Immigration Medical Exams & Form I-693

1. Immigration Medical Exams & Form I-693 USCIS Civil Surgeon Seminar Series June 12, 2012

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 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. Vaccination Requirements

4. Overview: All applicants applying for adjustment of status must show proof that they have received the vaccinations required for immigration purposes Some vaccinations are specifically required by statute; others are determined by CDC CDC uses specific vaccination criteria to determine whether a certain vaccine should be required for immigration purposes* *For more information, see: http://www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-criteria-immigration.html Completing Form I-693: Vaccination Record

5. Vaccination Criteria for U.S. Immigration • The vaccine must be age-appropriate* for the immigrant applicant • The vaccine must protect against a disease that has the potential to cause an outbreak • The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States. *The Advisory Committee on Immunization Practices (ACIP) recommends vaccines for a certain age range in the general U.S. public. These ACIP recommendations will be used to decide which vaccines are age-appropriate for the general immigrant population.

6. A table of all currently required vaccinations for change of status applicants, based on age*, is available in the on-line version of CDC's Technical Instructions at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html The applicant’s age at the time of the medical examination is used to determine which vaccines are age-appropriate to administer Completing Form I-693: Vaccination Record

7. Recent updates to the Vaccination TI’s:  As of November 2010, the flu vaccine is required for ALL applicants 6 months of age and older during the flu season*, unless contraindicated* For immigration purposes, the flu season is Oct 1 – Mar 31 annually Completing Form I-693: Vaccination Record

8. Completing Form I-693: Vaccination Record • Form I-693 includes a vaccination record, which the civil surgeon will complete as part of the immigration medical exam. The vaccination record will indicate whether the applicant has met the vaccination requirement for immigration purposes, and whether a waiver of those requirements is requested.

9. Completing Form I-693: Vaccination Record • The civil surgeon should ensure the vaccination record reflects: (1) The applicant’s vaccine history (including dates of properly documented vaccinations) (2) Any vaccines administered by the civil surgeon during the immigration medical exam, AND (3) Any vaccines that were not medically appropriate to administer during the immigration medical exam

10. A vaccine should not be administered if it is notmedically appropriatefor the applicant because It is not age appropriate to administer It is contraindicatedfor the applicant There is an insufficient time interval, either to administer the next dose in a vaccine series or to complete the vaccine series on the day of the immigration medical exam It is not flu season(for the influenza vaccine) Completing Form I-693: Vaccination Record

11. The “contraindication” box for a particular vaccine should be marked if it is not administered because The particular vaccine is medically contraindicatedfor the applicant, OR A precautionexists, and the civil surgeon decides that the precaution precludes vaccine administration. Completing Form I-693: Vaccination Record

12. Definitions from the Technical Instructions: A contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine is given. (See TIs for examples.) A precaution is a condition in a recipient that might increase the chance of a serious adverse reaction if the vaccine is administered, or a condition that might compromise the ability of the vaccine to produce immunity. (See TIs for examples.)  The civil surgeon should annotate the reason for the contraindication in the Remarks section. Completing Form I-693: Vaccination Record

13. The “insufficient time interval” box for a particular vaccine should be marked if it is not administered because The vaccine is one in which a series is not complete (only one dose of each vaccine series is required at the immigration medical exam); OR The most recent dose in a series was too recent for the next dose to be administered; OR An applicant has received any live injectable vaccine or the live intranasal influenza vaccine within 4 weeks of the visit to the civil surgeon’s office. Completing Form I-693: Vaccination Record

14. Spacing of Live Vaccines and Tuberculin Skin Test (TST): All vaccines can be given on the same day as a TST or any time after TST is applied. However, if MMR, varicella, or live attenuated intranasal influenza vaccine (LAIV) is given before TST, at least 4 weeks is recommended before administering the TST. Note on Vaccination Assessment and Tuberculosis Screening Tests

15. Can blood be drawn for IGRA testing after live-virus vaccine administration? As with TST, live virus vaccines might affect IGRA test results Effect not yet studied (June 2012) Until more information available, test as follows: Either same day as live-virus vaccine OR 4-6 weeks after live-virus vaccine administration, and At least one month after smallpox vaccination Source: http://www.cdc.gov/tb/publications/factsheets/testing/IGRA.pdf Note on Vaccination Assessment and Tuberculosis Screening Tests

