Report of Medical Examination and Vaccination Record Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or print in black ink. USCIS Form I-693 OMB No. 1615-0033 Expires 02/28/2019 Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the civil surgeon) 1. Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Physical Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 3. Other Information A. Sex Male Female E. Alien Registration Number (A-Number) (if any) B. Date of Birth (mm/dd/yyyy) C. City/Town/Village of Birth D. Country of Birth AF. USCIS Online Account Number (if any) Part 2. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-693 Instructions before completing this Part. You must submit Form I-693 in a sealed envelope to USCIS as directed in the Form I-693 Instructions. Applicant's Statement NOTE: Select the box for either Item A. or B. in Item Number 1. 1. Applicant's Statement Regarding the Interpreter A. B. I can read and understand English, and I have read and understand every question and instruction on this form and my answer to every question. The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question in , a language in which I am fluent, and I understood everything. Applicant's Contact Information 2. Applicant's Daytime Telephone Number 3. Applicant's Mobile Telephone Number (if any) 4. Applicant's Email Address (if any) Form I-693 02/07/17 N Page 1 of 13 American LegalNet, Inc. www.FormsWorkFlow.com Family Name (Last Name) Given Name (First Name) Middle Name A-Number (if any) A- Part 2. Applicant's Statement, Contact Information, Certification, and Signature (continued) Applicant's Certification I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further authorize release of information contained in this form, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my form; 2) I understood all of the information contained in, and submitted with, my form; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury that I am the person who is identified in Part 1. of this Form I-693, and that the information in Part 1. of this form is complete, true, and correct. I understand the purpose of this medical examination, and I authorize the required tests and procedures to be completed. If it is determined that I willfully misrepresented a material fact or provided false or altered information or documents with regard to my medical examination, I understand that any immigration benefit I derived from this medical examination may be revoked, that I may be removed from the United States, and that I may be subject to civil or criminal penalties. Applicant's Signature NOTE: Do not sign or date Form I-693 until instructed to do so by the civil surgeon. 5. Applicant's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS AND CIVIL SURGEONS: If you or the civil surgeon do not completely fill out this form according to the instructions USCIS may deny your immigration benefit. Part 3. Interpreter's Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Form I-693 02/07/17 N Page 2 of 13 American LegalNet, Inc. www.FormsWorkFlow.com Family Name (Last Name) Given Name (First Name) Middle Name A-Number (if any) A- Part 3. Interpreter's Contact Information, Certification, and Signature (continued) Interpreter's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any) 6. Interpreter's Email Address (if any) Interpreter's Certification I certify, under penalty of perjury, that: I am fluent in English and , which is the same language specified in Part 2., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this form and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the form, including the Applicant's Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy) Parts 4. - 9. of this form must be completed by the civil surgeon. Part 4. Applicant's Identification Information (To be completed by the civil surgeon) Please complete the following about the applicant: 1. Form of identification presented by applicant (for example, passport or driver's license) 2. Document Identification Number Form I-693 02/07/17 N Page 3 of 13 American LegalNet, Inc. www.FormsWorkFlow.com Family Name (Last Name) Given Name (First Name) Middle Name A-Number (if any) A- Part 5. Summary of Medical Examination (To be completed by the civil surgeon) 1. Summary of Overall Findings: A. B. C. 2. No Class A or Class B Condition Class B Conditions (See Item Numbers 1. - 4. in Part 7. Civil Surgeon Worksheet) Class A Conditions (See Item Numbers 1. - 3. in Part 7. Civil Surgeon Worksheet) Date of First Examination (mm/dd/yyyy) 3. Dates of Follow-up Examinations, if required: Date of Examination (mm/dd/yyyy) Date of Examination (mm/dd/yyyy) Date of Examination (mm/dd/yyyy) Part 6. Civil Surgeon's Contact Information, Certification, and Signature NOTE: Do not sign Form I-693 and do not have the applicant sign in Part 2. until all health-related follow-up requirements are met. Civil Surgeon's Information 1. Family Name (Last Name) Given Name (First