This form contains 446 fields organized into 105 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
A-Number
A-Number	Number	Provide the alien registration number, also known as the A-Number, if applicable. Max length: 9 characters
A-Number	Text	Provide your A-Number, if applicable. Max length: 9 characters
A-Number	Text	Provide your Alien Registration Number (A-Number) if you have one. Max length: 9 characters
A-Number	Text	Provide your A-Number, if applicable. Max length: 9 characters
Abnormal Chest X-Ray Findings
Infiltrate or consolidation	Checkbox	Check this box if the chest X-ray shows infiltrate or consolidation, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Reticular markings suggestive of fibrosis	Checkbox	Check this box if the chest X-ray shows reticular markings suggestive of fibrosis, indicating abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Miliary findings	Checkbox	Check this box if the chest X-ray shows miliary findings, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Nodule(s) or mass with poorly defined margins (such as tuberculoma)	Checkbox	Check this box if the chest X-ray shows nodule(s) or mass with poorly defined margins (such as tuberculoma), suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Cavitary lesion	Checkbox	Check this box if the chest X-ray shows a cavitary lesion, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Hilar/mediastinal adenopathy	Checkbox	Check this box if the chest X-ray shows hilar/mediastinal adenopathy, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Pleural effusion	Checkbox	Check this box if the chest X-ray shows pleural effusion, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Discrete linear opacity	Checkbox	Check this box if the chest X-ray shows discrete linear opacity, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Irregular thick pleural reaction	Checkbox	Check this box if the chest X-ray shows an irregular thick pleural reaction, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Volume loss or retraction	Checkbox	Check this box if the chest X-ray shows volume loss or retraction, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Discrete nodule(s) without calcification	Checkbox	Check this box if the chest X-ray shows discrete nodule(s) without calcification, suggesting abnormal findings for tuberculosis that require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Other (further describe in Remarks section below)	Checkbox	Check this box if the chest X-ray shows other abnormal findings suggestive of tuberculosis not listed, and further describe them in the Remarks section, as they require smears and cultures. Fill only if 'Abnormal findings suggestive of TB that require smears and cultures' is 'Yes'. Depends on: Abnormal findings suggestive of TB that require smears and cultures
Address of Evaluating Physician or Health Department
Street Number and Name	Text	Enter the street number and name for the address of the evaluating physician or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 25 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Apartment/Suite/Floor Number	Text	Enter the apartment, suite, or floor number for the address, if applicable. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 6 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Flr.	Checkbox	Check this box if the address is a floor. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Ste.	Checkbox	Check this box if the address is a suite. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Apt.	Checkbox	Check this box if the address is an apartment. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
City or Town	Text	Enter the city or town for the address of the evaluating physician or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 20 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
ZIP Code	Text	Enter the ZIP code for the address of the evaluating physician or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 5 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Applicant Full Name
Family Name	Text	Enter the applicant's family name or last name.
Given Name	Text	Enter the applicant's given name or first name.
Middle Name	Text	Enter the applicant's middle name, if applicable.
Applicant Identification
Given Name	Text	Enter the applicant's given name (first name). Max length: 18 characters
Family Name	Text	Enter the applicant's family name (last name). Max length: 30 characters
Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
A-Number	Text	Enter the applicant's A-Number, if one has been assigned. Max length: 9 characters
Applicant Information
Family Name	Text	Provide the applicant's family name or last name. Max length: 30 characters
Given Name	Text	Provide the applicant's given name or first name. Max length: 18 characters
Middle Name	Text	Provide the applicant's middle name, if applicable. Max length: 18 characters
A-Number	Text	Provide the applicant's A-Number, if one has been assigned. Max length: 9 characters
Given Name	Text	Enter the applicant's given name (first name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 18 characters Depends on: Eligible for Vaccination Record Portion Only
Family Name	Text	Enter the applicant's family name (last name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 30 characters Depends on: Eligible for Vaccination Record Portion Only
Middle Name	Text	Enter the applicant's middle name, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 18 characters Depends on: Eligible for Vaccination Record Portion Only
A-Number	Text	Enter the applicant's A-Number, if one has been assigned. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 9 characters Depends on: Eligible for Vaccination Record Portion Only
Given Name	Text	Enter the applicant's given name or first name. Max length: 18 characters
Family Name	Text	Enter the applicant's family name or last name. Max length: 30 characters
Middle Name	Text	Enter the applicant's middle name. Max length: 18 characters
A-Number	Text	Enter the applicant's Alien Registration Number (A-Number), if applicable. Max length: 9 characters
Applicant Name
Remarks / Additional Information	Text	Enter any additional comments, explanations, or clarifying information related to the civil surgeon worksheet (for example IGRA exceptions, TB evaluation details, abnormal findings, or other pertinent notes). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Applicant First Name	Text	Enter the applicant's given name or first name. Max length: 18 characters
Applicant Last Name	Text	Enter the applicant's family name or last name. Max length: 30 characters
Applicant Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
Given Name	Text	Enter the applicant's given name. Max length: 18 characters
Family Name	Text	Enter the applicant's family name. Max length: 30 characters
Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
Applicant Name and A-Number
Given Name	Text	Enter the applicant's given name (first name). Max length: 18 characters
Family Name	Text	Enter the applicant's family name (last name). Max length: 30 characters
Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
A-Number	Text	Enter the applicant's A-Number, if one has been assigned. Max length: 9 characters
Form footer page/control field	Text	Enter the footer control value or page number to appear in the form footer (usually the current page number). Fill only if 'Item A. in Item Number 4.' is 'Yes'.
Applicant Given Name	Text	Enter the applicant's given name or first name. Fill only if 'Item A. in Item Number 4.' is 'Yes'. Max length: 18 characters
Applicant Family Name	Text	Enter the applicant's family name or last name. Fill only if 'Item A. in Item Number 4.' is 'Yes'. Max length: 30 characters
Applicant Middle Name	Text	Enter the applicant's middle name, if applicable. Fill only if 'Item A. in Item Number 4.' is 'Yes'. Max length: 18 characters
Applicant A-Number	Text	Enter the applicant's Alien Registration Number (A-Number), if one has been assigned. Fill only if 'Item A. in Item Number 4.' is 'Yes'. Max length: 9 characters
Form ID / Footer Identifier	Text	Enter the form identification or footer identifier shown on the page (for example the form name, form number, or edition code that appears in the document footer).
Applicant Family Name	Text	Enter the applicant's family name or last name. Max length: 30 characters
Applicant Given Name	Text	Enter the applicant's given name or first name. Max length: 18 characters
Applicant Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
Applicant A-Number	Text	Enter the applicant's A-Number, if one has been assigned. Max length: 9 characters
Applicant Name and ID
Page Number (Footer)	Text	Enter the form page number that appears in the footer of the document (e.g., 1).
Applicant First Name	Text	Enter the applicant's given name or first name. Max length: 18 characters
Applicant Last Name	Text	Enter the applicant's family name or last name. Max length: 30 characters
Applicant Middle Name	Text	Enter the applicant's middle name, if applicable. Max length: 18 characters
Applicant A-Number	Text	Enter the applicant's Alien Registration Number (A-Number), if available. Max length: 9 characters
Applicant's Contact Information
Mobile Telephone Number	Text	Please provide the applicant's mobile telephone number, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Email Address	Text	Please provide the applicant's email address, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Daytime Telephone Number	Text	Please provide the applicant's daytime telephone number. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Applicant's Identification Information
Bottom Control Field 1	Text	Enter the form control value displayed at the bottom of the page (typically the small page/control number shown in the highlighted box).
Document Identification Number	Text	Enter the identification number from the document presented by the applicant.
Form of Identification Presented	Text	Enter the type of identification presented by the applicant, such as a passport or driver's license.
