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

Immigration Immigration Medical Exams & Medical Exams &

Form I-693Form I-693

USCIS Civil Surgeon Seminar USCIS Civil Surgeon Seminar SeriesSeries

June 5, 2012June 5, 20121

Overview: Health-related Overview: Health-related Grounds of Grounds of

InadmissibilityInadmissibility The following are health-related The following are health-related

grounds of inadmissibility (as grounds of inadmissibility (as defined by INA 212(a)(1)):defined by INA 212(a)(1)):

Communicable disease of public health Communicable disease of public health significance (Class A)significance (Class A)

Failure to show proof of required Failure to show proof of required vaccinations vaccinations (for lawful permanent (for lawful permanent resident applicants ONLY)resident applicants ONLY)

Physical or mental disorder with Physical or mental disorder with associated harmful behavior (Class A)associated harmful behavior (Class A)

Drug abuse or addiction (Class A)Drug abuse or addiction (Class A)

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Physical or Mental Physical or Mental Disorders with Disorders with

Associated Harmful Associated Harmful Behavior Behavior

(Form I-693: Civil Surgeon (Form I-693: Civil Surgeon Worksheet, Section 2)Worksheet, Section 2)

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Completing Form I-693: Completing Form I-693: Civil Surgeon Worksheet, Civil Surgeon Worksheet,

Section 2Section 2Physical or Mental Physical or Mental

Disorders with Disorders with Associated Harmful Associated Harmful

Behavior:Behavior: Results of a mental health Results of a mental health

evaluation should be evaluation should be recorded in Section 2 of the recorded in Section 2 of the Civil Surgeon WorksheetCivil Surgeon Worksheet

Civil surgeons should Civil surgeons should review the TIs onreview the TIs on Physical Physical or Mental Disorders with or Mental Disorders with Associated Harmful Associated Harmful Behavior and Substance-Behavior and Substance-related Disordersrelated Disorders at at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html 4


Section 2Section 2Overview of required Overview of required evaluation:evaluation:Diagnose any mental or physical Diagnose any mental or physical disorders using American disorders using American Psychiatric Association’s Psychiatric Association’s Diagnostic Diagnostic and Statistical Manual of Mental and Statistical Manual of Mental Disorders (DSM) criteriaDisorders (DSM) criteriaClassify whether mental or Classify whether mental or physical disorder is a Class A or physical disorder is a Class A or B conditionB condition

The civil surgeon must The civil surgeon must determine if the physical or determine if the physical or mental disorder has mental disorder has associated harmful associated harmful behaviorbehavior, current , current oror history history of harmful behavior judged of harmful behavior judged likely to recurlikely 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

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Section 2Section 2Steps for performing the Steps for performing the evaluation:evaluation:

STEP 1STEP 1: Review the applicant’s : Review the applicant’s medical history.medical history.

Review past medical recordsReview past medical records When possible, obtain other When possible, obtain other

relevant records (e.g. police, relevant records (e.g. police, military, school) that might military, school) that might indicate a history of harmful indicate a history of harmful behavior associated with physical behavior associated with physical or mental disordersor mental disorders

Ask questions about past medical Ask questions about past medical historyhistory

Ask about mental disorders in the Ask about mental disorders in the family and, when appropriate, family and, when appropriate, about signs of mental problems about signs of mental problems or odd behaviorsor odd behaviors

Ask about harmful behaviorsAsk about harmful behaviors

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Section 2Section 2Steps for performing the evaluation:Steps for performing the evaluation:

STEP 2STEP 2: Conduct an activities : Conduct an activities assessment and mental status assessment and mental status examination that assesses, at a examination that assesses, at a minimumminimum

OrientationOrientation Mood and affect,Mood and affect, Speech and language,Speech and language, Anxiety,Anxiety, Thought processes and content, andThought processes and content, and Behavior.Behavior.

