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Immigration Medical Exams Form I-693

Communicable Diseases (Form I-693: Civil Surgeon Worksheet, Section 1). 2. Overview: Health-related Grounds of Inadmissibility. The following are health-related grounds of inadmissibility (as defined by INA 212(a)(1)):Communicable disease of public health significance (Class A)Failure

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Immigration Medical Exams Form I-693

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    1. Immigration Medical Exams & Form I-693 USCIS Civil Surgeon Seminar Series May 22, 2012 1

    2. Communicable Diseases (Form I-693: Civil Surgeon Worksheet, Section 1) 2

    3. Overview: Health-related Grounds of Inadmissibility The following are health-related grounds of inadmissibility (as defined by INA 212(a)(1)): Communicable disease of public health significance (Class A) Failure to show proof of required vaccinations (for lawful permanent resident applicants ONLY) Physical or mental disorder with associated harmful behavior (Class A) Drug abuse or addiction (Class A) 3

    4. Tuberculosis 4

    5. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Tuberculosis: Section 1 of the Civil Surgeon Worksheet relates to communicable diseases, beginning with Tuberculosis in subsection A Civil surgeons should review TIs on Tuberculosis at: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/tuberculosis-civil-technical-instructions.html Civil surgeons should also review updates to the TIs at: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/updates/index.html 5

    6. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Overview of TB testing: Either TST or IGRA (not both) screening test may be used Results of screening test should be recorded in subsection A1 or A2, including whether result is positive or negative Annotate whether chest X-ray is required in A3 If X-ray is required, record results of chest X-ray in A4. See the TB TIs for more info 6

    7. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Steps for performing the TB component of the immigration medical exam: STEP 1: If age-appropriate, screen the applicant for TB with a cell-mediated immunity test (TST or IGRA). Generally, all applicants 2 years of age and older must be screened regardless of pregnancy or previous immunization with BCG vaccine Applicants under 2 years of age must also be screened if there is evidence of contact with a person known to have TB or any other reason to suspect TB Applicants may be excepted from a screening test in some circumstances. 7

    8. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB steps (cont’d): An applicant may be excepted from cell-mediated immunity testing (TST or IGRA test) if he or she has: Written documentation (with specific testing details and a health care provider’s signature) of a prior TST reaction of =5mm or positive IGRA, or History of a severe reaction with blistering to a previously performed TST. See 2008 TI Updates for details. 8

    9. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): STEP 2: Determine whether a chest X-ray is required. A chest X-ray (CXR) is required if : The result of the applicant’s TST or IGRA test is positive; The applicant is immunosuppressed, regardless of TST or IGRA result; The applicant has signs or symptoms of TB, regardless of TST or IGRA result; or The applicant was excepted from the screening test (since this indicates a prior positive reaction). 9

    10. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): Special note for pregnant applicants: If a CXR is required for an applicant, she may not be exempted from the CXR requirement due to pregnancy Pregnant applicants may defer the CXR until after pregnancy, but the civil surgeon cannot complete the exam and sign Form I-693 until the CXR is performed and required treatment measures are taken (if needed) 10

    11. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): If a CXR is required, the civil surgeon should request the applicant bring any prior CXRs performed. The civil surgeon should review prior CXRs for evidence suggestive of past TB disease or future development of TB disease. The physician interpreting the current CXR should also be made aware of prior CXRs and what they indicate. See the TB TIs for more details. 11

    12. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): The civil surgeon is also responsible for ensuring that the X-ray technician checks the applicant’s identity. This is to ensure that the CXR belongs to the individual actually applying for the immigration benefit. 12

    13. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): STEP 3: After the CXR is completed, the civil surgeon should complete the section on CXR results on Form I-693. The current CXR should be compared to prior CXRs, if available The CXR should be interpreted by a radiologist or qualified physician trained and experienced in reading chest radiographs demonstrating TB or other diseases of the lung 13