Applicant's Name
Given Name	Text	Please provide the applicant's given name (first name). Max length: 18 characters
Family Name	Text	Please provide the applicant's family name (last name). Max length: 30 characters
Middle Name	Text	Please provide the applicant's middle name. Max length: 18 characters
Applicant's Name and A-Number
Given Name	Text	Please provide the applicant's given name (first name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 18 characters Depends on: Eligible for Vaccination Record Portion Only
Family Name	Text	Please provide the applicant's family name (last name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 30 characters Depends on: Eligible for Vaccination Record Portion Only
Middle Name	Text	Please provide the applicant's middle name, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 18 characters Depends on: Eligible for Vaccination Record Portion Only
A-Number	Text	Please provide the applicant's A-Number, if one has been assigned. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 9 characters Depends on: Eligible for Vaccination Record Portion Only
Applicant's Signature and Date
Applicant's Signature	Text	Please provide the applicant's signature. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Date of Signature	Date	Please provide the date the applicant signed. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Birth Information
Country of Birth	Text	Enter the country where you were born.
Date of Birth	Date	Enter your date of birth.
City/Town/Village of Birth	Text	Enter the city, town, or village where you were born.
Chest X-Ray Dates
Date Chest X-Ray Taken	Date	Please provide the date when the chest X-ray was taken. Fill only if 'Chest X-ray required due to IGRA exception', 'Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)', 'Chest X-ray required due to initial screening test results' is 'Yes' for any. Depends on: Chest X-ray required due to IGRA exception, Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV), Chest X-ray required due to initial screening test results
Date Chest X-Ray Read	Date	Please provide the date when the chest X-ray results were read. Fill only if 'Chest X-ray required due to IGRA exception', 'Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)', 'Chest X-ray required due to initial screening test results' is 'Yes' for any. Depends on: Chest X-ray required due to IGRA exception, Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV), Chest X-ray required due to initial screening test results
Chest X-Ray Result
Normal	Checkbox	Check this box if the chest X-ray result is normal. Fill only if 'Chest X-ray required due to IGRA exception', 'Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)', 'Chest X-ray required due to initial screening test results' is 'Yes' for any. Depends on: Chest X-ray required due to IGRA exception, Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV), Chest X-ray required due to initial screening test results
Abnormal findings suggestive of TB that require smears and cultures	Checkbox	Check this box if the chest X-ray shows abnormal findings suggestive of TB that require smears and cultures. Fill only if 'Chest X-ray required due to IGRA exception', 'Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)', 'Chest X-ray required due to initial screening test results' is 'Yes' for any. Depends on: Chest X-ray required due to IGRA exception, Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV), Chest X-ray required due to initial screening test results
Civil Surgeon Identification Number
Civil Surgeon Identification Number	Text	Provide the Civil Surgeon Identification Number (CSID) assigned to the civil surgeon, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 6 characters Depends on: Eligible for Vaccination Record Portion Only
Civil Surgeon's Mailing Address
State / Province	Combobox	Enter the state or province for the mailing address (use the two-letter U.S. postal abbreviation if within the United States). MI MD NC CO VI GA WI TX HI AS KY CA MH MP AE WV AP MS NE NV OH DC AL UT AA SC ID PR ME PW NM MT TN MO WY IA NJ PA CT VA AR NH OR VT LA MA NY WA MN OK SD ND AZ IL RI IN AK GU KS FL DE FM
Civil Surgeon's Name
Civil Surgeon's Given Name	Text	Provide the civil surgeon's given name (first name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Civil Surgeon's Family Name	Text	Provide the civil surgeon's family name (last name). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Civil Surgeon's Middle Name	Text	Provide the civil surgeon's middle name, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Civil Surgeon's Physical Address
State	Combobox	Enter the state for the civil surgeon’s physical address (preferably the two‑letter postal abbreviation). MI MD NC CO VI GA WI TX HI AS KY CA MH MP AE WV AP MS NE NV OH DC AL UT AA SC ID PR ME PW NM MT TN MO WY IA NJ PA CT VA AR NH OR VT LA MA NY WA MN OK SD ND AZ IL RI IN AK GU KS FL DE FM
Civil Surgeon's Signature
Civil Surgeon Signature	Text	Enter the civil surgeon's full name as their signature. Fill only if 'Item A. in Item Number 4.' is 'Yes'. Max length: 1 characters
Date of Signature	Date	Enter the date the civil surgeon signed the form. Fill only if 'Item A. in Item Number 4.' is 'Yes'.
Contact Information
Mobile Telephone Number	Text	Enter the mobile telephone number, if available. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Daytime Telephone Number	Text	Enter the daytime telephone number. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Email Address	Text	Enter the email address, if available. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Current Physical Address
Street Number and Name	Text	Enter the street number and name of your current physical address. Max length: 34 characters
Apartment/Suite/Floor Number	Text	Provide the apartment, suite, or floor number of your current physical address, if applicable. Max length: 6 characters
Floor (Flr.)	Checkbox	Check this box if your current physical address includes a floor designation.
Suite (Ste.)	Checkbox	Check this box if your current physical address includes a suite designation.
Apartment (Apt.)	Checkbox	Check this box if your current physical address includes an apartment designation.
City or Town	Text	Enter the city or town of your current physical address. Max length: 20 characters
State	Combobox	Enter the state of your current physical address (U.S. states only). MI MD NC CO VI GA WI TX HI AS KY CA MH MP AE WV AP MS NE NV OH DC AL UT AA SC ID PR ME PW NM MT TN MO WY IA NJ PA CT VA AR NH OR VT LA MA NY WA MN OK SD ND AZ IL RI IN AK GU KS FL DE FM
ZIP Code	Text	Enter the ZIP code for your current physical address. Max length: 5 characters
In Care Of Name	Text	Provide the name of the person or entity in whose care the mail should be delivered, if applicable. Max length: 34 characters
Postal Code	Text	Enter the postal code for your current physical address. Max length: 9 characters
Province	Text	Provide the province of your current physical address, if applicable. Max length: 20 characters
Country	Text	Enter the country of your current physical address.
Date of First Examination
Date of First Examination	Date	Enter the date of the applicant's first medical examination. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Date of Referral
Date of Referral	Date	Provide the date the referral was made. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Dates of Follow-up Examinations
Follow-up Examination Date 1	Date	Enter the date of the first required follow-up examination. Fill only if 'Class B Conditions', 'Class A Conditions' is 'Yes' for any. Depends on: Class B Conditions, Class A Conditions
Follow-up Examination Date 3	Date	Enter the date of the third required follow-up examination. Fill only if 'Class B Conditions', 'Class A Conditions' is 'Yes' for any. Depends on: Class B Conditions, Class A Conditions
Follow-up Examination Date 2	Date	Enter the date of the second required follow-up examination. Fill only if 'Class B Conditions', 'Class A Conditions' is 'Yes' for any. Depends on: Class B Conditions, Class A Conditions
Daytime Telephone Number
Daytime Telephone Number	Text	Provide the daytime telephone number for contact. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 10 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Drug Abuse/Drug Addiction Findings
Substance (Drug) Addiction in Full Remission, Class B	Checkbox	Check this box if the individual has a diagnosis of substance drug addiction in full remission involving a Class B substance as listed in section 202 of the Controlled Substances Act.
Substance (Drug) Abuse in Full Remission, Class B	Checkbox	Check this box if the individual has a diagnosis of substance drug abuse in full remission involving a Class B substance as listed in section 202 of the Controlled Substances Act.
No Class A or B Substance (Drug) Abuse/Addiction	Checkbox	Check this box if the individual has no Class A or B substance drug abuse or addiction.
Substance (Drug) Abuse or Addiction, Class A	Checkbox	Check this box if the individual has a diagnosis of substance drug abuse or addiction involving a Class A substance as listed in section 202 of the Controlled Substances Act.