16. Steps for performing the vaccination assessment for U.S. immigration purposes: STEP 1: If the applicant presents valid documentation of prior immunization, then annotate the date the applicant received the vaccine in the appropriate row. Dates should include month, day, and year, otherwise the prior vaccine is considered invalid.  The civil surgeon should use his or her best judgment to determine whether documentation of prior immunization is valid or not. Completing Form I-693: Vaccination Record

17. Vaccination assessment (cont’d): STEP 2: If the applicant has completed the vaccination series, mark an “X” in the corresponding box in the “Completed Series” column.  NOTE: The civil surgeon is required to administer only one dose of each vaccine series at the time of the immigration examination. Completion of a vaccine series is not required to conclude the medical exam, since this could require multiple visits to the civil surgeon and could lead to unnecessary delay in the immigration process. Completing Form I-693: Vaccination Record

18. Vaccination assessment (cont’d): STEP 3: For any incomplete vaccination series, determine what vaccines the applicant needs based on the applicant’s age at the time of the medical exam. For those vaccines not age-appropriate, mark the corresponding box in the “Not Age Appropriate” column. Check the vaccination table in the TIs and the age-appropriate ACIP* vaccination schedule for specific vaccine indications contraindications and precautions *Advisory Committee on Immunization Practices Completing Form I-693: Vaccination Record

19. Accessible at: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/0-6yrs-schedule-pr.pdf Use yellow boxes for general population *Advisory Committee on Immunization Practices ACIP* Schedule: Persons 0-6 Years of Age

20. Accessible at: http://www.cdc.gov/vaccines/recs/schedules/downloads/child/7-18yrs-schedule-pr.pdf Use yellow boxes for general population *Advisory Committee on Immunization Practices ACIP* Schedule: Persons 7-18 Years of Age

21. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf Recommended Adult Immunization Schedule, Page 1 of 5

22. Vaccination assessment (cont’d): STEP 4: All remaining vaccines are age-appropriate. Determine whether any age-appropriate vaccines are not medically appropriate to receive because: Vaccine is contraindicated or a precaution exists that precludes administration of the vaccine (mark the “Contraindication” box in the appropriate row and annotate the reason in the Remarks section); Time interval is insufficient; or It is not flu season. Completing Form I-693: Vaccination Record

23. Vaccination assessment (cont’d): STEP 5: Administer remaining age-appropriate vaccines that are medically appropriate to receive. Annotate the date (month, day, and year) in the appropriate box. Completing Form I-693: Vaccination Record

24. Vaccination assessment (cont’d): STEP 6: Check the appropriate Results box below the vaccine chart. Applicant may be eligible for blanket waiver(s) – Check this box if any boxes under “Not Medically Appropriate” heading are checked Applicant will request an individual waiver based on religious or moral convictions Vaccine history complete for each vaccine, all requirements met – Check this box if the applicant has completed the series for all vaccines on Vaccination Record, not only vaccines required at time of the medical exam Applicant does not meet immunization requirements – Check this box if the applicant has not received all required vaccines Completing Form I-693: Vaccination Record

25. There are two types of waivers: (1) blanket waivers – separate form or fee is not required (2) individual waivers – separate form is required; fee may also be required  For most applicants other than those requesting an individual waiver, the Results box “Applicant may be eligible for blanket waiver(s)” will be checked Before completing the vaccination assessment, please make sure: There is at least one mark in every row in the vaccine chart The appropriate results box below the vaccine chart is checked Completing Form I-693: Vaccination Record

26. Waiver of the Vaccination Requirements • An applicant who refuses to receive vaccinations may be eligible for an individual waiver on religious or moral grounds under the following circumstances: • The applicant must be opposed to vaccinations in any form, • The objection must be based on religious beliefs or moral convictions, and • The religious or moral beliefs must be sincere. • If an applicant refuses to receive vaccinations, the civil surgeon should mark the Results box “Applicants will request an individual waiver based on religious or moral convictions” ⇨ The individual waiver must be filed separately on the appropriate waiver form (Form I-601 or I-602), with the appropriate fee and necessary evidence.

27. Special Note on Refugees • Refugees undergo an overseas medical exam as part of refugee processing; they are not required to receive vaccines at that time • Immigration medical examination in the U.S.: • The vast majority of refugees need only a vaccination assessment • Only refugees who entered the United States with Class A conditions are required to undergo a full medical examination in the U.S. Note: Refugees have the option of going to participating health departments to complete the vaccination assessment. State and local health departments are blanket designated as civil surgeons to perform the vaccination assessment of refugees adjusting status.

