1. Immigration Medical Exams & Form I-693 USCIS Civil Surgeon Seminar Series June 5, 2012 1

2. Overview: Health-related Grounds of Inadmissibility The following are health-related grounds of inadmissibility (as defined by INA 212(a)(1)): The following are health-related grounds of inadmissibility (as defined by INA 212(a)(1)): Communicable disease of public health significance (Class A) Communicable disease of public health significance (Class A) Failure to show proof of required vaccinations (for lawful permanent resident applicants ONLY) Failure to show proof of required vaccinations (for lawful permanent resident applicants ONLY) Physical or mental disorder with associated harmful behavior (Class A) Physical or mental disorder with associated harmful behavior (Class A) Drug abuse or addiction (Class A) Drug abuse or addiction (Class A) 2

3. Physical or Mental Disorders with Associated Harmful Behavior (Form I-693: Civil Surgeon Worksheet, Section 2) 3

4. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Physical or Mental Disorders with Associated Harmful Behavior: Results of a mental health evaluation should be recorded in Section 2 of the Civil Surgeon Worksheet Results of a mental health evaluation should be recorded in Section 2 of the Civil Surgeon Worksheet Civil surgeons should review the TIs on Physical or Mental Disorders with Associated Harmful Behavior and Substance-related Disorders at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html Civil surgeons should review the TIs on Physical or Mental Disorders with Associated Harmful Behavior and Substance-related Disorders at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html 4

5. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Overview of required evaluation: Diagnose any mental or physical disorders using American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria Diagnose any mental or physical disorders using American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria Classify whether mental or physical disorder is a Class A or B condition Classify whether mental or physical disorder is a Class A or B condition The civil surgeon must determine if the physical or mental disorder has associated harmful behavior, current or history of harmful behavior judged likely to recur The civil surgeon must determine if the physical or mental disorder has associated harmful behavior, current or history of harmful behavior judged likely to recur  Note: A civil surgeon should refer the applicant to a specialist if he or she is unable to make a diagnosis or classification 5

6. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation: STEP 1: Review the applicant’s medical history. Review past medical records Review past medical records When possible, obtain other relevant records (e.g. police, military, school) that might indicate a history of harmful behavior associated with physical or mental disorders When possible, obtain other relevant records (e.g. police, military, school) that might indicate a history of harmful behavior associated with physical or mental disorders Ask questions about past medical history Ask questions about past medical history Ask about mental disorders in the family and, when appropriate, about signs of mental problems or odd behaviors Ask about mental disorders in the family and, when appropriate, about signs of mental problems or odd behaviors Ask about harmful behaviors Ask about harmful behaviors 6

7. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation: STEP 2: Conduct an activities assessment and mental status examination that assesses, at a minimum Orientation Orientation Mood and affect, Mood and affect, Speech and language, Speech and language, Anxiety, Anxiety, Thought processes and content, and Thought processes and content, and Behavior. Behavior. The civil surgeon or specialist will generally not need to provide additional psychological or neuropsychological testing. However, for certain cases, these tests may aid in making a diagnosis. 7

8. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation:  Note: The civil surgeon can recognize that an applicant with a physical or mental disorder might have an associated harmful behavior at any point in the medical exam. While taking the medical history of the mental disorder While taking the medical history of the mental disorder While taking history of harmful behavior While taking history of harmful behavior While observing for current abnormal behavior during the physical exam While observing for current abnormal behavior during the physical exam 8

9. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation (cont’d): STEP 3: Determine whether the applicant has any physical or mental disorders using DSM criteria Note: If the civil surgeon is unable to determine whether an applicant has a diagnosis of a physical or mental disorder, diagnosis and classification may be deferred in order to obtain additional information (i.e. medical or other relevant records, laboratory or psychological testing). In this case, the civil surgeon should NOT sign Form I- 693 until a determination can be made and the medical exam can be considered complete. Note: If the civil surgeon is unable to determine whether an applicant has a diagnosis of a physical or mental disorder, diagnosis and classification may be deferred in order to obtain additional information (i.e. medical or other relevant records, laboratory or psychological testing). In this case, the civil surgeon should NOT sign Form I- 693 until a determination can be made and the medical exam can be considered complete. 9

10. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation (cont’d): STEP 4: If the applicant is diagnosed with a mental or physical disorder, determine whether the disorder has an associated harmful behavior Only a mental or physical disorder associated with a harmful behavior is a Class A condition (making one inadmissible under health-related grounds) Only a mental or physical disorder associated with a harmful behavior is a Class A condition (making one inadmissible under health-related grounds) 10

