1. Immigration Medical Exams & Form I-693 USCIS Civil Surgeon Seminar Series May 12, 2016 1

2. Disclaimer This presentation is intended to be used for informational purposes only. It is not intended to, does not, and may not be relied upon to create or confer any right(s) or benefit(s), substantive or procedural, enforceable at law by any individual or other party in benefit applications before USCIS, in removal proceedings, in litigation with the United States, or in any other form or manner. This presentation does not have the force of law, or of a DHS directive. 2

3. Dissemination This presentation may not be reproduced without the express written consent of USCIS Customer Service and Public Engagement. USCIS Customer Service and Public Engagement at public.engagement@uscis.dhs.gov. Please contact USCIS Customer Service and Public Engagement at public.engagement@uscis.dhs.gov.public.engagement@uscis.dhs.gov 3

4. Communicable Diseases Form I-693, Report of Medical Examination and Vaccination Record, Civil Surgeon Worksheet, Section 1 4

5. 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; Communicable disease of public health significance; Failure to show proof of Failure to show proof of required vaccinations (for lawful permanent resident applicants ONLY); Physical or mental disorder with associated harmful behavior (present or past with harmful behavior likely to reoccur); and Physical or mental disorder with associated harmful behavior (present or past with harmful behavior likely to reoccur); and Drug abuse or addiction. Drug abuse or addiction. 5

6. Communicable Diseases of Public Health Significance Defined by the U.S. Department of Health and Human Services in 42 CFR 34.2(a) Defined by the U.S. Department of Health and Human Services in 42 CFR 34.2(a) For purposes of the medical examination of foreign nationals for adjustment of status: For purposes of the medical examination of foreign nationals for adjustment of status: Tuberculosis, active. Tuberculosis, active. Syphilis, infectious; Syphilis, infectious; Gonorrhea; and Gonorrhea; and Hansen’s disease, infectious. Hansen’s disease, infectious. 6

7. Completing Form I-693: Testing and Checking the Applicant’s Identity Responsibility of the civil surgeon to: Make every reasonable effort to verify that the person examined is in fact the person identified in Form I-693, Part 1. Make every reasonable effort to verify that the person examined is in fact the person identified in Form I-693, Part 1. Ensure that all physicians or technicians conducting tests or X- rays check the applicant’s identity. Ensure that all physicians or technicians conducting tests or X- rays check the applicant’s identity.  This is to make certain that the belongs to the individual actually applying for the immigration benefit.  This is to make certain that the chest X-ray belongs to the individual actually applying for the immigration benefit. 7

8. Tuberculosis 8

9. Completing Form I-693, Tuberculosis Section Civil Surgeon Worksheet, Section 1.A. Review TIs on Tuberculosis at: http://www.cdc.gov/immigr antrefugeehealth/exams/ti/ci vil/tuberculosis-civil- technical-instructions.html. http://www.cdc.gov/immigr antrefugeehealth/exams/ti/ci vil/tuberculosis-civil- technical-instructions.html Also review updates to the TIs at: http://www.cdc.gov/immigr antrefugeehealth/exams/ti/ci vil/updates/index.html. http://www.cdc.gov/immigr antrefugeehealth/exams/ti/ci vil/updates/index.html 9

10. Completing Form I-693: Tuberculosis Section (Continued) Overview of TB testing: Either TST or IGRA (not both) screening test may be used. 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. 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. Annotate whether chest X-ray is required in A3. If X-ray is required, record results of chest X-ray in A4. If X-ray is required, record results of chest X-ray in A4. See the TB TIs for more information. 10

11. Completing Form I-693: Tuberculosis Section (Continued) STEP 1: Screen for TB with a cell- mediated immunity test (TST or IGRA). Generally, applicants 2 years of age and older, regardless of pregnancy or previous immunization with BCG vaccine. Generally, applicants under 2 years, if evidence of contact TB infection known or suspected. Applicants may be exempt from a screening test in some circumstances. 11

12. Completing Form I-693: Tuberculosis Section (Continued) Exemption from cell-mediated immunity testing (TST or IGRA) if the applicant 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 TB TI updates for details. 12

13. Completing Form I-693: Tuberculosis Section (Continued) S STEP 2: Determine whether a chest X-ray is required. A chest X-ray 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 is exempt from the screening test (since this indicates a prior positive reaction). 13

14. Completing Form I-693: Tuberculosis Section Pregnant applicants, if a chest X-ray is required: Applicants may defer the chest X-ray until after pregnancy. If chest X-ray is deferred, the civil surgeon cannot complete the exam and sign Form I-693 until the chest x- ray is performed and required treatment measures are taken (if needed). 14

