OMB No. 1615-0060 Form N-648, Medical Certification for Disability Exceptions Department of Homeland Security U.S. Citizenship and Immigration Services ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must conduct an in-person examination of the applicant. (See instructions for Form N-648 for additional information which is also located in the "FORMS" section at www.uscis.gov.) Reminder About Eligibility Requirements Completing and Certifying This Form This form is intended for an applicant who seeks an exception to the English and/or civics requirements due to a physical or developmental disability or mental impairment that has lasted, or is expected to last, 12 months or more. An applicant who with reasonable accommodations provided under the Rehabilitation Act of 1973 can satisfy the English and civics requirements does not need to submit this form. Reasonable accommodations include, but are not limited to, sign language interpreters, extended time for testing, and off-site testing. All questions or items must be answered fully and accurately. Responses should utilize common terminology, without abbreviations, that a person without medical training can understand. U.S. Citizenship and Immigration Services (USCIS) recommends that the certifying medical professional use the electronic Form N-648 located in the "FORMS" section www.uscis.gov. If the medical professional completes the form by hand, then responses must be legible and appear in black ink. Part I. APPLICANT INFORMATION USCIS USE ONLY Type or print clearly in black ink. This N-648 is: Sufficient I certify that I have examined: Last Name First Name Middle Name Insufficient USCIS A-Number A- Address (Street Number and Name) Continued/RFE U.S. Social Security Number Reviewer State or Province City Zip Code or Postal Code Date of Birth Gender Location & Date Telephone Number E-Mail Address (if any) Male Female Part II. MEDICAL PROFESSIONAL INFORMATION Type or print clearly in black ink. If you need more space to complete an answer, use a separate sheet of paper. Write the applicant's name and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. You must sign and date each continuation sheet. You must answer and complete each question since USCIS will not accept an incomplete Form N-648. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant. NOTE: Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S. territories of Guam, Puerto Rico, and the Virgin Islands) are authorized to certify the form. While staff of the medical practice associated with the medical professional certifying the form may assist in its completion, the medical professional is responsible for the accuracy of the form's content. Last Name First Name Business Address (Street Number and Name) City License Number Licensing State 1. Currently licensed as a (Check all that apply): Middle Name State or Province Zip Code or Postal Code Telephone Number E-Mail Address (if any) Medical Doctor Doctor of Osteopathy Clinical Psychologist 2. Medical practice type: Form N-648 (Rev. 06/17/11) N Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number A- Part III. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S) 1. Provide the clinical diagnosis and DSM IV code (if applicable) of the applicant's disability and/or impairment(s) that form the basis for seeking an exception to the English and/or civics requirements; e.g., "DSM-IV 318.0 Down syndrome". If you cannot provide a DSM IV code, write "N/A" and explain why you cannot provide a DSM IV code. 2. Provide a basic description of the disability and/or impairment(s), e.g., "Down syndrome is a genetic disorder that causes lifelong intellectual disability (also referred to as mental retardation), developmental delays, and other problems." 3. Date you first examined the applicant regarding the condition(s) listed in number 1. Date Location (if different from business address on Page 1; otherwise write "same as business address") 4. Date you last examined the applicant regarding the condition(s) listed in number 1, if different from above. Date Location (if different from business address on Page 1; otherwise write "same as business address") 5. Are you the medical professional regularly treating this applicant for the condition(s) listed in number 1? Yes (If "Yes," indicate duration of treatment.) Years Months No (If "No," provide the name of the applicant's regularly treating medical professional on the next page and explain why you are certifying this form instead of the regularly treating medical professional.) Form N-648 (Rev. 06/17/11) N Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number AName of Regularly Treating Medical Professional and Address. Last Name First Name Business Address City Middle Name State or Province Zip Code or Postal Code Telephone Number Explanation: 6. Has the applicant's disability and/or impairment(s) lasted, or do you expect it to last, 12 months or more? Yes (If "Yes,"continue to complete this form.) No (If "No," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.") 7. Is the applicant's disability and/or impairment(s) the result of the applicant's illegal use of drugs? Yes (If "Yes," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.") No (If "No," continue to complete this form.) 8. What caused this applicant's medical disability and/or impairment(s) listed in number 1, if known? Form N-648 (Rev. 06/17/11) N Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number A- 9. What clinical methods did you use to diagnose the applicant's medical disability and/or impairment(s) listed in number 1? 10. Clearly describe how the applicant's disability and/or impairment(s) affect his or her ability to demonstrate knowledge and understanding of English and/or civics. 11. In your professional medical opinion, does the applicant's disability or impairment(s) prevent him or her from demonstrating the following requirements? (Check all that apply. If none applies, the applicant is not eligible for this exception.) The ability to: Read English Write English Speak English Answer questions regarding United States history and civics, even in a language the applicant understands. Form N-648 (Rev. 06/17/11) N Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number A- 12. Was an interpreter used during your examination of the applicant? Yes (If "Yes," the interpreter must complete the "Interpreter Certification" section.) No Additional Comments (Optional) MEDICAL PROFESSIONAL' S CERTIFICATION Complete the following if an interpreter was not used during your examination of the applicant between the applicant and medical professional pertaining to the examination(s) that form the basis of this Form N-648 certification. I am fluent in English and used during my examination(s) of this applicant. , the language spoken by this patient. Therefore, an interpreter was not All medical professionals must complete the certification below. I certify that this applicant's identity has been verified through the following United States or State government-issued photographic identity document: Permanent Resident Card State ID Number: Other Identification (State type and ID Number): 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. I will furnish relevant medical records to USCIS, if requested to do so by USCIS, based on the applicant's consent. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties including under Title 18, U.S.C. Section 1546, civil penalties under Title 18, U.S.C. Section 247c of the Immigration and Nationality Act, and civil license suspension or revocation by the appropriate authorities. Licensed Medical Professional Signature Date Form N-648 (Rev. 06/17/11) N Page 5 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number A- INTERPRETER'S CERTIFICATION An interpreter must complete, and certify, the section below if an interpreter translated communications between the applicant and medical professional on the day of the examination that formed the basis of this Form N-648 certification. Interpreter Information Last Name First Name Address (Street Number and Name) Middle Name City Zip Code or Postal Code State or Province Was a phone interpreter used? Yes If yes, the interpreter is not required to complete the information below. No If no, the interpreter is required to complete the information below. Interpreter Certification As the interpreter, I certify that I am fluent in English and the following language: . I further certify that I have accurately and completely translated all communications between the medical professional and the applicant that occurred on , the date(s) of the examination(s) that form the basis of this certification. Interpreter Signature Date APPLICANT (PATIENT) ATTESTATION/RELEASE OF INFORMATION I, , authorize (Applicant's Name) (Licensed medical doctor, doctor of osteopathy, or clinical psychologist) to release to U.S. Citizenship and Immigration Services all relevant physical and mental health information related to my medical status for the purpose of applying for an exception from the English language and U.S. civics requirements for naturalization. I certify under penalty of perjury, pursuant to Title 28, U.S.C. Section 1746, that the information I provided to the medical professional is true and correct. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under Title 8, U.S.C. Section 1324c. I understand that if this form is not completely filled out or if I fail to submit any required documentation, I may not be found eligible for the requested disability exception. Applicant or Applicant's Authorized Representative Signature Date Form N-648 (Rev. 06/17/11) Y Page 6 American LegalNet, Inc. www.FormsWorkFlow.com