28. Blanket Civil Surgeon Designation of Health Departments • USCIS granted a blanket civil surgeon designation to all State and local health departments that have a physician who meets the civil surgeon professional qualifications: The blanket designation is only for the limited purpose of completing the vaccination portion of Form I-693 for refugees adjusting status • Participation in the blanket designation is optional; health department physicians are not required to act as civil surgeons • Blanket designation means no application for civil surgeon designation is required; health departments may act as civil surgeons immediately if they meet the requirements for the blanket designation • If a refugee needs to undergo the entire immigration medical exam, he or she must seek a civil surgeon designated under the standard application process

29. Refugees Applying for Adjustment of Status Health department physicians acting as civil surgeons under the blanket designation may ONLY perform the vaccination assessment and ONLY for a refugee who: • Is applying for adjustment of status under INA 209, • Already had an immigration medical examination overseas, AND • Is not required to repeat any part of the immigration medical examination (A refugee who enters the U.S. with a Class A condition will need a complete medical examination performed by a designated civil surgeon.) Completing Form I-693: • In this circumstance, only the vaccination page and page 1 of Form I-693 need to be completed

30. Special Note on K and V Nonimmigrant Visa Holders • K and V nonimmigrant visa holders are close family members of U.S. citizens and lawful permanent residents (green card holders) • Certain Ks and Vs undergo an overseas medical exam as part of visa processing; they may receive vaccines overseas • Immigration medical examination in the U.S.: • Ks and Vswho had an overseas medical exam are not required to undergo a full medical examination in the U.S. if the adjustment application is filed within one year of the overseas medical exam and the overseas medical exam did not reveal a Class A condition (or the individual received a waiver of inadmissibility and has complied with the waiver’s terms and conditions) • Even if a full examination in the U.S. is not required, Ks and Vs may have to see a civil surgeon to complete the vaccination requirements if they were not completed as part of the overseas medical exam

31. Special Note on Asylee Dependents • Certain spouses and children of asylees may undergo an overseas medical exam; they are not required to receive vaccines at that time • Immigration medical examination in the U.S.: • Asylee dependents who had an overseas medical exam are not required to undergo a full medical examination in the U.S. as long as the adjustment application is filed within one year of eligibility to file and the overseas medical exam did not reveal a Class A condition • Even if a full medical exam in the U.S. is not required, asylee dependents must still see a civil surgeon* to complete the vaccination assessment *Asylee dependents cannot go to blanket designated health departments for the vaccination assessment; the blanket civil surgeon designation for health departments only extends to refugees adjusting status.

32. U.S. Department of State Vaccination Documentation Worksheet (DS-3025) • Completed by DOS-designated panel physicians at time of overseas medical examination for U.S. immigration purposes • Acceptable as documentation of proof of prior vaccinations

33. Vaccines: References • 2009 Technical Instructions for Vaccination for Civil Surgeons • http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html • Updated ACIP Information • www.cdc.gov/vaccines • CDC Pink Book Epidemiology and Prevention of Vaccine-Preventable Diseases • www.cdc.gov/vaccines/Pubs/pinkbook/ • 12th edition released April 2011 • Download to eBook reader • Vaccination Guidelines for Pregnant Women • www.cdc.gov/vaccines/pubs/preg-guide.htm

34. Frequently Asked Questions

35. Frequently Asked Questions Q:Can an applicant receive age-appropriate vaccinations if she is pregnant? A: It depends on the vaccination. Pregnancy is a contraindication for live vaccines. According to the Vaccination TI’s, pregnancy is NOT a contraindication for Td, Tdap, inactivated influenza, or hepatitis B vaccine. See http://www.cdc.gov/vaccines/pubs/preg-guide.htm for more information. When a live vaccination is not administered because of pregnancy, the contraindication box should be checked and the reason should be noted in the Remarks section.

36. Frequently Asked Questions Q:When assessing the vaccinations an applicant has received, should I count the vaccinations received abroad? A: Yes. According to the Vaccination TI’s, most vaccines used worldwide are from reliable local or international manufacturers so it is reasonable to assume that any vaccines received abroad are of adequate potency. However, the civil surgeon should still ensure that any vaccines administered abroad were done so according to the ACIP-recommended vaccine schedules. Additionally, the civil surgeon should use his or her judgment to determine if documentation of prior immunization is valid. If the documentation appears invalid, the prior vaccinations should not be recorded on Form I-693, Vaccination Record. The civil surgeon is responsible for administering one dose of any age-appropriate vaccine for which there is no valid record, unless the vaccine is not medically appropriate (see reasons for blanket waiver).

37. Questions?

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 the Technical Instructions and medical exam requirements: • Go to: http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html