Drug Abuse/Drug Addiction Remarks
Drug Abuse/Addiction Remarks	Text	Provide any therapy given, counseling, or referrals related to drug abuse or addiction. Fill only if 'Substance (Drug) Addiction in Full Remission, Class B', 'Substance (Drug) Abuse in Full Remission, Class B', 'Substance (Drug) Abuse or Addiction, Class A' is 'Yes', any. Depends on: Substance (Drug) Abuse or Addiction, Class A, Substance (Drug) Abuse in Full Remission, Class B, Substance (Drug) Addiction in Full Remission, Class B
Eighth Vaccination Record (Pneumococcal)
Pneumococcal Date Received 1	Date	Enter the first date the Pneumococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Pneumococcal Date Received 2	Date	Enter the second date the Pneumococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Pneumococcal Date Received 3	Date	Enter the third date the Pneumococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Pneumococcal Date Given by Civil Surgeon	Date	Enter the date the Pneumococcal vaccine was given by the civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Pneumococcal Date Received 4	Date	Enter the fourth date the Pneumococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contraindication	Checkbox	Check this box if there is a medical contraindication to receiving the Pneumococcal vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if the Pneumococcal vaccine was not given due to an insufficient time interval between doses or before the immigration medical examination. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if the Pneumococcal vaccine is not age-appropriate for the applicant. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Pneumococcal Complete Series/Immunity Status	Text	Mark 'X' if the series is complete, write the date of a lab test if the applicant is immune, or write 'VH' if there is a varicella history for the Pneumococcal vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Eleventh Vaccination Record (Hepatitis A)
Hepatitis A Date Received 1	Date	Enter the first date the Hepatitis A vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Date Received 2	Date	Enter the second date the Hepatitis A vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Date Received 3	Date	Enter the third date the Hepatitis A vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Date Given by Civil Surgeon	Date	Enter the date the Hepatitis A vaccine was given by a civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Date Received 4	Date	Enter the fourth date the Hepatitis A vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Contraindication	Checkbox	Check this box if a blanket waiver is being requested for the Hepatitis A vaccine due to a medical contraindication for the applicant. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Insufficient Time Interval	Checkbox	Check this box if a blanket waiver is being requested for the Hepatitis A vaccine because there was an insufficient time interval between vaccine doses. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Not Age-Appropriate	Checkbox	Check this box if a blanket waiver is being requested for the Hepatitis A vaccine because it is not age-appropriate for the applicant. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis A Complete Series/Immune Status	Text	Mark 'X' if the Hepatitis A vaccine series is complete, or write the date of the lab test if immune, or 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Evaluating Physician's Full Name
Given Name	Text	Please enter the evaluating physician's or health department's given name (first name). Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Family Name	Text	Please enter the evaluating physician's or health department's family name (last name). Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Middle Name	Text	Please enter the evaluating physician's or health department's middle name, if applicable. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Fifth Vaccination Record (Hib)
Hib Date Received 1	Date	Enter the first date the Hib vaccination was received, transferred from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hib Date Received 2	Date	Enter the second date the Hib vaccination was received, transferred from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hib Date Received 3	Date	Enter the third date the Hib vaccination was received, transferred from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hib Date Given by Civil Surgeon	Date	Enter the date the Hib vaccine was given by the Civil Surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hib Date Received 4	Date	Enter the fourth date the Hib vaccination was received, transferred from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contraindication	Checkbox	Check this box if there is a medical contraindication for the applicant to receive the Hib vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if there was an insufficient time interval between the Hib vaccine doses for the applicant. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if the Hib vaccine is not age-appropriate for the applicant to receive. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hib Complete Series or Immunity Info	Text	Mark 'X' if the Hib vaccine series is complete, write the date of a lab test if immune, or 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
First Additional Information Entry
Page Number	Text	Enter the page number that the additional information provided refers to. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 2 characters Depends on: Remarks
Part Number	Text	Enter the part number that the additional information provided refers to. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Item Number	Text	Enter the item number that the additional information provided refers to. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Additional Information Entry	Text	Provide any additional information or explanation required for the form in this space. Fill only if 'Remarks (Part 8, Item 5)' requires more space Depends on: Remarks
First Sputum Culture Result
First Culture Negative Result	Text	Indicate if the first sputum culture result was negative. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Culture Positive Result	Text	Indicate if the first sputum culture result was positive. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Culture Specimen Obtained Date	Date	Enter the date the first sputum culture specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Culture Result Reported Date	Date	Enter the date the first sputum culture result was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Culture Contaminated Result	Text	Indicate if the first sputum culture result was contaminated. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Culture NTM Result	Text	Indicate if the first sputum culture result was NTM (Non-Tuberculous Mycobacteria). Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Sputum Smear Result
First Smear Result Negative	Text	Indicate if the first sputum smear result was negative. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Smear Result Positive	Text	Indicate if the first sputum smear result was positive. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Date First Specimen Obtained	Date	Enter the date the first sputum specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Date First Smear Result Reported	Date	Enter the date the first sputum smear result was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
First Vaccination Record (DT/DTaP/DTP)
DT	Checkbox	Check this box if the first vaccination recorded is for DT (Diphtheria and Tetanus). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
DTP	Checkbox	Check this box if the first vaccination recorded is for DTP (Diphtheria, Tetanus, and Pertussis - whole-cell). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
DTaP	Checkbox	Check this box if the first vaccination recorded is for DTaP (Diphtheria, Tetanus, and acellular Pertussis). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
First Dose Date Received	Date	Enter the date the first dose of the DT/DTaP/DTP vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Second Dose Date Received	Date	Enter the date the second dose of the DT/DTaP/DTP vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third Dose Date Received	Date	Enter the date the third dose of the DT/DTaP/DTP vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Fourth Dose Date Received	Date	Enter the date the fourth dose of the DT/DTaP/DTP vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Date Given by Civil Surgeon	Date	Enter the date the DT/DTaP/DTP vaccine was given by the Civil Surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if a blanket waiver for the first vaccination record is requested because it is not age-appropriate. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contra-indication	Checkbox	Check this box if a blanket waiver for the first vaccination record is requested due to a medical contra-indication. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if a blanket waiver for the first vaccination record is requested due to an insufficient time interval for administration. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Complete Series or Immunity Record	Text	Mark 'X' if the complete series of DT/DTaP/DTP vaccine was received, write the date of the lab test if immune, or write 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Footer Field
Current Page Number	Text	Enter the current page number of the form.
Footer Field (Form ID/Page Number)
Form ID	Number	Provide the unique identifier for this form.
Form Footer Field
Page Number	Text	Enter the current page number of the form.
Page Number	Text	Please enter the current page number of this form.
Form Footer Field 1
Page Number	Text	Enter the current page number of the form.
Form I-693 Page Bottom Field
Current Page Number	Text	Provide the current page number of the form.
Fourth Additional Information Entry
Page Number	Text	Enter the page number to which the additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 2 characters Depends on: Remarks
Part Number	Text	Enter the part number of the form section to which the additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Item Number	Text	Enter the item number within the form part to which the additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Additional Information Details	Text	Provide any additional information that does not fit into the standard fields of the form, referencing the specified page, part, and item numbers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Depends on: Remarks
Fourth Vaccination Record (MMR)
MMR Date Received Dose 1	Date	Enter the date the first dose of the MMR vaccine was received from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
MMR Date Received Dose 2	Date	Enter the date the second dose of the MMR vaccine was received from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
MMR Date Received Dose 3	Date	Enter the date the third dose of the MMR vaccine was received from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
MMR Date Given by Civil Surgeon	Date	Enter the date the MMR vaccine was given by the Civil Surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
MMR Date Received Dose 4	Date	Enter the date the fourth dose of the MMR vaccine was received from a written record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contraindication	Checkbox	Check this box if a blanket waiver is being requested for the MMR vaccine due to a medical contraindication. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if a blanket waiver is being requested for the MMR vaccine due to an insufficient time interval between doses. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if a blanket waiver is being requested for the MMR vaccine because the recipient is not of an age appropriate for the vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
MMR Complete Series Status	Text	Indicate if the MMR vaccine series is complete by marking 'X', or enter the date of a lab test if immune, or 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Full Legal Name
Page Number	Text	Enter the current page number of this form.