15. Completing Form I-693: Tuberculosis Section (Continued) If a chest X-ray is required, the civil surgeon shoul If a chest X-ray is required, the civil surgeon should: Request the applicant bring any prior chest X-rays performed. Request the applicant bring any prior chest X-rays performed. Review prior chest X-rays for evidence suggestive of past TB disease or future development of TB disease. Review prior chest X-rays for evidence suggestive of past TB disease or future development of TB disease. The physician interpreting the current chest X-ray should also be made aware of prior chest X-rays and what they indicate. The physician interpreting the current chest X-ray should also be made aware of prior chest X-rays and what they indicate. See the TB TIs for more details. 15

16. Completing Form I-693: Tuberculosis Section STEP 3: After the chest X-ray is completed, the civil surgeon should complete the section on chest X-ray results on Form I- 693. The current chest X-ray should be compared to prior chest X-rays, if available. The chest X-ray should be interpreted by a radiologist or qualified physician trained and experienced in reading chest radiographs demonstrating TB or other diseases of the lung. 16

17. Completing Form I-693: Tuberculosis Section (Continued) Specific descriptions of the chest x- ray 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. 17

18. Completing Form I-693: Tuberculosis Section (Continued) 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 information. 18

19. Completing Form I-693: Tuberculosis Section (Continued) Civil Surgeons must indicate TB classification findings on the Form I-693. The TB TIs include a TB classification chart to help civil surgeons determine next steps after the screening test and chest X-ray: 19

20. Completing Form I-693: Tuberculosis and Referral to Health Department or Other Doctor Report a required referral on Form I- 693: If referral to local health department is required, the civil surgeon should complete Section 5 (“Referral to Health Department or Other Doctor”). If referral to local health department is required, the civil surgeon should complete Section 5 (“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. 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. 20

21. Completing Form I-693:Tuberculosis and Referral to Health Department or Other Doctor (Continued) Reporting referrals on Form I-693: 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. 21

22. Completing Form I-693:Tuberculosis and Referral to Health Department or Other Doctor (Continued) When referring an applicant, the civil surgeon should: Complete Section 5 of the Civil Surgeon Worksheet and ensure the following are completed: Part 1 (applicant information). Part 3 (civil surgeon information) – but do not sign or date Part 3. Copy Form I-693 for your records and give the original to the applicant in a sealed envelope. Advise the applicant that the appropriate follow- up must be completed before the Form I-693 can be completed. Advise the physician or health department receiving the referral that the physician/health department must verify the applicant’s identity. Sign Part 3 of Form I-693 only after referral evaluation and treatment, if any, is completed. 22

23. Syphilis 23

24. Completing Form I-693: Syphilis In addition to Tuberculosis, Section 1 also requires the civil surgeon to evaluate the applicant for Syphilis in subsection B. http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/syphilis.html. Review the TIs on Syphilis, available at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/syphilis.html. http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/syphilis.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/syphilis.html 24

25. Completing Form I-693: Syphilis Who must be tested? All applicants 15 years of age or older must be tested for evidence of 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. 25

26. Other Communicable Diseases: Leprosy (Hansen’s Disease) and Gonorrhea 26

27. Completing Form I-693: Other Communicable Diseases As part of the physical exam portion of the immigration medical exam, determine whether any other communicable diseases of public health significance exist in the applicant. The TIs provide information about how to examine for these diseases. The TIs Findings of other communicable diseases should be addressed in subsection C. 27

28. Chancroid Granuloma Inguinale Lymphogranuloma Venereum  As of March 28, 2016, these diseases are no longer classified as communicable diseases of public health significance. 28

29. Change in Regulation as of March 28, 2016 Based on a change in regulation that was effective on March 28, 2016, Chancroid, Granuloma Inguinale, Lymphogranuloma Venereum, are no longer categorized as communicable diseases of public health significance for purposes of the immigration medical examination.   A civil surgeon should no longer examine for these diseases.   Applicants with these infections are no longer found inadmissible to the United States on account of health-related grounds.   USCIS is currently updating the Form I-693 and the USCIS Policy Manual. 29

30. Rationale for Removing Chancroid, Granuloma Inguinale, and Granuloma Venereum Do not represent significant risk for introduction, transmission, and spread from foreign countries to the United States. Uncommon Less than 30 Chancroid cases are reported annually in the United States. Rates are declining worldwide. 30

