Report of Medical Examination and Vaccination Record

• Legal Form Number: I-693
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-693 Edition 07/19/22 Page 1 of 14

Report of Medical Examination and Vaccination Record

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-693

OMB No. 1615-0033

Expires 07/31/2025

START HERE - Type or print in black ink.►

Part 1. Information About You (To be completed by the person requesting a medical examination, NOT the

civil surgeon)

Family Name (Last Name) Given Name (First Name) Middle Name

2.

3.

E.

1.

Street Number and Name

Physical Address

Other Information

Flr.Ste.Apt. Number

City or Town State ZIP Code

Gender

Male Female

Country of Birth

D.

►A-

Alien Registration Number (A-Number) (if any)

Applicant's Statement

B. The interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question

in , a language in which I am fluent, and I understood everything.

I can read and understand English, and I have read and understand every question and instruction on this form and my

answer to every question.

A.

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

Date of Birth (mm/dd/yyyy)B.

Your Full Name

C. City/Town/Village of Birth

F. USCIS Online Account Number (if any)

►

Part 2. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form I-693 Instructions before completing this section. You must submit Form I-693 in a

sealed envelope to USCIS as directed in the Form I-693 Instructions.

Applicant's Statement Regarding the Interpreter1.

A.

(USPS ZIP Code Lookup)

At my request, the preparer named in Part 4.,

2.

prepared this application for me based only upon information I provided or authorized.

Applicant's Statement Regarding the Preparer

,