    14. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): Specific descriptions of the radiographic findings can be found in the TB TIs. Note that the radiographic presentation of children with pulmonary TB can be quite distinct from that of adults. 14

    15. Completing Form I-693: Civil Surgeon Worksheet, Section 1 TB Steps (cont’d): STEP 4: Determine whether the applicant should be referred to the TB Control Program of the local health department for TB work-up, which is REQUIRED for: Any applicant with an abnormal chest X-ray suggestive of active or inactive TB Any applicants with clinical signs or symptoms suggestive of TB, regardless of cell-mediated immunity test or X-ray result Any applicant who appears very ill and in whom TB is suspected, requires immediate referral to avoid delay in treatment See the TB TIs for more info 15

    16. Completing Form I-693: Civil Surgeon Worksheet, Section 1 The TB TIs include a TB classification chart to help civil surgeons determine next steps after the screening test and CXR: 16

    17. Completing Form I-693: Civil Surgeon Worksheet, Sections 5-6 Report a required referral on Form I-693: If referral to local health department is required, the civil surgeon should complete Section 5 of the Civil Surgeon Worksheet (“Referral to Health Department or Other Doctor”) Note in the Remarks box in Section 5: Any signs or symptoms of TB, the date of U.S. arrival, and reason for referral ? Section 6 (“Referral Evaluation”) should be completed by the local health department receiving the required TB referral from the civil surgeon 17

    18. Completing Form I-693: Civil Surgeon Worksheet, Sections 5-6 Reporting referrals on Form I-693 (cont’d): Referrals for Class B—Latent TB Infection Needing Evaluation for Treatment are recommended, not required ? Section 5 (“Referral to Health Department or Other Doctor”) and Section 6 (“Referral Evaluation”) do not need to be completed for recommended referrals, only for required referrals 18

    19. Completing Form I-693: Civil Surgeon Worksheet, Sections 5-6 When referring an applicant, the civil surgeon should: Complete Section 5 of the Civil Surgeon Worksheet Ensure the following are completed: Part 1 (applicant information) Part 3 (civil surgeon information) – but do not sign or date Part 3 Make a copy of Form I-693 for your records and give the original form to the applicant in a sealed envelope Advise the applicant that the appropriate follow-up must be obtained before the immigration medical exam can be considered complete Sign Part 3 of Form I-693 only after referral evaluation and treatment, if any, is completed 19

    20. Syphilis 20

    21. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Syphilis: In addition to Tuberculosis, Section 1 also requires the civil surgeon to evaluate the applicant for Syphilis in subsection B Civil surgeons should review the TIs on Syphilis, available at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/required-evaluation-components/syphilis.html 21

    22. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Who must be tested for syphilis? All applicants 15 years of age or older must be tested for evidence of syphilis Applicants under the age of 15 must be tested if there is reason to suspect syphilis infection The TIs provide specific information on acceptable screening tests for syphilis, how to read and report results of screening tests, and treatment. 22

    23. Other Communicable Diseases 23

    24. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Other communicable diseases: As part of the physical exam portion of the immigration medical exam, the civil surgeon should determine whether any other communicable diseases of public health significance exist in the applicant The TIs require that the physical exam include an external genitalia examination Findings of other communicable diseases should be addressed in subsection C 24

    25. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Other communicable diseases: Civil surgeons should review the TIs on Other Sexually Transmitted Diseases (STD) at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/required-evaluation-components/other-sexually-transmitted.html Civil surgeons should also follow the 2010 STD Treatment Guidelines at http://www.cdc.gov/std/treatment/2010/default.htm 25

    26. Completing Form I-693: Civil Surgeon Worksheet, Section 1 Other communicable diseases (cont’d): Civil surgeons should review the TIs on Hansen’s Disease at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/required-evaluation-components/hansen-leprosy.html 26

    27. Completing Form I-693: Civil Surgeon Worksheet, Section 4 Other Medical Conditions: In Section 4 of the Civil Surgeon Worksheet, civil surgeons should note any other physical or mental disorder that represents a substantial departure from normal health or well-being Civil surgeons should review the TIs on Other Physical or Mental Abnormality, Disease or Disability at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/required-evaluation-components/other-disease-disability.html 27