Middle Name	Text	Provide your full legal middle name, if applicable, as it appears on your official documents.
Given Name	Text	Provide your full legal given name (first name) as it appears on your official documents.
Family Name	Text	Provide your full legal family name as it appears on your official documents.
Gonorrhea Findings
Gonorrhea, Class B (treated in the last year)	Checkbox	Check this box if the applicant has Class B Gonorrhea that was treated in the last year.
Gonorrhea, Class A (untreated)	Checkbox	Check this box if the applicant has untreated Class A Gonorrhea.
No Class A or Class B Gonorrhea	Checkbox	Check this box if the applicant does not have Class A or Class B Gonorrhea findings.
Gonorrhea Laboratory Test Information
Date Result Reported	Date	Enter the date the Gonorrhea test result was reported.
Screening NAAT Name	Text	Enter the name of the Screening Nucleic Acid Amplification Test (NAAT) used for Gonorrhea.
Positive	Checkbox	Check this box if the Gonorrhea laboratory test result is positive.
Negative	Checkbox	Check this box if the Gonorrhea laboratory test result is negative.
Gonorrhea Treatment Remarks
Gonorrhea Treatment Remarks	Text	Provide any symptoms observed, treatment administered, including doses and dates of administration for Gonorrhea. Fill only if 'Gonorrhea, Class B (treated in the last year)', 'Gonorrhea, Class A (untreated)' is 'Yes' for any. Depends on: Gonorrhea, Class A (untreated), Gonorrhea, Class B (treated in the last year)
Gonorrhea Drug Name	Text	Enter the name of the drug administered for Gonorrhea. Fill only if 'Gonorrhea, Class B (treated in the last year)', 'Gonorrhea, Class A (untreated)' is 'Yes' for any. Depends on: Gonorrhea, Class A (untreated), Gonorrhea, Class B (treated in the last year)
Gonorrhea Drug Dosage	Text	Enter the dosage of the drug administered for Gonorrhea. Fill only if 'Gonorrhea, Class B (treated in the last year)', 'Gonorrhea, Class A (untreated)' is 'Yes' for any. Depends on: Gonorrhea, Class A (untreated), Gonorrhea, Class B (treated in the last year)
Gonorrhea Treatment Start Date	Date	Provide the date when the Gonorrhea treatment started. Fill only if 'Gonorrhea, Class B (treated in the last year)', 'Gonorrhea, Class A (untreated)' is 'Yes' for any. Depends on: Gonorrhea, Class A (untreated), Gonorrhea, Class B (treated in the last year)
Gonorrhea Treatment End Date	Date	Provide the date when the Gonorrhea treatment ended. Fill only if 'Gonorrhea, Class B (treated in the last year)', 'Gonorrhea, Class A (untreated)' is 'Yes' for any. Depends on: Gonorrhea, Class A (untreated), Gonorrhea, Class B (treated in the last year)
Hansen's Disease Findings
No Class A/B Condition	Checkbox	Check this box if the individual has no Class A or Class B condition related to communicable diseases of public health significance, specifically concerning Hansen's Disease findings. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Hansen's Disease (leprosy, any classification) untreated, Class A	Checkbox	Check this box if the individual has untreated Hansen's Disease (leprosy) classified as Class A. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)	Checkbox	Check this box if the individual has untreated Hansen's Disease (Class A) with an indeterminate, tuberculoid, or borderline tuberculoid (paucibacillary) classification. Fill only if 'Hansen's Disease (leprosy, any classification) untreated, Class A' is checked. Depends on: Hansen's Disease (leprosy, any classification) untreated, Class A
Mid-borderline, borderline lepromatous, lepromatous (multibacillary)	Checkbox	Check this box if the individual has untreated Hansen's Disease (Class A) with a mid-borderline, borderline lepromatous, or lepromatous (multibacillary) classification. Fill only if 'Hansen's Disease (leprosy, any classification) untreated, Class A' is checked. Depends on: Hansen's Disease (leprosy, any classification) untreated, Class A
Hansen's Disease (leprosy, any classification) treated or partially treated, Class B	Checkbox	Check this box if the individual has treated or partially treated Hansen's Disease (leprosy) classified as Class B. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Indeterminate, tuberculoid, borderline tuberculoid (paucibacillary)	Checkbox	Check this box if the individual has treated or partially treated Hansen's Disease (Class B) with an indeterminate, tuberculoid, or borderline tuberculoid (paucibacillary) classification. Fill only if 'Hansen's Disease (leprosy, any classification) treated or partially treated, Class B' is checked. Depends on: Hansen's Disease (leprosy, any classification) treated or partially treated, Class B
Mid-borderline, borderline lepromatous, lepromatous (multibacillary)	Checkbox	Check this box if the individual has treated or partially treated Hansen's Disease (Class B) with a mid-borderline, borderline lepromatous, or lepromatous (multibacillary) classification. Fill only if 'Hansen's Disease (leprosy, any classification) treated or partially treated, Class B' is checked. Depends on: Hansen's Disease (leprosy, any classification) treated or partially treated, Class B
Hansen's Disease Remarks
Hansen's Disease Remarks	Text	Provide any additional remarks regarding Hansen's Disease, including details on therapy given, counseling, or referrals. Fill only if 'Hansen's Disease (leprosy, any classification) untreated, Class A', 'Hansen's Disease (leprosy, any classification) treated or partially treated, Class B' is checked, any. Depends on: Hansen's Disease (leprosy, any classification) untreated, Class A, Hansen's Disease (leprosy, any classification) treated or partially treated, Class B
Health Department's Name
Health Department's Name	Text	Provide the full name of the health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Identification Numbers
Alien Registration Number	Text	Please provide your Alien Registration Number (A-Number), if applicable. Max length: 9 characters
USCIS Online Account Number	Text	Please provide your USCIS Online Account Number, if applicable. Max length: 12 characters
IGRA Administration Status
Not Administered	Checkbox	Check this box if the Interferon Gamma Release Assay (IGRA) was not administered due to an exception.
IGRA Result
Negative	Checkbox	Check this box if the IGRA result is negative and no chest X-ray is required. Fill only if 'Not Administered' is 'No'. Depends on: Not Administered
Positive	Checkbox	Check this box if the IGRA result is positive and a chest X-ray is required. Fill only if 'Not Administered' is 'No'. Depends on: Not Administered
Indeterminate	Checkbox	Check this box if the IGRA result is indeterminate, including borderline or equivocal, and no chest X-ray is required. Fill only if 'Not Administered' is 'No'. Depends on: Not Administered
Immigration Medical Examination Requirement
Eligible for Vaccination Record Portion Only	Checkbox	Check this box if you are eligible for completion of only the vaccination record portion because you previously completed an overseas immigration medical examination, as detailed in the form instructions.
Initial Chest X-Ray Determination
Chest X-ray not required (medically cleared for TB)	Checkbox	Check this box if a chest X-ray is not required because the individual is medically cleared for TB.
Chest X-ray required due to IGRA exception	Checkbox	Check this box if a chest X-ray is required due to an IGRA exception, and ensure the specific exception is detailed in the Remarks section. Fill only if 'Not Administered' is 'Yes'. Depends on: Not Administered
Chest X-ray required due to TB signs or symptoms, or due to immunosuppression (such as HIV)	Checkbox	Check this box if a chest X-ray is required due to the individual exhibiting TB signs or symptoms, or having immunosuppression (such as HIV).
Chest X-ray required due to initial screening test results	Checkbox	Check this box if a chest X-ray is required based on the initial screening test results.
Interpreter's Business or Organization Name
Business or Organization Name	Text	Enter the name of the interpreter's business or organization. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 34 characters Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Certification and Signature
Interpreter's Other Fluent Language	Text	Please enter the other language, besides English, in which the interpreter is fluent.
