N-648, Medical Certification for Disability Exceptions (United States)
This form is to apply for disability exceptions for naturalization in the United States. The form provided here is simply a sample of what the actual Form N-648 looks like.
Department of Homeland Security
U.S Citizenship and Immigration Services
N-648, Medical Certification for Disability Exceptions
Part I. This section to be completed by applicant. (Please print or type information in black ink)
Last Name _____________________________
First Name _____________________________,
Middle Name _____________________________,
Address _____________________________,
City _____________________________,
State _____________________________,
Zip Code _____________________________,
Alien Registration Number _____________________________,
U. S. Social Security Number _____________________________,
Telephone Number _____________________________,
Date of Birth (mm/dd/yyyy) _____________________________,
Gender _____________________________,
I, _____________________________ (Applicant's Name), authorize _____________________________ (Licensed medical doctor, doctor of osteopathy or clinical psychologist)
To release all relevant physical and mental health information related to my medical status to the U.S. Citizenship and Immigration Services (USCIS) for the purpose of applying for an exception from the English language and U.S. civics testing requirements for naturalization. I certify under penalty of perjury, pursuant to Title 28 U.S.C. Section 1746, that the information on this form and any evidence submitted with it are all true and correct. I am aware that the knowing placement of false information on the Form N-648 and related documents may also subject me to civil penalties under 8 U.S.C. 1324c.
Signature _____________________________
Date _____________________________
Part II. This section to be completed by a licensed medical doctor, doctor of osteopathy or licensed clinical psychologist. (See Instructions.)
Purpose of This Form: The individual named above is applying to become a U. S. citizen. Applicants for naturalization are required to learn and/or demonstrate knowledge of the English language, including an ability to read, write and speak words in ordinary usage in the English language, as well as knowledge and understanding of the fundamentals of the history, and of the principles and form of government of the United States. Individuals who are unable, because of a disability and/or impairment(s) to learn and/or demonstrate this required knowledge may apply for a waiver. The purpose of this form is to help determine whether your patient is eligible for this waiver.
Definition of Disability and/or Impairment(s):
An individual is eligible for this waiver if he or she is unable to learn and/or demonstrate knowledge of English and/or U.S. history and civics because of a physical or developmental disability, or mental impairment (or a combination of impairments). These disability and/or impairment(s) must result from anatomical, physiological or psychological abnormalities, which can be shown by medically acceptable clinical and laboratory diagnostic techniques. The disability and/or impairment(s) must result in functioning so impaired as to render an individual unable to demonstrate the required knowledge.
NOTE: This definition of disability is different from the definition used by the Social Security Administration, Department of Veterans
Affairs or worker's compensation programs. If your responses do not address the applicant's disability for the purposes of naturalization, we will require the applicant to submit a revised or second Form N-648 with the appropriate information.
Provide all of the following required information, using common terminology that a person without medical training can understand, with no abbreviations. Type or print clearly in black ink. Illegible and incomplete forms will be returned. If you need additional space to provide your answers, attach additional pages.
Nature and duration of disability and/or impairment(s).
(a) Based on your examination of the applicant, the applicant's symptoms, previous medical records, clinical findings or tests, does the applicant have any disability and/or impairment(s) that affect his or her ability to learn and/or demonstrate knowledge?
____ Yes ____ No. NOTE: If you answer "No," applicant is ineligible for a waiver; please continue with Part II. 6.
(b) Has the applicant's disability and/or impairment(s) lasted or do you expect it to last 12 months or longer?
____ Yes ____ No NOTE: If you answer "No," applicant is ineligible for a waiver; please continue with Part II. 6.
(c) Is the applicant's disability and/or impairment(s) the direct effect of the illegal use of drugs?
____ Yes ____ No NOTE: If you answer "Yes," applicant is ineligible for a waiver; please continue with Part II. 6.
Diagnosis of disability and/or impairments(s).
2. (a) Provide your clinical diagnosis of the applicant's disability and/or impairment(s) and describe the impairment(s) in terms a person without medical training can understand. (See Instructions for examples).
(b) Provide the relevant DSM-IV code(s) for each disability and/or mental impairment(s) that you described above. If a DSM-IV code does not exist, write "N/A."
Connection between disability and/or impairment(s) and inability to learn/demonstrate
The law requires that applicants for citizenship demonstrate (1) an understanding of the English language, including the ability to read, write and speak simple words and phrases in ordinary usage; and (2) a knowledge and understanding of the fundamentals of U.S. history and civics. An applicant's difficulty in fulfilling the requirements is not sufficient to support a waiver. In addition, illiteracy in the applicant's native language is not sufficient, by itself, to support a finding of inability to learn and/or demonstrate knowledge.
3. Based on your examination of the applicant, provide detailed information on the connection between the disability and/or impairment(s) and the applicant's inability to learn and/or demonstrate knowledge of English and/or U.S. history and civics (see Instructions for examples).
NOTE: This description should address the severity of the effects of the disability and/or impairment(s), including the specific limitations that affect the applicant's ability to learn and/or demonstrate knowledge.
_____________________________
_____________________________
Professional certified opinion.
The law requires that in order to be eligible for the disability exception, the applicant must be unable to fulfill the requirements for English proficiency and/or knowledge of U.S. history and civics. An applicant's difficulty in fulfilling the requirements is not sufficient to support a waiver. In addition, illiteracy in the applicant's native language is not sufficient, by itself, to support a finding of inability to learn and/or demonstrate knowledge.
4. English Requirement:
(a) In your professional opinion, has the disability impairment(s) described above affected the applicant's functioning to such a degree that he or she is unable to learn and/or demonstrate an ability to speak, read or write English?
____ Yes ____ No
(b) If Yes, which of the following is the applicant unable to learn and/or demonstrate? (Check all that apply)
____ Speaking ____ Reading ____ Writing
5. U.S. History and Civics Requirement:
In your professional opinion, has the disability impairment(s) described above affected the applicant's functioning to such a degree that he or she is unable to learn and/or demonstrate knowledge of U.S. history and civics, even in a language the applicant understands?
____ Yes ____ No
Background information.
6. Date of your most recent examination of the applicant (mm/dd/yyyy), __________________________________
7. Is this your first examination of the individual?
____ Yes If Yes, from whom does the applicant usually receive medical care (i.e., name of doctor/clinic; if the applicant does not have an ongoing source of medical care, please write "N/A").
____ No If No, for how long and for what conditions have you been treating the applicant? (If the conditions are the same as in Part II. 2, specify the length of time and write "Conditions -- Same as Part II. 2.")
8. What is the nature of your medical practice? (e.g., family/general practice, internal medicine, psychiatry, cardiology)
__________________________________
__________________________________
I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and any evidence submitted with it are all true and correct. Upon consent of the applicant, I agree to release this applicant's relevant medical records upon request from U.S. Citizenship and Immigration Services. I am aware that the knowing placement of false information on the Form N-648 and related documents may also subject me to criminal penalties under Title 18, U.S.C. 1546 and civil penalties under 8 U.S.C. section 1324c.
Signature __________________________________
Date __________________________________
Type or print the following information:
Last Name __________________________________
First Name __________________________________
Middle Name __________________________________
Business Address __________________________________
City __________________________________
State __________________________________
Zip Code __________________________________
Telephone Number __________________________________
License Number __________________________________
Licensing State __________________________________
E-Mail Address, if any __________________________________