11. Completing Form I-693: Civil Surgeon Worksheet, Section 2 For purposes of the immigration medical exam, harmful behavior is an action associated with a mental or physical disorder that results in: Serious psychological or physical injury to the applicant or others (e.g. suicide attempt or pedophilia) Serious psychological or physical injury to the applicant or others (e.g. suicide attempt or pedophilia) A serious threat to health or safety (e.g. driving while intoxicated or verbally threatening to kill someone) A serious threat to health or safety (e.g. driving while intoxicated or verbally threatening to kill someone) Major property damage Major property damage 11

12. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Examples of mental disorders most frequently associated with harmful behavior include: major depression major depression bipolar disorder bipolar disorder schizophrenia schizophrenia mental retardation mental retardation (These disorders occur within broader categories of disorders. See TIs for more info.)  Note: Physical disorders are rarely associated with harmful behaviors. 12

13. Completing Form I-693: Civil Surgeon Worksheet, Section 2 As part of the evaluation, civil surgeons may also have to determine: Remission status of previously diagnosed disorder Remission status of previously diagnosed disorder Likelihood of recurrence of harmful behaviors associated with physical or mental disorder Likelihood of recurrence of harmful behaviors associated with physical or mental disorder The physical or mental disorder must at least be in remission or reliably controlled by medication or other effective treatment for a civil surgeon to find that the harmful behavior is unlikely to recur. The physical or mental disorder must at least be in remission or reliably controlled by medication or other effective treatment for a civil surgeon to find that the harmful behavior is unlikely to recur. If it has been 12 months since the harmful behavior occurred, it is less likely to recur (general guideline) If it has been 12 months since the harmful behavior occurred, it is less likely to recur (general guideline) 13  See TIs for more info, including a list of factors affecting the applicant’s likelihood of maintaining remission or having a disorder under control.

14. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Steps for performing the evaluation (cont’d): STEP 5: Determine whether the applicant has any Class A or B conditions based on physical or mental disorders with associated harmful behavior. Mark the appropriate finding on Form I-693 (Section 2 of the Civil Surgeon Worksheet). 14  Civil surgeons should also note in the Remarks box any harmful behavior not associated with mental or physical disorder, since this information may be relevant in determining inadmissibility on other grounds

15. Completing Form I-693: Civil Surgeon Worksheet, Section 2 15 The TIs illustrate how civil surgeons should determine whether an applicant has a Class A or B condition (see p. 9 of the 2010 TIs).

16. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Specialist Referral: Civil surgeons should refer the applicant to a specialist if he or she is unable to: Arrive at a probable psychiatric diagnosis to determine if the applicant has or had a mental or physical disorder with associated harmful behavior Arrive at a probable psychiatric diagnosis to determine if the applicant has or had a mental or physical disorder with associated harmful behavior Rule out the presence of a physical or mental disorder Rule out the presence of a physical or mental disorder Determine if harmful behavior has been associated with a physical or mental disorder or if it is likely to recur Determine if harmful behavior has been associated with a physical or mental disorder or if it is likely to recur Determine if any diagnosed physical or mental disorders affecting behavior are in remission or under control, or the likelihood of the applicant maintaining remission or effective control Determine if any diagnosed physical or mental disorders affecting behavior are in remission or under control, or the likelihood of the applicant maintaining remission or effective control ⇨ As with any referral, sections 5-6 of the Civil Surgeon Worksheet should be completed by the civil surgeon and physician receiving referral, respectively 16

17. Completing Form I-693: Civil Surgeon Worksheet, Section 2 Special Note on Alcohol Abuse and Dependence: Classified as a mental disorder, not substance abuse or dependence Classified as a mental disorder, not substance abuse or dependence Diagnosis made using DSM criteria for abuse or dependence Diagnosis made using DSM criteria for abuse or dependence To classify, must determine if associated harmful behavior is present or if in past, is likely to recur (see Figure 2 in TIs) To classify, must determine if associated harmful behavior is present or if in past, is likely to recur (see Figure 2 in TIs) If civil surgeon is unable to make diagnosis or classification, he or she must refer applicant to specialist If civil surgeon is unable to make diagnosis or classification, he or she must refer applicant to specialist 17