Interpreter's Signature	Text	Please provide the interpreter's signature. Max length: 1 characters
Date of Signature	Date	Please enter the date the interpreter signed the certification.
Interpreter's Contact Information
Interpreter's Mobile Telephone Number	Text	Provide the mobile telephone number for the interpreter, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Daytime Telephone Number	Text	Provide the daytime telephone number for the interpreter. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Max length: 10 characters Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Email Address	Text	Provide the email address for the interpreter, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Full Name
Page Number	Text	Enter the current page number of this form to display in the footer. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Given Name	Text	Provide the given name or first name of the interpreter. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Interpreter's Family Name	Text	Provide the family name or last name of the interpreter. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Mailing Address
Street Number and Name (PO Box)	Text	Provide the street number and name, or PO box, for the mailing address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 34 characters Depends on: Eligible for Vaccination Record Portion Only
Apartment/Suite/Floor Number	Text	Enter the apartment, suite, or floor number for the mailing address, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 6 characters Depends on: Eligible for Vaccination Record Portion Only
Flr. (Floor)	Checkbox	Check this box when the civil surgeon's mailing address includes a floor number and you will enter that floor number in the adjacent field. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Ste. (Suite)	Checkbox	Check this box when the civil surgeon's mailing address includes a suite number and you will enter that suite number in the adjacent field. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Apt. (Apartment)	Checkbox	Check this box when the civil surgeon's mailing address includes an apartment number and you will enter that apartment number in the adjacent field. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
City or Town	Text	Enter the city or town for the mailing address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 20 characters Depends on: Eligible for Vaccination Record Portion Only
ZIP Code	Text	Provide the ZIP code for the mailing address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 5 characters Depends on: Eligible for Vaccination Record Portion Only
Name of Medical Practice or Health Department
Medical Practice or Health Department Name	Text	Enter the full name of the medical practice or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Name of Medical Practice, Facility, or Health Department
Medical Practice, Facility, or Health Department Name	Text	Please provide the full name of the medical practice, facility, or health department. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Ninth Vaccination Record (Influenza)
Footer Form ID	Text	Enter the form identifier text that appears in the footer (for example, the form name/ID such as "Form I-693" or other footer form code). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Dose 1 Date Received	Date	Enter the date the first dose of the Influenza vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Dose 2 Date Received	Date	Enter the date the second dose of the Influenza vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Dose 3 Date Received	Date	Enter the date the third dose of the Influenza vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Date Given by Civil Surgeon	Date	Enter the date the Influenza vaccine was given by a civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Dose 4 Date Received	Date	Enter the date the fourth dose of the Influenza vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contraindication (Influenza Waiver)	Checkbox	Check this box if a blanket waiver for the Influenza vaccine is requested due to a medical contraindication. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval (Influenza Waiver)	Checkbox	Check this box if a blanket waiver for the Influenza vaccine is requested because there was an insufficient time interval between vaccine doses. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate (Influenza Waiver)	Checkbox	Check this box if a blanket waiver for the Influenza vaccine is requested because the recipient's age is not appropriate for the vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Influenza Complete Series Status	Text	Mark 'X' if the Influenza vaccine series is complete, write the date of a lab test if immune, or 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
See Below Table (Influenza Waiver)	Checkbox	Check this box if a blanket waiver for the Influenza vaccine is requested for a reason detailed in a table or instructions provided elsewhere on the form or in accompanying documents. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Other Medical Conditions
Other Class B Medical Conditions	Text	Please list any other Class B medical conditions, including examples such as hypertension or diabetes, and any required evaluation components as outlined in the CDC's Technical Instructions for Civil Surgeons.
Physical Address
Street Number and Name	Text	Please provide the street number and name of the physical address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 34 characters Depends on: Eligible for Vaccination Record Portion Only
Apartment, Suite, or Floor Number	Text	Please provide the apartment, suite, or floor number of the physical address, if applicable. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 6 characters Depends on: Eligible for Vaccination Record Portion Only
Flr. (Floor)	Checkbox	Check this box if the civil surgeon's physical address includes a floor number (and enter the floor number in the adjacent field). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Ste. (Suite)	Checkbox	Check this box if the civil surgeon's physical address includes a suite number (and enter the suite number in the adjacent field). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Apt. (Apartment)	Checkbox	Check this box if the civil surgeon's physical address includes an apartment number (and enter the apartment number in the adjacent field). Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
City or Town	Text	Please provide the city or town of the physical address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 20 characters Depends on: Eligible for Vaccination Record Portion Only
ZIP Code	Text	Please provide the ZIP code of the physical address. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Max length: 5 characters Depends on: Eligible for Vaccination Record Portion Only
Physical or Mental Disorder Findings
No Class A or B Physical or Mental Disorder	Checkbox	Check this box if the individual does not have any Class A or B physical or mental disorder. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Physical/Mental Disorder with a History of Associated Harmful Behavior Unlikely to Recur, Class B	Checkbox	Check this box if the individual has a Class B physical or mental disorder with a history of associated harmful behavior that is judged unlikely to recur. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Physical/Mental Disorder without Associated Harmful Behavior, Class B	Checkbox	Check this box if the individual has a Class B physical or mental disorder without associated harmful behavior. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Physical/Mental Disorder with a History of Associated Harmful Behavior Likely to Recur, Class A	Checkbox	Check this box if the individual has a Class A physical or mental disorder with a history of associated harmful behavior that is judged likely to recur. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Physical/Mental Disorder with Associated Harmful Behavior, Class A	Checkbox	Check this box if the individual has a Class A physical or mental disorder with currently associated harmful behavior. Fill only if 'Eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Physical or Mental Disorder Remarks
Physical or Mental Disorder Remarks	Text	Provide details on diagnosis, likelihood of recurrence of harmful behavior, therapy given, and any counseling or referrals related to physical or mental disorders. Fill only if 'Physical/Mental Disorder with a History of Associated Harmful Behavior Unlikely to Recur, Class B', 'Physical/Mental Disorder without Associated Harmful Behavior, Class B', 'Physical/Mental Disorder with a History of Associated Harmful Behavior Likely to Recur, Class A', 'Physical/Mental Disorder with Associated Harmful Behavior, Class A' is checked, any. Depends on: Physical/Mental Disorder with Associated Harmful Behavior, Class A, Physical/Mental Disorder with a History of Associated Harmful Behavior Likely to Recur, Class A, Physical/Mental Disorder without Associated Harmful Behavior, Class B, Physical/Mental Disorder with a History of Associated Harmful Behavior Unlikely to Recur, Class B
Preparer's Business or Organization Name
Preparer's Business or Organization Name	Text	Provide the full legal name of the business or organization of the preparer. Fill only if 'Application prepared by someone other than the applicant' is 'Yes' Max length: 34 characters
Preparer's Certification and Signature
Preparer's Signature	Text	Enter the preparer's signature. Fill only if 'Application prepared by someone other than the applicant' is 'Yes' Max length: 1 characters
Signature Date	Date	Enter the date the preparer signed the application. Fill only if 'Application prepared by someone other than the applicant' is 'Yes'
Preparer's Contact Information
Mobile Telephone Number	Text	Provide the preparer's mobile telephone number, if applicable. Fill only if 'Application prepared by someone other than the applicant' is 'Yes' Max length: 10 characters
Daytime Telephone Number	Text	Enter the preparer's daytime telephone number. Fill only if 'Application prepared by someone other than the applicant' is 'Yes' Max length: 10 characters
Email Address	Text	Provide the preparer's email address, if applicable. Fill only if 'Application prepared by someone other than the applicant' is 'Yes'
Preparer's Full Name
Preparer's Given Name	Text	Please provide the preparer's given name. Fill only if 'Application prepared by someone other than the applicant' is 'Yes'