31. Civil Surgeon Actions Based On The Changes Stop screening for Chancroid, Granuloma Inguinale, and Lymphogranuloma Venereum. Leave boxes for these diseases blank on current version of Form I-693 until the new version is published. New version of the Form I-693, once finalized, will be posted on USCIS’ web site at www.uscis.gov/i-693.www.uscis.gov/i-693 Sign-up for updates from USCIS at www.uscis.gov, “Get Email Updates” (https://public.govdelivery.com/accounts/USDHSCIS/subscrib er/new).www.uscis.gov 31

32. Gonorrhea 32

33. New Technical Instructions (TIs) for Gonorrhea – Coming Soon! CDC plans to publish new TIs for Gonorrhea in May of 2016. Until new TIs for Gonorrhea are published, civil surgeons should continue to follow the TIs for Other Sexually Transmitted Diseases at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/techn ical-instructions/civil-surgeons/required-evaluation- components/other-sexually-transmitted.html. http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/techn ical-instructions/civil-surgeons/required-evaluation- components/other-sexually-transmitted.html CDC will post information about new TIs for Gonorrhea at- http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/techn ical-instructions-civil-surgeons.html. http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/techn ical-instructions-civil-surgeons.html   Civil surgeons should monitor CDC’s website for new information. 33

34. New Technical Instructions (TIs) for Gonorrhea – Coming Soon! (Continued) Civil Surgeons should be using new TIs for Gonorrhea as soon as able after publication and no later than August 1, 2016. Applicants 15 years of age or older must be tested for Gonorrhea. Applicants less than 15 years of age should be tested if there is reason to suspect gonorrhea. 34

35. New Technical Instructions (TIs) for Gonorrhea – Coming Soon! (Continued) 35

36. New Technical Instructions (TIs) for Gonorrhea – Coming Soon! (Continued) Laboratory testing will be required. CDC recommends that civil surgeons use Nucleic acid amplification tests (NAAT) as screening test. Urine specimen from men and women. Self-collected vaginal swab from women. If civil surgeon does not have access to one of these tests, a different screening test must be used. Treatment for Gonorrhea should be done as provided in STD treatment guidelines at http://www.cdc.gov/std/tg2015/default.htm. http://www.cdc.gov/std/tg2015/default.htm 36

37. New Technical Instructions (TIs) for Gonorrhea – Coming Soon! (Continued) Once the new Gonorrhea TIs become effective, and until the I-693 is revised to capture Gonorrhea test, results, and treatment: Civil surgeons should record the test used, the test results, and treatment (if applicable) on the Form I-693 in the Remarks section of Part 5, C. Other Class A/Class B Conditions for Communicable Diseases of Public Health Significance. 37

38. Leprosy (Hansen’s Disease) 38

39. Completing Form I-693: Other Communicable Diseases: Hansen’s Disease Hansen’s Disease at http://www.cdc.gov/im migrantrefugeehealth/ex ams/ti/civil/technical- instructions/civil- surgeons/required- evaluation- components/hansen- leprosy.html. Review the TIs on Hansen’s Disease at http://www.cdc.gov/im migrantrefugeehealth/ex ams/ti/civil/technical- instructions/civil- surgeons/required- evaluation- components/hansen- leprosy.html. http://www.cdc.gov/im migrantrefugeehealth/ex ams/ti/civil/technical- instructions/civil- surgeons/required- evaluation- components/hansen- leprosy.html http://www.cdc.gov/im migrantrefugeehealth/ex ams/ti/civil/technical- instructions/civil- surgeons/required- evaluation- components/hansen- leprosy.html 39

40. Frequently Asked Questions 40

41. 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. 41

42. 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. 42

43. 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. 43

44. 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. 44

45. 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.) 45

46. 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. http://www.cdc.gov/immigrantrefugeehealth/exams/ti/hiv- guidance-panel-civil.html 46

47. Contact Information Go to USCIS’ Designated Civil Surgeon Website at Go to USCIS’ Designated Civil Surgeon Website at https://www.uscis.gov/tools/designated-civil- surgeons https://www.uscis.gov/tools/designated-civil- surgeons For questions about CDC’s Technical Instructions and medical exam requirements go to: http://www.cdc.gov/immigrantrefugeehealth/exa ms/ti/civil/technical-instructions-civil- surgeons.html For questions about CDC’s Technical Instructions and medical exam requirements go to: http://www.cdc.gov/immigrantrefugeehealth/exa ms/ti/civil/technical-instructions-civil- surgeons.html http://www.cdc.gov/immigrantrefugeehealth/exa ms/ti/civil/technical-instructions-civil- surgeons.html http://www.cdc.gov/immigrantrefugeehealth/exa ms/ti/civil/technical-instructions-civil- surgeons.html 47

48. Questions? 48