Report of Medical Examination and Vaccination Record

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USCIS I-693 Information
Report of Medical Examination and Vaccination Record
Name

Given Name (First Name)Middle NameFamily Name (Last Name)
Street Number and Name
Apt.Ste.Flr.Number
City or Town
State
ZIP Code
A.Gender

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

MonthDayYear
Date
C.City/Town/Village of Birth
D.Country of Birth
E.Alien Registration Number (A-Number) (if any)
A-Number
If Any
F.USCIS Online Account Number (if any)
Applicant's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. Applicant's Statement Regarding the Interpreter
answer to every question.

I can read and understand English, and I have read and understand every question and instruction on this form and myThe interpreter named in Part 3. read to me every question and instruction on this form and my answer to every question
in
Applicant's Contact Information
4.Applicant's Mobile Telephone Number (if any)
Applicant's Email Address*
example@example.com
2. ID Type (Passport or State issued card)
Passport, DL, State ID card
ID Number
Medical Conditions List any, such as hypertension or diabetes, and all required evaluation
Vaccine History. Add dates received

Skip if you do not have them
DTaP
Dates received
Tdap
Dates received
Td
Dates received
IPV-Polio
Dates received
OPV- Polio
Dates received
Measle-mumps-rubella or MMR
Dates received
Hib
Dates received
Hepatitis B
Dates received
Varicella
Dates received
Pneumococcal
Dates received
Influenza (Seasonal flushot)
Dates received
Rotavirus
Dates received
Hepatitis A
Dates received
Meningococcal
Dates received
Covid 19 ( enter dates of the series if available )
Signature CONSENT to gather PHI

Clear
Should be Empty:

COMPLETE AS MUCH AS YOU CAN THEN SUBMIT

USCIS I-693 Information

Report of Medical Examination and Vaccination Record

Applicant's Statement

Applicant's Contact Information

Vaccine History. Add dates received