Preparer's Family Name	Text	Please provide the preparer's family name. Fill only if 'Application prepared by someone other than the applicant' is 'Yes'
QuantiFERON Test Information
QuantiFERON	Checkbox	Check this box if QuantiFERON was the Interferon Gamma Release Assay performed. Fill only if 'Not Administered' is 'No'. Depends on: Not Administered
QuantiFERON Blood Sample Date	Date	Please enter the date the blood sample was drawn for the QuantiFERON test. Fill only if 'QuantiFERON' is 'Yes'. Depends on: QuantiFERON
Referral Evaluation - Address
State	Combobox	Enter the state or province for the address (use the usual postal abbreviation or full name as preferred). Fill only if 'Doctor or Health Department Name' is completed. MI MD NC CO VI GA WI TX HI AS KY CA MH MP AE WV AP MS NE NV OH DC AL UT AA SC ID PR ME PW NM MT TN MO WY IA NJ PA CT VA AR NH OR VT LA MA NY WA MN OK SD ND AZ IL RI IN AK GU KS FL DE FM
Referred Doctor or Health Department Address
Street Number and Name	Text	Enter the street number and name of the referred doctor or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 34 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Apartment, Suite, or Floor Number	Text	Provide the apartment, suite, or floor number of the referred doctor or health department, if applicable. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 6 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Flr. (Floor)	Checkbox	Check this box when the referral address includes a floor number and you will enter that floor number in the adjacent Number field. Fill only if 'Doctor or Health Department Name' is completed. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Ste. (Suite)	Checkbox	Check this box when the referral address includes a suite number and you will enter that suite number in the adjacent Number field. Fill only if 'Doctor or Health Department Name' is completed. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Apt. (Apartment)	Checkbox	Check this box when the referral address includes an apartment number and you will enter that apartment number in the adjacent Number field. Fill only if 'Doctor or Health Department Name' is completed. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
City or Town	Text	Enter the city or town where the referred doctor or health department is located. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 20 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
ZIP Code	Text	Enter the ZIP code of the referred doctor or health department. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Max length: 5 characters Depends on: Substance (Drug) Abuse or Addiction, Class A
Referred Doctor or Health Department Name
Referred Doctor or Health Department Name	Text	Provide the name of the doctor or health department receiving the required referral. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Remarks
Remarks	Text	Include any signs or symptoms of TB, additional tests and therapy given, with start and stop dates and any changes. If you did not perform IGRA, give the reason why an exception applies. Fill only if 'Interferon Gamma Release Assay' is 'Not Administered' Depends on: Not Administered
Remarks	Text	Enter the name of the medical condition and the reasons for the referral. If more space is needed, use Part 11. Additional Information. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Remarks	Text	Provide any additional comments or reasons, such as contraindications for vaccinations. Fill only if 'Does not meet immunization requirements' is 'Yes'. Depends on: Does not meet immunization requirements
Repeat Treponemal Test Information
Name of Repeat Treponemal Test	Text	Please enter the name of the repeat Treponemal Test. Fill only if 'Treponemal Test Reactive' is 'Yes' and using reverse algorithm where nontreponemal test is nonreactive. Depends on: Treponemal Test Reactive
Date Repeat Treponemal Test Reported	Date	Please provide the date the repeat Treponemal Test was reported. Fill only if 'Treponemal Test Reactive' is 'Yes' and using reverse algorithm where nontreponemal test is nonreactive. Depends on: Treponemal Test Reactive
Repeat Treponemal Test Nonreactive	Checkbox	Check this box if the repeat treponemal test result is nonreactive. Fill only if 'Treponemal Test Reactive' is 'Yes' and using reverse algorithm where nontreponemal test is nonreactive. Depends on: Treponemal Test Reactive
Repeat Treponemal Test Reactive	Checkbox	Check this box if the repeat treponemal test result is reactive. Fill only if 'Treponemal Test Reactive' is 'Yes' and using reverse algorithm where nontreponemal test is nonreactive. Depends on: Treponemal Test Reactive
Required Referral - Address
State	Combobox	Enter the state for the address (use the two-letter postal abbreviation or full state name). Fill only if 'Doctor or Health Department Name' is completed. MI MD NC CO VI GA WI TX HI AS KY CA MH MP AE WV AP MS NE NV OH DC AL UT AA SC ID PR ME PW NM MT TN MO WY IA NJ PA CT VA AR NH OR VT LA MA NY WA MN OK SD ND AZ IL RI IN AK GU KS FL DE FM
Second Additional Information Entry
Additional Information Page Number 2	Text	Enter the page number to which this block of additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 2 characters Depends on: Remarks
Additional Information Part Number 2	Text	Enter the part number to which this block of additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Additional Information Item Number 2	Text	Enter the item number to which this block of additional information refers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Second Additional Information Details	Text	Provide the detailed explanation or additional information related to the specified page, part, and item numbers. Fill only if 'Remarks (Part 8, Item 5)' requires more space Depends on: Remarks
Second Sputum Culture Result
Second Sputum Culture Negative Count	Text	Enter the number of negative second sputum culture results. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Culture Positive Count	Text	Enter the number of positive second sputum culture results. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Culture Specimen Date	Date	Enter the date the second sputum culture specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Culture Reported Date	Date	Enter the date the second sputum culture result was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Culture Contaminated Count	Text	Enter the number of contaminated second sputum culture results. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Culture NTM Count	Text	Enter the number of NTM (Non-Tuberculous Mycobacteria) second sputum culture results. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Smear Result
Second Sputum Smear Negative Result	Text	Indicate if the second sputum smear result was negative. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Smear Positive Result	Text	Indicate if the second sputum smear result was positive. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Specimen Obtained Date	Date	Provide the date the second sputum specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Sputum Smear Result Reported Date	Date	Provide the date the result of the second sputum smear was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Second Vaccination Record (Td/Tdap)
Tdap	Checkbox	Check this box if the Tdap vaccine is specified for this record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td	Checkbox	Check this box if the Td vaccine is specified for this record. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Dose 1 Received Date	Date	Enter the date the first dose of the Td or Tdap vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Dose 2 Received Date	Date	Enter the date the second dose of the Td or Tdap vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Dose 3 Received Date	Date	Enter the date the third dose of the Td or Tdap vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Civil Surgeon Administered Date	Date	Enter the date the Td or Tdap vaccine was administered by a civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Dose 4 Received Date	Date	Enter the date the fourth dose of the Td or Tdap vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contra-indication	Checkbox	Check this box if a blanket waiver is requested due to a medical contra-indication for the Td/Tdap vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if a blanket waiver is requested due to an insufficient time interval between doses for the Td/Tdap vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if a blanket waiver is requested because the Td/Tdap vaccine is not age-appropriate. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Td/Tdap Complete Series/Immunity Status	Text	Indicate if the Td or Tdap vaccine series is complete by marking "X", or provide the date of a lab test if immune. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Seventh Vaccination Record (Varicella)
Varicella First Date Received	Date	Enter the first date the varicella vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Varicella Second Date Received	Date	Enter the second date the varicella vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Varicella Third Date Received	Date	Enter the third date the varicella vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Varicella Date Given by Civil Surgeon	Date	Enter the date the varicella vaccine was given by the civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Varicella Fourth Date Received	Date	Enter the fourth date the varicella vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Seventh Vaccine Row (Varicella) - Contraindication	Checkbox	Check this box when the applicant has a medical contraindication that prevents administration of the varicella vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Seventh Vaccine Row (Varicella) - Insufficient Time Interval	Checkbox	Check this box when the applicant has not met the required minimum time interval since a prior dose and the varicella vaccine should be delayed. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Seventh Vaccine Row (Varicella) - Not Age-Appropriate	Checkbox	Check this box when the varicella vaccine is not age-appropriate for the applicant and therefore should not be given. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Varicella Complete Series / Immunity Record	Text	Mark 'X' if the varicella vaccine series is complete, write the date of a lab test if immune, or write 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Sex
Male	Checkbox	Check this box if the applicant's sex is male.
Female	Checkbox	Check this box if the applicant's sex is female.