The civil surgeon or specialist will The civil surgeon or specialist will generally not need to provide generally not need to provide additional psychological or additional psychological or neuropsychological testing. neuropsychological testing. However, for certain cases, these However, for certain cases, these tests may aid in making a tests may aid in making a diagnosis.diagnosis.

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Section 2Section 2Steps for performing the Steps for performing the evaluation:evaluation:

Note: The civil surgeon can Note: The civil surgeon can recognize that an applicant with recognize that an applicant with a physical or mental disorder a physical or mental disorder might have an associated might have an associated harmful behavior harmful behavior at any point in at any point in the medical examthe medical exam..

While taking the medical history of While taking the medical history of the mental disorderthe mental disorder

While taking history of harmful While taking history of harmful behaviorbehavior

While observing for current While observing for current abnormal behavior during the abnormal behavior during the physical examphysical exam

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Section 2Section 2Steps for performing the Steps for performing the evaluation (cont’d):evaluation (cont’d):

STEP 3STEP 3: Determine whether the : Determine whether the applicant has any applicant has any physical or mental physical or mental disordersdisorders using DSM criteria using DSM criteriaNote: If the civil surgeon is unable to Note: If the civil surgeon is unable to determine whether an applicant has a determine whether an applicant has a diagnosis of a physical or mental diagnosis of a physical or mental disorder, diagnosis and classification disorder, diagnosis and classification may be may be deferred deferred in order to obtain in order to obtain additional information (i.e. medical or additional information (i.e. medical or other relevant records, laboratory or other relevant records, laboratory or psychological testing). In this case, psychological testing). In this case, the civil surgeon should the civil surgeon should NOTNOT sign sign Form I-693 until a determination can Form I-693 until a determination can be made and the medical exam can be be made and the medical exam can be considered complete.considered complete.

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STEP 4STEP 4: If the applicant is : If the applicant is diagnosed with a mental or diagnosed with a mental or physical disorder, determine physical disorder, determine whether the disorder has an whether the disorder has an associated harmful associated harmful behaviorbehaviorOnly a mental or physical Only a mental or physical disorder disorder associated withassociated with a a harmful behavior is a harmful behavior is a Class A Class A conditioncondition (making one (making one inadmissible under health-inadmissible under health-related grounds)related grounds)

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Section 2Section 2For purposes of the For purposes of the

immigrationimmigrationmedical exam, medical exam, harmful harmful

behavior behavior is is an action an action associated with a mental or associated with a mental or physical disorder that results physical disorder that results in:in:

Serious psychological or Serious psychological or physical injury to the physical injury to the applicant or others (e.g. applicant or others (e.g. suicide attempt or suicide attempt or pedophilia)pedophilia)

A serious threat to health or A serious threat to health or safety (e.g. driving while safety (e.g. driving while intoxicated or verbally intoxicated or verbally threatening to kill someone)threatening to kill someone)

Major property damageMajor property damage

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Section 2Section 2Examples of mental disorders Examples of mental disorders most frequently associated with most frequently associated with harmful behavior include: harmful behavior include:

major depressionmajor depression bipolar disorderbipolar disorder schizophreniaschizophrenia mental retardationmental retardation

(These disorders occur within (These disorders occur within broader categories of disorders. broader categories of disorders. See TIs for more info.)See TIs for more info.)

Note: Physical disorders are Note: Physical disorders are rarely associated with harmful rarely associated with harmful behaviors.behaviors.

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Section 2Section 2As part of the evaluation, civil As part of the evaluation, civil surgeons may also have to surgeons may also have to determine:determine:Remission status of previously Remission status of previously diagnosed disorderdiagnosed disorderLikelihood of recurrence of Likelihood of recurrence of harmful behaviors associated harmful behaviors associated with physical or mental disorderwith physical or mental disorder

The physical or mental disorder The physical or mental disorder must must at least at least be in remission or be in remission or reliably controlled by medication reliably controlled by medication or other effective treatment for a or other effective treatment for a civil surgeon to find that the civil surgeon to find that the harmful behavior is unlikely to harmful behavior is unlikely to recur.recur.