    28. Completing Form I-693: Civil Surgeon Worksheet, Section 4 Other Medical Conditions: Medical conditions listed in Section 4 should be significant enough to possibly interfere with the person’s ability to care for him- or herself, attend school or work, or that may require extensive medical treatment or institutionalization in the future Examples of medical conditions that should be listed in Section 4: HIV Diabetes Hypertension 28

    29. Completing Form I-693: Final Review Before signing and dating the Form I-693 in Part 3: Ensure that all follow-up evaluation and treatment is completed Ensure that all Findings/Results boxes are completed for each section Ensure that Part 2 (“Summary of Medical Examination”) is completed 29

    30. Frequently Asked Questions 30

    31. Frequently Asked Questions Q: How long are TST/IGRA and chest X-ray results valid after obtained by the civil surgeon? A: The immigration medical exam is intended to be a “snapshot” of the applicant’s medical status. Therefore, the TST/IGRA and chest X-ray results must be closely related in time to the physical examination and laboratory results. 31

    32. Frequently Asked Questions Q: Can the civil surgeon accept prior TST or IGRA results submitted by an outside doctor’s office, in lieu of performing the TST or IGRA him- or herself? A: A prior negative TST or IGRA result cannot be accepted since the civil surgeon must verify that the person applying for immigration benefits is the person appearing for the immigration medical exam (including any required tests such as the TST). However, a positive TST or IGRA result may be accepted based on an exception outlined in the TB TIs and updates. 32

    33. Frequently Asked Questions Q: When should an applicant be classified with latent TB infection (LTBI)? A: A TB classification of LTBI should be used for all applicants who Are recent arrivals to the U.S. (arrived within the last 5 years) from countries with a high TB prevalence, Have a TST reaction of 10mm or greater of induration, AND Have no evidence of TB disease. Treatment for LTBI is recommended, but not required. 33

    34. Frequently Asked Questions Q: What if the local TB Control Program is unable to provide treatment for latent TB infection (LTBI)? A: Treatment for LTBI is recommended, but not required. If a health department TB Control Program is not able to accept a referral, the civil surgeon may ask if the TB Control Program can provide treatment consultation for an applicant with LTBI. The TB Control Program may also have arrangements with other health care providers in the community to provide treatment for LTBI. 34

    35. Frequently Asked Questions Q: Can I (the civil surgeon) sign Form I-693 if the applicant is undergoing required TB treatment? A: No. Civil surgeons should not sign Form I-693 until all follow-up evaluations and required treatments are completed. If an applicant is undergoing required TB treatment, the health department should sign Section 6 (Referral Evaluation) once the treatment is completed and the applicant is no longer infectious. The applicant should then return to the civil surgeon with Form I-693. Other parts of the medical exam may need to be repeated if out-of-date. The civil surgeon should sign Form I-693 only when all parts of the form reflect the applicant’s current medical state. (Note: This does not apply if treatment is for latent TB infection (LTBI), since LTBI treatment is only recommended, not required.) 35

    36. Frequently Asked Questions Q: Do I need to do HIV testing as part of the immigration medical examination? A: No. As of 2010, HIV is no longer an inadmissible health condition. Therefore, HIV testing is not required. However, the civil surgeon may advise applicants about HIV testing if clinically indicated. If the civil surgeon knows that the applicant has HIV, the HIV condition must be noted as a Class B condition in Section 4 of the Civil Surgeon Worksheet (Other Medical Conditions). For more information, see the HIV guidance at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/hiv-guidance-panel-civil.html. 36

    37. Questions? 37

    38. Contact Information For questions on civil surgeon designation, Form I-693, or immigration issues in general, please contact the civil surgeon coordinator in your jurisdiction For questions about CDC’s Technical Instructions and medical exam requirements: Go to: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html 38

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