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Report of Medical Examination and Vaccination Record Form Uscis 1-693

This document is a USCIS Form 1-693, which is a Report of Medical Examination and Vaccination Record. It contains information about an applicant, including their name, date of birth, place of birth, and A-Number. It is completed by both the applicant and a civil surgeon. The civil surgeon summarizes the overall findings of the medical exam as having no Class A or B conditions, or Class B or A conditions. They certify that they performed the exam in accordance with CDC guidelines.

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Fernando Alvarenga
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199 views1 page

Report of Medical Examination and Vaccination Record Form Uscis 1-693

This document is a USCIS Form 1-693, which is a Report of Medical Examination and Vaccination Record. It contains information about an applicant, including their name, date of birth, place of birth, and A-Number. It is completed by both the applicant and a civil surgeon. The civil surgeon summarizes the overall findings of the medical exam as having no Class A or B conditions, or Class B or A conditions. They certify that they performed the exam in accordance with CDC guidelines.

Uploaded by

Fernando Alvarenga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

USCIS

Report of Medical Examination and Vaccination Record Form1-693


Department of Homeland Security OMBNo.1615-0033
U.S. Citizenship and Immigration Services Expires01/31/2015

START HERE - Type or print in CAPITAL letters (Use black ink)


civil surgeon)
Part I. Information About You (To becom letedbythe rson requesting a medical examination, not the
Full Middle Name
NATALIA
A t. Number Gender:
Male
Zi Code Phone Number
-7005
Country of A-Number
Date of Birth Place of Birth
Birth (if any)
(Ci [Town/Vi11a e)

Applicant's Certification
Part 1 of this Form 1-693, Report of
I certify under penalty of perjury under United States law that I am the person who is identified in
the best of my knowledge. I
Medical Examination and Vaccination Record, and that the information in Part 1 of this form is true to
completed. If it is determined that
understand the purpose of this medical exam, and I authorize the required tests and procedures to be
to my medical exam, I
I willfully misrepresented a material fact or provided false/altered information or documents with regard
be removed from the United
understand that any immigration benefit I derived from this medical exam may be revoked, that I may
States, and that I may be subject to civil or criminal penalties.
Signature - Do not sign or date this form until instructed to do so by the civil surgeon
Date of Signature (mm/dd/yyyy)

To be completed bõvil surgeon: Form of applicant ID ID Number


presented (e.g., passport, driver's license)

Part 2. Summary of Medical Examination (To becom leted by the civil surgeon)
No Class A or Class B Class B Conditions (see Civil Class A Conditions (see Civil
Summary of Overall
Condition Surgeon Worksheet,sections 1-4) Surgeon Worksheet,sections 1-3)
Findings:

Date of First Examination Date(s) of Follow-up Examination(s) below if required:


(mm/dd/ ) Date of Exam mm/dd/ Date of Exam mm/dd/ Date of Exam (mm/dd/ )
05/16/2014
applicant sign in Part I until all health follow-up
Part 3. Civil Surgeon's Certification (Do not sign form or have the
requirements have been met)
designated to examine applicants seeking certain
I certify under penalty of perjury under United States law that: I am a civil surgeon
who qualifies under a blanket designation specified by policy or law; I have a
immigration benefits in the U.S. OR a physician
currently valid and unrestricted license to practice medicine in the state where I am performing medical examinations unless otherwise
exempted; I performed this examination of the person identified in Part 1 of this Form 1-693, after having made every reasonable
effort to verify that the person whom I examined is in fact the person identified in Part 1; that I performed the examination in
accordance with the Centers for Disease Control and Prevention's Technical Instructions, and all supplemental information or
updates; and that all information provided by me on this form is true and correct to the best of my knowledge, and belief.
or Print Full Name Firs Middle Last
MIKE M. HEYDARI, M.D. (Health Departments MUST
Address Street Number and Name Ci State and Zi Code place their official stamp or seal here)
2460 MISSION ST #112 SAN FRANCISCO, CA 94110
Name or Medical Practi Facili or Health De artment
MERIDIAN MEDICAL GROUP
Da time Phone Number E-Mail

Form 1-693 01/15/13 Y Page 1 of 5

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