18. Drug Abuse and Drug Addiction (Form I-693: Civil Surgeon Worksheet, Section 3) 18

19. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Drug Abuse/Drug Addiction : Any drug abuse or drug addiction should be recorded in Section 3 of the Civil Surgeon Worksheet (on pp. 3-4 of Form I-693) Any drug abuse or drug addiction should be recorded in Section 3 of the Civil Surgeon Worksheet (on pp. 3-4 of Form I-693) Civil surgeons should review the TIs on Physical or Mental Disorders with Associated Harmful Behavior and Substance-related Disorders at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html Civil surgeons should review the TIs on Physical or Mental Disorders with Associated Harmful Behavior and Substance-related Disorders at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/mental- civil-technical-instructions.html 19

20. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Overview of required evaluation: Diagnose any substance abuse or dependence using American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria Diagnose any substance abuse or dependence using American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria Classify whether the applicant has a Class A or B condition Classify whether the applicant has a Class A or B condition 20

21. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Steps for performing evaluation: STEP 1: Based on the evaluation performed for the mental or physical disorder component of the immigration medical exam, determine whether the applicant has a diagnosis of substance abuse or dependence based on DSM criteria. Note: Random screening for drugs is not part of the routine immigration medical exam. However, the civil surgeon may decide to perform drug screening on an individual basis depending on the applicant’s history, behavior, and physical appearance. Note: Random screening for drugs is not part of the routine immigration medical exam. However, the civil surgeon may decide to perform drug screening on an individual basis depending on the applicant’s history, behavior, and physical appearance. 21  See TIs for more info, including a list of indications for laboratory drug screening.

22. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Deferring diagnosis and classification: If the civil surgeon is unable to determine whether an applicant has a diagnosis of substance abuse or dependence, diagnosis and classification may be deferred for 3-6 months to give the applicant an opportunity to show abstinence or obtain additional information (i.e. medical or other relevant records, laboratory or psychological testing). In this case, the civil surgeon should explain to the applicant what is expected of the applicant during the 3-6 months (e.g. requiring clinical reports from health care professionals to demonstrate participation in drug treatment program). The civil surgeon should consider documenting the expectations and obtaining the applicant’s signature. 22

23. Completing Form I-693: Civil Surgeon Worksheet, Section 3 The civil surgeon should use the DSM’s definition of substance abuse and dependence when making a diagnosis for purposes of the immigration medical exam: Substance abuse is generally characterized by a pattern of recurrent substance use despite adverse consequences and impairment Substance abuse is generally characterized by a pattern of recurrent substance use despite adverse consequences and impairment Substance dependence is generally characterized by compulsive long-term substance use despite significant substance- related physical, psychological, social, occupational, or behavioral problems Substance dependence is generally characterized by compulsive long-term substance use despite significant substance- related physical, psychological, social, occupational, or behavioral problems 23

24. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Steps for performing evaluation (cont’d): STEP 2: If substance abuse or dependence is found, determine whether with the specific substance used is listed in Schedules I – IV of Section 202 of the Controlled Substances Act (see Appendix C in the TIs for list) 24

25. Completing Form I-693: Civil Surgeon Worksheet, Section 3 If the applicant meets the DSM criteria for substance abuse or dependence of a controlled substance, then the applicant has a Class A condition If the applicant meets the DSM criteria for substance abuse or dependence of a controlled substance, then the applicant has a Class A condition If the applicant’s substance abuse or dependence does not involve a controlled substance, then the applicant suffers from a physical or mental disorder. The civil surgeon should then determine whether an associated harmful behavior exists (If yes, then the applicant has a Class A condition) If the applicant’s substance abuse or dependence does not involve a controlled substance, then the applicant suffers from a physical or mental disorder. The civil surgeon should then determine whether an associated harmful behavior exists (If yes, then the applicant has a Class A condition) 25

26. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Substances used for clinical care in medical practice should not be considered for substance abuse Substances used for clinical care in medical practice should not be considered for substance abuse Prescription drugs should generally be considered for substance abuse only if drugs are not taken according to prescription Prescription drugs should generally be considered for substance abuse only if drugs are not taken according to prescription ⇨ Civil surgeons should classify alcohol dependence or abuse as a physical or mental disorder (see Section 2 of the Civil Surgeon Worksheet) 26

27. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Steps for performing evaluation (cont’d): STEP 3: Based on any findings of substance abuse or dependence, determine whether the applicant has any Class A or B conditions. Any substance abuse or dependence, past or present, that involves a controlled substance should be recorded in Section 3 of the Civil Surgeon Worksheet Any substance abuse or dependence, past or present, that involves a controlled substance should be recorded in Section 3 of the Civil Surgeon Worksheet 27  Note: No determination of associated harmful behavior is needed to classify applicant as having Class A substance abuse or dependence

28. Completing Form I-693: Civil Surgeon Worksheet, Section 2 28 The TIs illustrate how civil surgeons should determine whether an applicant has a Class A or B condition (see p. 10 of the 2010 TIs).

