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I-693, Medical Examination of Aliens Seeking Adjustment of Status (United States)

This form is for aliens seeking adjustment of status and requires medical clearance in the United States. The form provided here is simply a sample of what the actual Form I-693 looks like.

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-693, Medical Examination of Aliens Seeking Adjustment of Status

Please Print or Type in Black Ink.

1. Name (Last Name in CAPS) ____________________________

(First Name) ____________________________

(Middle Name) ____________________________

2. Address (Street Number and Name ____________________________

(Apt. Number) ____________________________

(City) ____________________________

(State) ____________________________

(Zip Code) ____________________________

3. File Number (A Number) ____________________________

4. Gender ____ Male ____ Female

5. Date of Birth (mm/dd/yyyy) ____________________________

6. Country of Birth ____________________________

7. Date of Examination (mm/dd/yyyy) ____________________________

General Physical Examination: I examined specifically for evidence of the conditions listed below. My examination revealed:

____ No apparent defect, disease, or disability. ____ The conditions listed below were found (check all boxes that apply).

Class A Conditions

____ Chancroid
____ Chronic alcoholism
____ Gonorrhea
____ Granuloma inguinal
____ Hansen's disease, infectious
____ HIV infection
____ Insanity
____ Lymphogranuloma venereum
____ Mental defect
____ Mental retardation
____ Narcotic drug addiction
____ Previous occurrence of one or more attacks of insanity
____ Psychopathic personality
____ Sexual deviation
____ Syphilis, infectious
____ Tuberculosis, active

Class B Conditions

____ Hansen's disease, not infectious ____Tuberculosis, not active

Other physical defect, disease or disability (specify below).

____________________________

Doctor's name (please print) ____________________________

Date read ____________________________

Examination for Tuberculosis - Tuberculin Skin Test

____ Reaction ____________ mm ____ No reaction ____ Not Done

Examination for Tuberculosis - Chest X-Ray Report

____ Abnormal

____ Normal Not done

Doctor's name (please print) ____________________________

Date read ____________________________

Immunization Determination (DTP, OPV, MMR, Td-Refer to PHS Guidelines for recommendations.)

____ Applicant is current for recommended age-specific immunizations.

____ Applicant is not current for recommended age-specific immunizations and I have encouraged that appropriate immunizations be obtained.

Remarks ____________________________

Civil Surgeon Referral for Follow-up of Medical Condition

The alien named above has applied for adjustment of status. A medical examination conducted by me identified the conditions above which require resolution before medical clearance is granted or for which the alien may seek medical advice. Please provide follow-up services or refer the alien to an appropriate health care provider. The actions necessary for medical clearance are detailed on the reverse of this form.

Follow-up Information:
The alien named above has complied with the recommended health follow-up.

Doctor's name and address (please type or print clearly) ____________________________

Doctor's signature ____________________________

Date ____________________________

Application Certification
I certify that I understand the purpose of the medical examination, I authorize the required tests to be completed, and the information on this form refers to me.

Signature ____________________________

Date ____________________________

Civil Surgeon Certification:

My examination showed the applicant to have met the medical examination and health follow-up requirements for adjustment of status.

Doctor's name address ____________________________

Doctor's signature ____________________________

Date ____________________________


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Medical Clearance Requirements for Aliens Seeking Adjustment of Status

Medical Condition: *Suspected Mental Conditions
Estimated Time for Clearance: 5-30 Days
Action Required: The applicant must provide to a civil surgeon a psychological or psychiatric evaluation from a specialist or medical facility for final classification and clearance.

Medical Condition: Tuberculin Skin Test Reaction and Normal Chest X-Ray or Abnormal Chest X-Ray
Estimated Time for Clearance: Immediate
Action Required: The applicant should be encouraged to seek further medical evaluation for possible preventive treatment.

Medical Condition: Tuberculin Skin Test Reaction and Abnormal Chest X-Ray (Inactive/Class B)
Estimated Time for Clearance: 10-30 days
Action Required: The applicant should be referred to a physician or local health department for further evaluation. Medical clearance may not be granted until the application returns to the civil surgeon with documentation of medical evaluation for tuberculosis.

Medical Condition: Tuberculin, Skin Test Reaction and Abnormal Chest X-Ray or Abnormal Chest X-Ray (Active of Suspected Active/Class A)
Estimated Time for Clearance: 10-300 days Action Required: The applicant should obtain an appointment with physical or local health department. If treatment for active disease is started, it must be completed (usually nine months) before a medical clearance may be granted. At the completion of treatment, the applicant must present to the civil surgeon documentation of completion. If treatment is not started, the applicant must present to the civil surgeon documentation of medical evaluation for tuberculosis.

Medical Condition: Hansen's Disease
Estimated Time for Clearance: 30-210 Days
Action Required: Obtain an evaluation from a specialist or Hansen's disease clinic. If the disease is indeterminate or Tuberculoid, the applicant must present to the civil surgeon documentation of medical evaluation. If disease is Lepromotous of Borderline (dimorphous) and treatment is started, the applicant must complete at least six months and present documentation to the civil surgeon showing adequate supervision, treatment, and clinical response before a medical clearance is granted.

Medical Condition: ** Venereal Diseases
Estimated Time for Clearance: 1-30 Days
Action Required: Obtain an appointment with a physician or local public health department. An applicant with a reactive serologic test for syphilis must provide to the civil surgeon documentation of evaluation for treatment. If any of the venereal diseases are infectious, the applicant must present to the civil surgeon documentation of completion of treatment.

Medical Condition: Immunizations Incomplete
Estimated Time for Clearance: Immediate
Action Required: Immunizations are not required, but the applicant should be encouraged to go to a physician or local health department for appropriate immunizations.

Medical Condition: HIV Infection
Estimated Time for Clearance: Immediate
Action Required: Post-test counseling is not required, but the applicant should be encouraged to seek appropriate post-test counseling.

*Mental retardation; insanity; previous attack of insanity; psychopathic personality, sexual deviation or mental defect; narcotic drug addition; and chronic alcoholism.

**Chancroid; gonorrhea; granuloma inguinal; lymphogranuloma venereum; and syphilis.

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