If it has been If it has been 12 months 12 months since since the harmful behavior occurred, it the harmful behavior occurred, it is less likely to recur (general is less likely to recur (general guideline)guideline)

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See TIs for more info, including a list of factors affecting the applicant’s likelihood of maintaining remission or having a disorder under control.



STEP 5STEP 5: Determine whether : Determine whether the applicant has any Class A the applicant has any Class A or B conditions based on or B conditions based on physical or mental disorders physical or mental disorders with associated harmful with associated harmful behavior. Mark the behavior. Mark the appropriate finding on Form I-appropriate finding on Form I-693 (Section 2 of the Civil 693 (Section 2 of the Civil Surgeon Worksheet) . Surgeon Worksheet) .

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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


Section 2Section 2

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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).


Section 2Section 2Specialist Referral:Specialist Referral:Civil surgeons should refer the Civil surgeons should refer the

applicant to applicant to a specialist if he or she is unable to:a specialist if he or she is unable to: Arrive at a probable psychiatric Arrive at a probable psychiatric

diagnosis to determine if the diagnosis to determine if the applicant has or had a mental or applicant has or had a mental or physical disorder with associated physical disorder with associated harmful behaviorharmful behavior

Rule out the presence of a Rule out the presence of a physical or mental disorder physical or mental disorder

Determine if harmful behavior Determine if harmful behavior has been associated with a has been associated with a physical or mental disorder or if it physical or mental disorder or if it is likely to recuris likely to recur

Determine if any diagnosed Determine if any diagnosed physical or mental disorders physical or mental disorders affecting behavior are in affecting behavior are in remission or under control, or the remission or under control, or the likelihood of the applicant likelihood of the applicant maintaining remission or effective maintaining remission or effective controlcontrol

⇨ ⇨ As with any referral, sections As with any referral, sections 5-6 of the Civil Surgeon 5-6 of the Civil Surgeon Worksheet should be completed Worksheet should be completed by the civil surgeon and by the civil surgeon and physician receiving referral, physician receiving referral, respectivelyrespectively

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Section 2Section 2Special Note on Alcohol Abuse Special Note on Alcohol Abuse and Dependence:and Dependence:Classified as a mental disorder, Classified as a mental disorder, not not substance abuse or substance abuse or dependencedependenceDiagnosis made using DSM Diagnosis made using DSM criteria for abuse or dependencecriteria for abuse or dependenceTo classify, must determine if To classify, must determine if associated harmful behavior is associated harmful behavior is present or if in past, is likely to present or if in past, is likely to recur (see Figure 2 in TIs)recur (see Figure 2 in TIs)If civil surgeon is unable to make If civil surgeon is unable to make diagnosis or classification, he or diagnosis or classification, he or she must refer applicant to she must refer applicant to specialistspecialist

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Drug Abuse and Drug Abuse and

Drug AddictionDrug Addiction(Form I-693: Civil Surgeon (Form I-693: Civil Surgeon

Worksheet, Section 3)Worksheet, Section 3)

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Section 3Section 3Drug Abuse/Drug Addiction Drug Abuse/Drug Addiction

:: Any drug abuse or drug Any drug abuse or drug

addiction should be addiction should be recorded in Section 3 of the recorded in Section 3 of the Civil Surgeon Worksheet Civil Surgeon Worksheet (on pp. 3-4 of Form I-693)(on pp. 3-4 of Form I-693)

Civil surgeons should Civil surgeons should review the TIs onreview the TIs on Physical Physical or Mental Disorders with or Mental Disorders with Associated Harmful Associated Harmful Behavior and Substance-Behavior and Substance-related Disordersrelated Disorders at at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/mental-civil-technical-instructions.html 19