Signature and Date Signed
Date Signed	Date	Enter the date the referral evaluation was signed. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Signature	Text	Provide the signature of the health department individual or other doctor performing the referral evaluation. Fill only if 'Substance (Drug) Abuse or Addiction, listed in section 202 of the Controlled Substances Act, Class A' is 'Yes'. Depends on: Substance (Drug) Abuse or Addiction, Class A
Sixth Vaccination Record (Hepatitis B)
Hepatitis B - Date Received 1	Date	Enter the first date the Hepatitis B vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis B - Date Received 2	Date	Enter the second date the Hepatitis B vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis B - Date Received 3	Date	Enter the third date the Hepatitis B vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis B - Date Given by Civil Surgeon	Date	Enter the date the Hepatitis B vaccine was given by a Civil Surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis B - Date Received 4	Date	Enter the fourth date the Hepatitis B vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contraindication	Checkbox	Check this box if there is a contraindication for the Hepatitis B vaccination for a blanket waiver requested from USCIS. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if there is an insufficient time interval for the Hepatitis B vaccination for a blanket waiver requested from USCIS. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if the Hepatitis B vaccination is not age-appropriate for a blanket waiver requested from USCIS. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Hepatitis B - Complete Series / Immunity / Varicella History	Text	Mark 'X' if the Hepatitis B vaccination series is complete, write the date of the lab test if immune, or 'VH' if there is varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Sputum Smears and Cultures Decision
No, not indicated	Checkbox	Check this box if sputum smears and cultures are not indicated for the patient. Fill only if 'Chest X-Ray' on page 6 was performed Depends on: Normal
Yes, indicated due to signs or symptoms of TB	Checkbox	Check this box if sputum smears and cultures are indicated because the patient shows signs or symptoms of Tuberculosis (TB). Fill only if 'Chest X-Ray Result' on page 6 is 'Abnormal findings suggestive of TB' Depends on: Abnormal findings suggestive of TB that require smears and cultures
Yes, indicated due to chest X-ray suggestive of TB	Checkbox	Check this box if sputum smears and cultures are indicated because the patient's chest X-ray is suggestive of Tuberculosis (TB). Fill only if 'Chest X-Ray Result' on page 6 is 'Abnormal findings suggestive of TB' Depends on: Abnormal findings suggestive of TB that require smears and cultures
Yes, indicated for end of treatment cultures	Checkbox	Check this box if sputum smears and cultures are indicated for end-of-treatment evaluation. Fill only if 'Chest X-Ray Result' on page 6 is 'Abnormal findings suggestive of TB' Depends on: Abnormal findings suggestive of TB that require smears and cultures
Yes, indicated due to known HIV infection or extrapulmonary TB	Checkbox	Check this box if sputum smears and cultures are indicated because the patient has a known HIV infection or extrapulmonary Tuberculosis (TB). Fill only if 'Chest X-Ray Result' on page 6 is 'Abnormal findings suggestive of TB' Depends on: Abnormal findings suggestive of TB that require smears and cultures
Summary of Overall Findings
Class B Conditions	Checkbox	Check this box if the medical examination found Class B conditions. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
No Class A or Class B Condition	Checkbox	Check this box if the medical examination found no Class A or Class B conditions. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Class A Conditions	Checkbox	Check this box if the medical examination found Class A conditions. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'No'. Depends on: Eligible for Vaccination Record Portion Only
Syphilis Findings
No Class A or Class B Syphilis	Checkbox	Check this box if the findings indicate that there is no Class A or Class B Syphilis present.
Syphilis, Class B (treated in the last year)	Checkbox	Check this box if the findings indicate the presence of Class B Syphilis that was treated within the last year.
Syphilis, Class A (untreated)	Checkbox	Check this box if the findings indicate the presence of untreated Class A Syphilis.
Syphilis Serologic Test Details
Date Nontreponemal Test Collected	Date	Enter the date the nontreponemal test sample was collected. Fill only if 'Applicant's age' is between 18 and 44
Screening Reactive Titer	Text	Enter the titer value if the screening test was reactive. Fill only if 'Screening Reactive, Titer' is 'Yes'. Depends on: Screening Reactive, Titer
Screening Reactive, Titer	Checkbox	Check this box if the syphilis screening test result was reactive and a titer value is provided. Fill only if 'Applicant's age' is between 18 and 44
Nontreponemal Test Nonreactive Date Reported	Checkbox	Check this box if the nontreponemal test result was nonreactive and the date of reporting is provided. Fill only if 'Screening Reactive, Titer' is 'No'. Depends on: Screening Reactive, Titer
Nontreponemal Test Nonreactive Date Reported	Date	Enter the date the nontreponemal test was reported as nonreactive. Fill only if 'Applicant's age' is between 18 and 44
Nontreponemal Test Name	Text	Enter the name of the nontreponemal test performed. Fill only if 'Applicant's age' is between 18 and 44
Syphilis Treatment Remarks
Remarks on Syphilis Diagnosis and Treatment	Text	Provide detailed remarks including the stage of syphilis diagnosed and any therapy given with doses and dates of administration. Fill only if 'Syphilis, Class B (treated in the last year)', 'Syphilis, Class A (untreated)' is 'Yes' for any. Depends on: Syphilis, Class A (untreated), Syphilis, Class B (treated in the last year)
Drug	Text	Enter the name of the drug used for treatment. Fill only if 'Syphilis, Class B (treated in the last year)', 'Syphilis, Class A (untreated)' is 'Yes' for any. Depends on: Syphilis, Class A (untreated), Syphilis, Class B (treated in the last year)
Dosage	Text	Enter the dosage of the drug administered. Fill only if 'Syphilis, Class B (treated in the last year)', 'Syphilis, Class A (untreated)' is 'Yes' for any. Depends on: Syphilis, Class A (untreated), Syphilis, Class B (treated in the last year)
Treatment Start Date	Date	Enter the start date of the treatment. Fill only if 'Syphilis, Class B (treated in the last year)', 'Syphilis, Class A (untreated)' is 'Yes' for any. Depends on: Syphilis, Class A (untreated), Syphilis, Class B (treated in the last year)
Treatment End Date	Date	Enter the end date of the treatment. Fill only if 'Syphilis, Class B (treated in the last year)', 'Syphilis, Class A (untreated)' is 'Yes' for any. Depends on: Syphilis, Class A (untreated), Syphilis, Class B (treated in the last year)
T-Spot Test Information
T-Spot	Checkbox	Check this box if the T-Spot test was administered for the Interferon Gamma Release Assay. Fill only if 'Not Administered' is 'No'. Depends on: Not Administered
T-Spot Blood Sample Date	Date	Provide the date the blood sample was drawn for the T-Spot test. Fill only if 'T-Spot' is 'Yes'. Depends on: T-Spot
TB Classification/Findings
Question 6 - No Class A or Class B TB	Checkbox	Check this box if a chest X-ray was performed and the individual does not meet criteria for any Class A or Class B TB classification. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class A Pulmonary TB Disease	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class A Pulmonary TB Disease. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class B1 Pulmonary TB	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class B1 Pulmonary TB. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class B0 Pulmonary TB	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class B0 Pulmonary TB. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class B1 Extrapulmonary TB	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class B1 Extrapulmonary TB. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class B2 TB, Latent TB Infection	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class B2 (latent TB infection). Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Question 6 - Class B, Other Chest Condition (non-TB)	Checkbox	Check this box if a chest X-ray was performed and the individual is being classified as Class B for another chest condition that is not TB. Fill only if 'Chest X-Ray' was performed. Fill only if 'Yes, indicated due to chest X-ray suggestive of TB' is 'Yes'. Depends on: Yes, indicated due to chest X-ray suggestive of TB
Tenth Vaccination Record (Rotavirus)
Rotavirus Date Received 1	Date	Enter the first date the Rotavirus vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Date Received 2	Date	Enter the second date the Rotavirus vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Date Received 3	Date	Enter the third date the Rotavirus vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Date Given by Civil Surgeon	Date	Enter the date the Rotavirus vaccine was given by the civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Date Received 4	Date	Enter the fourth date the Rotavirus vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Contraindication	Checkbox	Check this box if a waiver is requested due to a medical contraindication for the Rotavirus vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Insufficient Time Interval	Checkbox	Check this box if a waiver is requested because there was an insufficient time interval between Rotavirus vaccine doses. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Not Age-Appropriate	Checkbox	Check this box if a waiver is requested because the Rotavirus vaccine was not age-appropriate. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Rotavirus Complete Series/Immune Status	Text	Mark 'X' if the Rotavirus vaccine series is complete, write the date of a lab test if immune, or write 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third Additional Information Entry