29. Completing Form I-693: Civil Surgeon Worksheet, Section 3 If substance abuse or dependence is found, the civil surgeon (or specialist, if referred) must document the applicant’s pattern of use and behavioral, physical, and psychological effects associated with the substance use or cessation of use. Attach supporting documentation to Form I-693 if needed. If substance abuse or dependence is found, the civil surgeon (or specialist, if referred) must document the applicant’s pattern of use and behavioral, physical, and psychological effects associated with the substance use or cessation of use. Attach supporting documentation to Form I-693 if needed. 29

30. Completing Form I-693: Civil Surgeon Worksheet, Section 3 Specialist Referral: Civil surgeons should refer the applicant to a specialist if he or she is unable to: Arrive at a probable diagnosis of drug abuse or addiction according to DSM criteria Arrive at a probable diagnosis of drug abuse or addiction according to DSM criteria Determine whether any diagnosed drug abuse or addiction is in remission Determine whether any diagnosed drug abuse or addiction is in remission ⇨ As with any referral, Sections 5-6 of the Civil Surgeon Worksheet should be completed by the civil surgeon and physician receiving referral, respectively 30

31. Completing Form I-693: Civil Surgeon Worksheet, Sections 5-6 Sections 5-6 of the Civil Surgeon Worksheet should only be completed if a referral was made during the immigration medical exam Sections 5-6 of the Civil Surgeon Worksheet should only be completed if a referral was made during the immigration medical exam 31

32. Completing Form I-693: Civil Surgeon Worksheet, Sections 5-6 When referring an applicant, the civil surgeon should: 1. Complete Section 5 of the Civil Surgeon Worksheet 2. Ensure the following are completed: Part 1 (applicant information) Part 1 (applicant information) Part 3 (civil surgeon information) – but do not sign or date Part 3 Part 3 (civil surgeon information) – but do not sign or date Part 3 3. Make a copy of Form I-693 for your records and give the original form to the applicant in a sealed envelope 4. Advise the applicant that the appropriate follow-up must be obtained before the immigration medical exam can be considered complete 5. Sign Part 3 of Form I-693 only after referral evaluation and treatment, if any, is completed 32

33. 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 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/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/other-disease- disability.html Civil surgeons should review the TIs on Other Physical or Mental Abnormality, Disease or Disability at http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/other-disease- disability.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/other-disease- disability.html http://www.cdc.gov/immigrantref ugeehealth/exams/ti/civil/technic al-instructions/civil- surgeons/required-evaluation- components/other-disease- disability.html 33

34. 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, or attend school or work, or that may require extensive medical treatment or institutionalization in the future Medical conditions listed in Section 4 should be significant enough to possibly interfere with the person’s ability to care for him- or herself, or 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: Examples of medical conditions that should be listed in Section 4: HIV HIV Diabetes Diabetes Hypertension Hypertension Medical conditions listed in Section 4 are Class B conditions 34

35. 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 follow-up evaluation and treatment is completed Ensure that all Findings/Results boxes are completed for each section Ensure that all Findings/Results boxes are completed for each section Ensure that Part 2 (“Summary of Medical Examination”) is completed Ensure that Part 2 (“Summary of Medical Examination”) is completed 35

36. Frequently Asked Questions 36

37. Frequently Asked Questions Q: Do I need to perform any blood tests to determine if an applicant has an alcohol abuse or dependence problem? A: No. Civil surgeons do not need to perform a liver function test or any other blood test on applicants. Alcohol abuse and/or dependence should be treated as a mental disorder. Therefore, the DSM criteria for a mental disorder must be met; in addition, harmful behavior associated with the mental disorder must be evaluated in the applicant to classify the condition as Class A. 37

38. Questions? 38

39. 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 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: For questions about the Technical Instructions and medical exam requirements: Go to: http://www.cdc.gov/immigrantrefugeehealth/exam s/ti/civil/technical-instructions-civil-surgeons.html Go to: http://www.cdc.gov/immigrantrefugeehealth/exam s/ti/civil/technical-instructions-civil-surgeons.html http://www.cdc.gov/immigrantrefugeehealth/exam s/ti/civil/technical-instructions-civil-surgeons.html http://www.cdc.gov/immigrantrefugeehealth/exam s/ti/civil/technical-instructions-civil-surgeons.html 39