFR 42.22(http://www.uscis.gov/ilink/docView/22CFR/HTML/22CFR/0-0-0-1/0-0-0-1978/0-0-0-2091.html#0-0-0-443). 

50. [^] 

 See INA 101(b)(1)(F)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-434.html#0-0-0-1153). See Chapter 9, Vaccination Requirement, Section G, Exceptions for Certain Adopted Children [8 USCIS-PM B.9(G)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter9.html#S-G)] for more on this exception.

51. [^] 

 See INA 212(a)(1)(C)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2321), as amended by Section 2 of the International Adoption Simplification Act, Pub. L. 111-287, 124 Stat. 3058 (2010).

52. [^] 

 As of October 1, 2013, panel physicians only use DS-2054. The DS-2053 is no longer used after that date.

53. [^] 

 The Technical Instructions for Panel Physicians may differ from the Technical Instructions for Civil Surgeons. As long as the DS form is properly completed, the officer should accept the finding of the consular officer as correct.

54. [^] 

 In this case, because the DS form was completed by a panel physician, the officer should retain the original document. The RFE must specify which sections of Form I-693(http://www.uscis.gov/i-693) have to be completed by a civil surgeon.

55. [^] 

 See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html)] for specific information on who is required to be examined and to what extent.

56. [^] 

 Form I-693(http://www.uscis.gov/i-693) can only be used for immigration benefits that are granted in the United States.

57. [^] 

 See INA 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-5339.html) and 8 CFR 232(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-22375.html#0-0-0-8887a).

58. [^] 

 Some parts of the form may not be required. For example, if an applicant is not required to undergo a chest X-ray in the TB section of the medical examination report, the chest X-ray section would not have to be completed.

59. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html#S-C-3)].

60. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html#S-C-3)].

61. [^] 

 See Subsection 3, Signatures [8 USCIS-PM B.4(C)(3)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html#S-C-3)].

62. [^] 

 See Subsection 4, Validity Period of Form I-693 (Including Use of Prior Versions) [8 USCIS-PM B.4(C)(4)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html#S-C-4)].

63. [^] 

As part of completing the Form I-693(http://www.uscis.gov/i-693), the civil surgeon must ensure that the applicant has signed the applicant’s certification.

64. [^] 

 Along with the original Form I-693(http://www.uscis.gov/i-693), if separate from the corrected form. 

65. [^] 

 See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC.html)] for more on waivers.

66. [^] 

 See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartC.html)] for more information on the blanket civil surgeon designation for health departments.

67. [^] 

 See Part C, Civil Surgeon Designation and Revocation [8 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartC.html)for more information on the blanket civil surgeon designation for military physicians.

68. [^] 

 By signing the form, the civil surgeon certifies that he or she has examined the applicant according to the procedures and requirements outlined in the Technical Instructions, Form I-693(http://www.uscis.gov/i-693), and form instructions. Officers do not need to verify whether the civil surgeon instructed the referring physician to check the applicant’s identity.

69. [^] 

 See 8 CFR 103.2(a)(2)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-11261/0-0-0-11630/0-0-0-11646.html#0-0-0-9429). 

70. [^] 

 Civil surgeons are, however, still responsible for ensuring that the contractor properly checks the applicant’s ID. 

71. [^] 

 See INA 212(a)(1)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2301).

72. [^] 

 See Section C, Documentation Completed by Civil Surgeon [8 USCIS-PM B.4(C)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter4.html#S-C)]. 

73. [^] 

 USCIS will use the date the Form I-693(http://www.uscis.gov/i-693) was signed by the civil surgeon (including blanket-designated health departments and military physicians) to determine whether the report was submitted less than one year after completion of the examination.

74. [^] 

 For example, an Application to Register Permanent Residence or Adjust Status (Form I-485(http://www.uscis.gov/i-485)).

75. [^] 

 USCIS will use the date that USCIS received the Form I-693(http://www.uscis.gov/i-693) to determine whether the medical examination report is more than one year old at time of adjudication of the benefit application. Although the medical examination report is generally valid for adjudicatory purposes up to one year after filing, the officer may order an additional immigration medical examination at any time if he or she has concerns as to an applicant’s inadmissibility on health-related grounds. For more information, see Chapter 11, Inadmissibility Determination, Section C, Other Information [8 USCIS-PM B.11(C)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html#S-C)].

76. [^] 

 For more information on determining inadmissibility based on medical grounds, see Chapter 5, Review of Overall Findings [8 USCIS-PM B.5(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter5.html)] through Chapter 11, Inadmissibility Determination [8 USCIS-PM B.11(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html)].

77. [^] 

 See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html)] for more information on these special considerations.