Section 3Section 3Overview of required Overview of required

evaluation:evaluation: Diagnose any substance Diagnose any substance

abuse or dependence abuse or dependence using American using American Psychiatric Association’s Psychiatric Association’s Diagnostic and Statistical Diagnostic and Statistical Manual of Mental Manual of Mental Disorders (DSM) criteriaDisorders (DSM) criteria

Classify whether the Classify whether the applicant applicant has a Class A or B has a Class A or B conditioncondition

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Section 3Section 3Steps for performing evaluation:Steps for performing evaluation:

STEP 1STEP 1: Based on the evaluation : Based on the evaluation performed for the mental or performed for the mental or physical disorder component of physical disorder component of the immigration medical exam, the immigration medical exam, determine whether the applicant determine whether the applicant has a diagnosis of substance has a diagnosis of substance abuse or dependence based on abuse or dependence based on DSM criteria.DSM criteria.

Note: Random screening for Note: Random screening for drugs is drugs is notnot part of the routine part of the routine immigration medical exam. immigration medical exam. However, the civil surgeon may However, the civil surgeon may decide to perform drug decide to perform drug screening on an individual basis screening on an individual basis depending on the applicant’s depending on the applicant’s history, behavior, and physical history, behavior, and physical appearance.appearance.

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See TIs for more info, including a list of indications for laboratory drug screening.


Section 3Section 3Deferring diagnosis and classification:Deferring diagnosis and classification:If the civil surgeon is unable to determine If the civil surgeon is unable to determine whether an applicant has a diagnosis of whether an applicant has a diagnosis of substance abuse or dependence, diagnosis substance abuse or dependence, diagnosis and classification may be and classification may be deferred deferred for 3-6 for 3-6 months to give the applicant an months to give the applicant an opportunity to show abstinence or obtain opportunity to show abstinence or obtain additional information (i.e. medical or additional information (i.e. medical or other relevant records, laboratory or other relevant records, laboratory or psychological testing).psychological testing).

In this case, the civil surgeon should In this case, the civil surgeon should explain to the applicant what is expected explain to the applicant what is expected of the applicant during the 3-6 months of the applicant during the 3-6 months (e.g. requiring clinical reports from health (e.g. requiring clinical reports from health care professionals to demonstrate care professionals to demonstrate participation in drug treatment program). participation in drug treatment program). The civil surgeon should consider The civil surgeon should consider documenting the expectations and documenting the expectations and obtaining the applicant’s signature.obtaining the applicant’s signature.

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Section 3Section 3The civil surgeon should use the The civil surgeon should use the DSM’s definition of substance DSM’s definition of substance abuse and dependence when abuse and dependence when making a diagnosis for purposes making a diagnosis for purposes of the immigration medical exam: of the immigration medical exam:

Substance abuseSubstance abuse is generally is generally characterized by a pattern of characterized by a pattern of recurrent substance use despite recurrent substance use despite adverse consequences and adverse consequences and impairmentimpairment

Substance dependenceSubstance dependence is is generally characterized by generally characterized by compulsive long-term substance compulsive long-term substance use despite significant substance-use despite significant substance-related physical, psychological, related physical, psychological, social, occupational, or behavioral social, occupational, or behavioral problemsproblems

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Section 3Section 3Steps for performing Steps for performing evaluation (cont’d):evaluation (cont’d):

STEP 2STEP 2: If substance abuse : If substance abuse or dependence is found, or dependence is found, determine whether with the determine whether with the specific substance used is specific substance used is listed in Schedules I – IV of listed in Schedules I – IV of Section 202 of the Controlled Section 202 of the Controlled Substances Act (see Substances Act (see Appendix C in the TIs for list)Appendix C in the TIs for list)

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Section 3Section 3If the applicant meets the DSM If the applicant meets the DSM criteria for substance abuse or criteria for substance abuse or dependence dependence of aof a controlled controlled substancesubstance, then the applicant has , then the applicant has a Class A conditiona Class A condition