Additional Information (Item 5)	Text	Provide any additional information or details relevant to item 5 in this space. Fill only if 'Remarks (Part 8, Item 5)' requires more space Depends on: Remarks
Item Number (Item 5)	Text	Enter the specific item number within the part that this additional information for item 5 refers to. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Part Number (Item 5)	Text	Enter the part number on the form that this additional information for item 5 refers to. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 6 characters Depends on: Remarks
Page Number (Item 5)	Text	Enter the page number where the additional information for item 5 begins. Fill only if 'Remarks (Part 8, Item 5)' requires more space Max length: 2 characters Depends on: Remarks
Third Sputum Culture Result
Third Negative Result	Text	Indicate if the third sputum culture result was negative. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Positive Result	Text	Indicate if the third sputum culture result was positive. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Date Specimen Obtained	Date	Enter the date the third sputum culture specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Date Culture Result Reported	Date	Enter the date the third sputum culture result was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Contaminated Result	Text	Indicate if the third sputum culture specimen was contaminated. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third NTM Result	Text	Indicate if the third sputum culture result showed Non-tuberculous mycobacteria (NTM). Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Sputum Smear Result
Third Sputum Smear Result Negative	Text	Indicate if the third sputum smear result was negative. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Sputum Smear Result Positive	Text	Indicate if the third sputum smear result was positive. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Max length: 1 characters Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Sputum Smear Date Specimen Obtained	Date	Please enter the date the third sputum smear specimen was obtained. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Sputum Smear Date Result Reported	Date	Please enter the date the result for the third sputum smear was reported. Fill only if 'Yes, indicated due to signs or symptoms of TB', 'Yes, indicated due to chest X-ray suggestive of TB', 'Yes, indicated for end of treatment cultures', 'Yes, indicated due to known HIV infection or extrapulmonary TB' is 'Yes', any. Depends on: Yes, indicated due to signs or symptoms of TB, Yes, indicated due to chest X-ray suggestive of TB, Yes, indicated for end of treatment cultures, Yes, indicated due to known HIV infection or extrapulmonary TB
Third Vaccination Record (OPV/IPV)
OPV	Checkbox	Check this box to specify that the Oral Polio Vaccine (OPV) was administered. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
IPV	Checkbox	Check this box to specify that the Inactivated Polio Vaccine (IPV) was administered. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Date Received 1	Date	Enter the first date the OPV/IPV vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Date Received 2	Date	Enter the second date the OPV/IPV vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Date Received 3	Date	Enter the third date the OPV/IPV vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Date Given by Civil Surgeon	Date	Enter the date the OPV/IPV vaccine was given by a civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Date Received 4	Date	Enter the fourth date the OPV/IPV vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contra-indication	Checkbox	Check this box if a blanket waiver is requested for the OPV/IPV vaccine due to a medical contra-indication. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if a blanket waiver is requested for the OPV/IPV vaccine because there was an insufficient time interval between doses. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if a blanket waiver is requested for the OPV/IPV vaccine because its administration was not age-appropriate. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Third OPV/IPV Complete Series Status	Text	Indicate if the OPV/IPV vaccination series is complete (X), or provide the date of a lab test if immune, or 'VH' for varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Thirteenth Vaccination Record (COVID-19)
COVID-19 Complete Series Status	Date	Indicate if the COVID-19 vaccine series is complete by marking 'X', or provide the date of a lab test if immune, or 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if the COVID-19 vaccine is not appropriate for the applicant based on their age. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if the applicant has not met the required time interval between doses for the COVID-19 vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contra-indication	Checkbox	Check this box if there is a medical condition or circumstance that contraindicates the applicant receiving the COVID-19 vaccine. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
COVID-19 Date Received 4	Date	Enter the fourth date the COVID-19 vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
COVID-19 Date Given by Civil Surgeon	Date	Enter the date the COVID-19 vaccine was given by the civil surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
COVID-19 Date Received 3	Date	Enter the third date the COVID-19 vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
COVID-19 Date Received 2	Date	Enter the second date the COVID-19 vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
COVID-19 Date Received 1	Date	Enter the first date the COVID-19 vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
See Below Table	Checkbox	Check this box if the reason for a COVID-19 vaccine waiver is provided in the table referenced elsewhere on the form. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Treponemal Test Information
Treponemal Test Reported Date	Date	Enter the date the Treponemal Test was reported. Fill only if 'Nontreponemal Test' is 'Reactive'. Depends on: Screening Reactive, Titer
Treponemal Test Reactive Result	Text	Provide the result or specific information if the Treponemal Test was reactive. Fill only if 'Nontreponemal Test' is 'Reactive'. Depends on: Screening Reactive, Titer
Treponemal Test Reactive	Checkbox	Check this box if the treponemal test results are reactive. Fill only if 'Nontreponemal Test' is 'Reactive'. Depends on: Screening Reactive, Titer
Treponemal Test Nonreactive	Checkbox	Check this box if the treponemal test results are nonreactive. Fill only if 'Nontreponemal Test' is 'Reactive'. Depends on: Screening Reactive, Titer
Treponemal Test Name	Text	Enter the name of the Treponemal Test. Fill only if 'Nontreponemal Test' is 'Reactive'. Depends on: Screening Reactive, Titer
Twelfth Vaccination Record (Meningococcal)
Meningococcal Date Received 1	Date	Enter the first date the Meningococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Meningococcal Date Received 2	Date	Enter the second date the Meningococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Meningococcal Date Received 3	Date	Enter the third date the Meningococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Meningococcal Date Given by Civil Surgeon	Date	Enter the date the Meningococcal vaccine was given by the Civil Surgeon. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Meningococcal Date Received 4	Date	Enter the fourth date the Meningococcal vaccine was received. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Contra-indication	Checkbox	Check this box if there is a medical contra-indication for administering the Meningococcal vaccine, indicating a blanket waiver is requested. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Insufficient Time Interval	Checkbox	Check this box if there is an insufficient time interval to administer the Meningococcal vaccine, indicating a blanket waiver is requested. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Not Age-Appropriate	Checkbox	Check this box if a Meningococcal vaccine is not age-appropriate for the applicant, indicating a blanket waiver is requested. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
Meningococcal Complete Series/Immunity Status	Text	Indicate if the Meningococcal vaccine series is complete by marking 'X', provide the date of a lab test if immune, or write 'VH' if there is a varicella history. Fill only if 'I am eligible for completion of the vaccination record portion only' is 'Yes'. Depends on: Eligible for Vaccination Record Portion Only
USCIS Use Only Remarks
USCIS Remarks	Text	Provide any necessary remarks or comments for USCIS use.
Vaccination Results
Vaccination requirements met or eligible for blanket waivers	Checkbox	Check this box if the applicant has completed all vaccination requirements or qualifies for blanket waivers as described in the instructions.
Does not meet immunization requirements	Checkbox	Check this box if the applicant fails to meet the required immunization requirements.
Request individual waiver (religious/moral)	Checkbox	Check this box if the applicant intends to request an individual waiver from vaccination requirements based on religious or moral convictions.

Form I-693, Report of Immigration Medical Examination and Vaccination Record Instructions