78. [^] 

 See http://www.uscis.gov/i-693(http://www.uscis.gov/i-693) for the current and accepted version(s) of the form.

79. [^] 

 This includes a request to bring the medical examination report to the interview.

80. [^] 

 See http://www.uscis.gov/i-693(http://www.uscis.gov/i-693) for location information.

81. [^] 

 See INA 212(a)(1)(A)(i)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2305).

82. [^] 

 See 42 CFR 34.2(b)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html).

83. [^] 

 See 42 CFR 34.2(b)(2)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html) and 42 CFR 34.2(b)(3)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html). 

84. [^] 

 An officer will not encounter such annotations on Form I-693(http://www.uscis.gov/i-693), but may on the DS-2053/DS-2054.

85. [^] 

 The current revised list of quarantinable communicable diseases is available at http://www.cdc.gov(http://www.cdc.gov) and http://www.archives.gov/federal-register(http://www.archives.gov/federal-register). 

86. [^] 

 See Pub. L. 110-293 and 42 CFR 34.2(b)(http://www.uscis.gov/sites/default/files/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-44228.html) as amended by 74 FR 56547 (November 2, 2009).

87. [^] 

 Often referred to as the “BCG” vaccine. BCG vaccine is a tuberculosis vaccination that is administered in many countries outside of the United States, especially those with a high TB rate. For more information, please see CDC’s website at www.cdc.gov(http://www.cdc.gov). 

88. [^] 

 Under the new Technical Instructions, among other assessments, sputum cultures are required for applicants with chest X-ray findings suggestive of active TB diseases. Drug susceptibility testing is required for positive cultures results. These tests can take months to complete. Also, a referral to the health department and the TB treatment can take months. Officers, applicants, and their representatives should be aware that it can take a long time, and that the civil surgeon is not permitted to sign the Form I-693(http://www.uscis.gov/i-693) until after follow-up assessments and treatment have been completed.

89. [^] 

 Available online at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/tuberculosis-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/tuberculosis-civil-technical-instructions.html). 

90. [^] 

 See INA 212(a)(2)(A)(iii)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2327).

91. [^] 

 See INA 212(a)(2)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-1203).

92. [^] 

 See CDC’s Technical Instructions for Physical or Mental Disorders with Associated Harmful Behaviors and Substance-Related Disorders, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html).

93. [^] 

 See CDC’s Technical Instructions for Physical or Mental Disorders with Associated Harmful Behaviors and Substance-Related Disorders, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html).

94. [^] 

 See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC.html)] for more on waivers.

95. [^] 

 See INA 212(a)(1)(A)(iv)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2317).

96. [^] 

 See CDC’s Technical Instructions for Physical or Mental Disorders with Associated Harmful Behaviors and Substance-Related Disorders, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html). 

97. [^] 

 The DSM is a publication of the American Psychiatric Association. Considerations that were relevant under previous Technical Instructions, such as a pattern of abuse or a history of experimental use of drugs, no longer play a direct role in the admissibility determination; they are now only considered as one of the elements under the DSM assessment. The assessment under the DSM is complicated. For more information, please see the Technical Instructions.

98. [^] 

 Under the pre-2010 Technical Instructions, an applicant’s substance abuse or addiction was in remission if the applicant had not engaged in non-medical use of a controlled substance within the past three years, or non-medical use of a non-controlled substance within the past two years.

99. [^] 

 See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC.html)] for more on waivers.

100. [^] 

 Effective December 14, 2009, CDC changed its methods on how to assess which vaccines should be required for immigration purposes. This led to changes in the list of required vaccines; some that were required prior to 2009 are no longer required since December 14, 2009. 

101. [^] 

 See INA 212(a)(1)(A)(ii)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2309).

102. [^] 

 Applicants who have completed the initial DTP/DTaP/DT or Td/Tdap series should receive a Td/Tdap booster shot every 10 years. If the last dose was received more than 10 years ago, the applicant is required to have the booster shot, otherwise the applicant is inadmissible under INA 212(a)(1)(A)(ii)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2309).

103. [^] 

 See Section D, Vaccination Chart [8 USCIS-PM B.9(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter9.html#S-D)] for more information.

104. [^] 

 In these cases, the civil surgeon will administer the dose due at the time of the medical examination and mark on the form that there is not sufficient time to complete the entire vaccination series (insufficient time interval).

105. [^] 

 See INA 212(g)(2)(B)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006/0-0-0-2364.html#0-0-0-2827).

106. [^] 

 See Section D, Vaccination Chart. [8 USCIS-PM B.9(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter9.html#S-D)].

107. [^] 

 Immuno-compromised condition refers to a medical state that does not allow the body to fight off infection.