If the applicant’s substance abuse If the applicant’s substance abuse or dependence or dependence does not does not involve a involve a controlled substancecontrolled substance, then the , then the applicant suffers from a physical or applicant suffers from a physical or mental disorder. The civil surgeon mental disorder. The civil surgeon should then determine whether an should then determine whether an associated harmful behavior exists associated harmful behavior exists (If yes, then the applicant has a (If yes, then the applicant has a Class A condition)Class A condition)

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Section 3Section 3Substances used for clinical Substances used for clinical care in medical practice care in medical practice should should notnot be considered for be considered for substance abuse substance abuse Prescription drugs should Prescription drugs should generally be considered for generally be considered for substance abuse only if drugs substance abuse only if drugs are not taken according to are not taken according to prescription prescription

⇨⇨ Civil surgeons should Civil surgeons should classify classify alcohol dependence or alcohol dependence or abuseabuse as a physical or mental as a physical or mental disorder (see Section 2 of the disorder (see Section 2 of the Civil Surgeon Worksheet)Civil Surgeon Worksheet)

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Section 3Section 3Steps for performing Steps for performing evaluation (cont’d):evaluation (cont’d):

STEP 3:STEP 3: Based on any Based on any findings of substance abuse findings of substance abuse or dependence, determine or dependence, determine whether the applicant has whether the applicant has any Class A or B conditions.any Class A or B conditions.Any substance abuse or Any substance abuse or dependence, past or present, dependence, past or present, that that involves a controlled involves a controlled substance substance should be should be recorded in Section 3 of the recorded in Section 3 of the Civil Surgeon WorksheetCivil Surgeon Worksheet

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Note: No determination of associated harmful behavior is needed to classify applicant as having Class A substance abuse or dependence


Section 2Section 2

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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).


Section 3Section 3 If substance abuse or If substance abuse or

dependence is found, the dependence is found, the civil surgeon (or specialist, civil surgeon (or specialist, if referred) must if referred) must documentdocument the applicant’s the applicant’s pattern of use and pattern of use and behavioral, physical, and behavioral, physical, and psychological effects psychological effects associated with the associated with the substance use or cessation substance use or cessation of use. Attach supporting of use. Attach supporting documentation to Form I-documentation to Form I-693 if needed.693 if needed.

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Section 3Section 3Specialist Referral:Specialist Referral:Civil surgeons should refer the Civil surgeons should refer the applicant to a specialist if he or applicant to a specialist if he or

she is she is unable to:unable to: Arrive at a probable diagnosis Arrive at a probable diagnosis

of drug abuse or addiction of drug abuse or addiction according to DSM criteriaaccording to DSM criteria

Determine whether any Determine whether any diagnosed drug abuse or diagnosed drug abuse or addiction is in remissionaddiction is in remission

⇨⇨ As with any referral, Sections As with any referral, Sections 5-6 of the Civil Surgeon 5-6 of the Civil Surgeon Worksheet should be Worksheet should be completed by the civil completed by the civil surgeon and physician surgeon and physician receiving referral, receiving referral, respectivelyrespectively

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Sections 5-6Sections 5-6 Sections 5-6 of the Sections 5-6 of the

Civil Surgeon Civil Surgeon Worksheet should Worksheet should onlyonly be completed if a be completed if a referral was made referral was made during the during the immigration medical immigration medical examexam

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Sections 5-6Sections 5-6When referring an applicant, the civilWhen referring an applicant, the civilsurgeon should: surgeon should: 1.1. Complete Section 5 of the Civil Complete Section 5 of the Civil

Surgeon Worksheet Surgeon Worksheet 2.2. Ensure the following are Ensure the following are

completed:completed: Part 1 (applicant information)Part 1 (applicant information) Part 3 (civil surgeon Part 3 (civil surgeon

information) – but do not sign information) – but do not sign or date Part 3 or date Part 3

3.3. Make a copy of Form I-693 for Make a copy of Form I-693 for your records and give the original your records and give the original form to the applicant in a sealed form to the applicant in a sealed envelopeenvelope

4.4. Advise the applicant that the Advise the applicant that the appropriate follow-up must be appropriate follow-up must be obtained before the immigration obtained before the immigration medical exam can be considered medical exam can be considered completecomplete

5.5. Sign Part 3 of Form I-693 Sign Part 3 of Form I-693 only only afterafter referral evaluation and referral evaluation and treatment, if any, is treatment, if any, is completedcompleted

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Section 4Section 4Other Medical Conditions:Other Medical Conditions: In Section 4 of the Civil In Section 4 of the Civil

Surgeon Worksheet, civil Surgeon Worksheet, civil surgeons should note any surgeons should note any otherother physical or mental physical or mental disorder that represents a disorder that represents a substantial departure from substantial departure from normal health or well-normal health or well-beingbeing

Civil surgeons should Civil surgeons should review the TIs onreview the TIs on Other Other Physical or Mental Physical or Mental Abnormality, Disease or Abnormality, Disease or DisabilityDisability at at http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions/civil-surgeons/required-evaluation-components/other-disease-disability.html

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Section 4Section 4Other Medical Conditions:Other Medical Conditions: Medical conditions listed in Medical conditions listed in

Section 4 should be Section 4 should be significant enough to possibly significant enough to possibly interfere with the person’s interfere with the person’s ability to care for him- or ability to care for him- or herself, or attend school or herself, or attend school or work, or that may require work, or that may require extensive medical treatment extensive medical treatment or institutionalization in the or institutionalization in the future future

Examples of medical Examples of medical conditions that should be conditions that should be listed in Section 4:listed in Section 4:

HIVHIV DiabetesDiabetes HypertensionHypertension

Medical conditions Medical conditions listed in Section 4 listed in Section 4

are are Class B Class B

conditionsconditions

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Completing Form I-693: Completing Form I-693: Final ReviewFinal Review

Before signing and dating Before signing and dating the the

Form I-693 in Part 3:Form I-693 in Part 3: Ensure that all follow-up Ensure that all follow-up

evaluation and treatment evaluation and treatment is completedis completed

Ensure that all Ensure that all Findings/Results boxes Findings/Results boxes are completed for each are completed for each section section

Ensure that Part 2 Ensure that Part 2 (“Summary of Medical (“Summary of Medical Examination”) is Examination”) is completedcompleted

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Frequently Asked Frequently Asked QuestionsQuestions

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Frequently Asked Questions Frequently Asked Questions

Q:Q: Do I need to perform any blood tests Do I need to perform any blood tests to determine if an applicant has an to determine if an applicant has an alcohol abuse or dependence alcohol abuse or dependence problem?problem?

A: No. Civil surgeons do not need to perform a A: No. Civil surgeons do not need to perform a liver function test or any other blood test on liver function test or any other blood test on applicants. Alcohol abuse and/or dependence applicants. Alcohol abuse and/or dependence should be treated as a mental disorder. should be treated as a mental disorder. Therefore, the DSM criteria for a mental disorder Therefore, the DSM criteria for a mental disorder must be met; in addition, harmful behavior must be met; in addition, harmful behavior associated with the mental disorder must be associated with the mental disorder must be evaluated in the applicant to classify the evaluated in the applicant to classify the condition as Class A.condition as Class A.

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Questions?Questions?

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Contact InformationContact Information

For questions on civil surgeon For questions on civil surgeon designation, Form I-693, or immigration designation, Form I-693, or immigration issues in general, please contact the civil issues in general, please contact the civil surgeon coordinator in your jurisdictionsurgeon coordinator in your jurisdiction

For questions about the Technical For questions about the Technical Instructions and medical exam Instructions and medical exam requirements: requirements: Go to: Go to:

http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html 39