108. [^] 

 See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate during pregnancy, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html). 

109. [^] 

 See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate for immuno-compromised persons, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html(http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html). 

110. [^] 

 See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter3.html)] for more information on applicants who may use the vaccination assessment completed overseas for adjustment purposes.

111. [^] 

 See Section D, Vaccination Chart [8 USCIS-PM B.9(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter9.html#S-D)] for a chart of vaccine requirements by age

112. [^] 

 Since the applicant was not required to receive non-age appropriate vaccines at the time of the medical exam, the officer does not need to review these vaccine rows at the time of adjudication.

113. [^] 

 Please see information immediately above for the zoster and the HPV vaccine, since these vaccines have not been required since December 2009.

114. [^] 

 Under INA 212(a)(1)(C)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2321), as amended by Section 2 of the International Adoption Simplification Act, Pub. L. 111-287, 124 Stat. 3058 (2010).

115. [^] 

 See INA 101(b)(1)(F)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-434.html#0-0-0-1153) and INA 101(b)(1)(G)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-101/0-0-0-434.html#0-0-0-1161), respectively.

116. [^] 

 Under INA 201(b)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-914.html#0-0-0-1157); a child can either obtain an IR-3 or IR-4 immigrant visa as an immediate relative if the child is an “orphan” or an IH-3 or IH-4 immigrant visa if the child is a Hague Convention adoptee.

117. [^] 

 The affidavit is made under oath or affirmation in the presence of either the consular officer or a notary public.

118. [^] 

 See INA 212(g)(2)(B)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006/0-0-0-2364.html#0-0-0-2827). This waiver authority has been delegated to the Department of State and a consular officer can grant the waiver. Neither a form nor a fee is required.

119. [^] 

 When the waiver application is for a child, the child’s parent must satisfy the waiver requirements under INA 212(g)(2)(C)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006/0-0-0-2364.html#0-0-0-2829). The waiver is filed by submitting an Application For Waiver of Grounds of Inadmissibility (Form I-601(http://www.uscis.gov/i-601)), along with the required fee. See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility, Chapter 3, Waiver of Immigrant Vaccination Requirement [9 USCIS-PM C.3(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC-Chapter3.html)] for more information on the requirements for vaccination waivers based on religious beliefs or moral objections. 

120. [^] 

 See Section D, Other Grounds of Inadmissibility [8 USCIS-PM B.11(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html#S-D)] for more information.

121. [^] 

 See Section D, Other Grounds of Inadmissibility [8 USCIS-PM B.11(D)(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume8-PartB-Chapter11.html#S-D)] for more information.

122. [^] 

 See INA 291(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-9611.html).

123. [^] 

 See INA 212(a)(4)(B)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2489).

124. [^] 

 Whether the person is likely to become a public charge is determined according to standard public charge guidance: Is it likely that the person will become primarily dependent on the Government for subsistence, as shown by (a) receipt of public cash assistance for income maintained or (b) long-term institutionalization at public expense? See 64 FR 28689 (1999)

125. [^] 

 See INA 212(a)(2)(A)(http://www.uscis.gov/ilink/docView/SLB/HTML/SLB/0-0-0-1/0-0-0-29/0-0-0-2006.html#0-0-0-2327).

126. [^] 

 A valid admission (absent a conviction) for purposes of criminal inadmissibility grounds “requires that the [foreign national] be given an adequate definition of the crime, including all essential elements, and that it be explained in understandable terms.” See Matter of K-, 7 I&N Dec. 594 (BIA 1957)

127. [^] 

 See Matter of K-, 7 I&N Dec. 594 (BIA 1957). Even in the Ninth Circuit, USCIS officers should continue to follow Matter of K-, rather than Pazcoguin v. Radcliffe, 292 F.3d 1209 (9th Cir. 2002). Following Matter of K- will ensure that any admission the person may make is a fully informed one

128. [^] 

 Such as CDC.

129. [^] 

 See Application for Waiver of Grounds of Inadmissibility (Form I-601(http://www.uscis.gov/i-601)), Application By Refugee for Waiver of Grounds of Exludability (Form I-602(http://www.uscis.gov/i-602)), or Application for Waiver of Grounds of Inadmissibility Under Section 245A or 210 of the Immigration and Nationality Act (Form I-690(http://www.uscis.gov/i-690)).

130. [^] 

 See Volume 9, Waivers, Part C, Waivers for Health-Related Grounds of Inadmissibility [9 USCIS-PM C(http://www.uscis.gov/policymanual/HTML/PolicyManual-Volume9-PartC.html)] for more information on waivers of medical grounds of inadmissibility.