Primary Navigation for the CDC Website

• Home
• About CDC
• Press Room
• A-Z Index
• Contact Us

CDC en Español
Search: Go Button:

Adjustment Of Status For U.S. Permanent Residence Requirements: Technical Instructions for Vaccination 2008

 

 

 

 

 

 

Preface

On September 30, 1996, the U.S. Congress amended the Immigration and Nationality Act (INA) by adding to the health-related grounds of inadmissibility a new subsection, “Proof of Vaccination Requirements for Immigrants.”  This new subsection requires any person who seeks an immigrant visa or adjustment of status for permanent residence to show proof of having received vaccination against vaccine-preventable diseases, as recommended by the U.S. Advisory Committee on Immunization Practices (ACIP).  The ACIP is an advisory committee to the Centers for Disease Control and Prevention (CDC) that makes general recommendations on immunizations, including safe and effective vaccination schedules.  Updated ACIP recommendations are available at CDC’s National Center for Immunization and Respiratory Diseases (NCIRD) website:  http://www.cdc.gov/vaccines

The instructions in this document supersede all previous vaccination-related “Technical Instructions,” “Updates to the Technical Instructions” and memoranda and letters to civil surgeons.  These instructions are to be followed for vaccination requirements for all persons applying for adjustment of status for permanent U.S. residence.  If in the future, there are changes or updates in ACIP recommendations, those recommendations available in the CDC/NCIRD website should be followed.

CDC’s Division of Global Migration and Quarantine (DGMQ) staff is available for consultation on issues related to vaccination requirements for immigration and can be reached at 404-498-1600.   

Back to top ^

Significant Changes in the Vaccination Requirements

 

 

 

 

Significant changes to the vaccination requirements since the last revision of the “Technical Instructions to Civil Surgeons for Vaccination Requirements” are―

• Rotavirus vaccine should be given orally to children 6 through 32 weeks of age.
• Hepatitis A vaccine should be given to children 12 through 23 months of age.
• Tetravalent meningococcal conjugate vaccine (MCV4) should be given to persons 11 through 18 years of age.  Tetravalent meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative.
• Human papillomavirus vaccine should be given to females 11 through 26 years of age.
• Zoster vaccine should be given to persons 60 years of age or older.
• Hepatitis B vaccine should be given from birth through 18 years of age.
• Influenza vaccine should be given annually to children 6 through 59 months of age.  It continues to be required for adults 50 years of age or older.
• Acellular pertussis-containing vaccines are available for use in persons at least 10 years of age.  The adolescent and adult formulation of tetanus and diphtheria toxoid and acellular pertussis (Tdap) vaccine is given as a single (booster) dose for persons 10 through 64 years of age who have completed the recommended childhood diphtheria and tetanus toxoids and the pertussis/diphtheria and tetanus toxoids and acellular pertussis (DTP/DTaP) vaccine series. 

Further information and updates on the required vaccines are available at CDC/DGMQ’s website, http://www.cdc.gov/ncidod/dq/health.htm, and CDC/NCIRD’s website, http://www.cdc.gov/vaccines. 

 

Back to top ^

Procedure for Vaccination Assessment Status

The following instructions have been developed to provide guidance to civil surgeons performing the medical examinations and assessments of vaccination status.

 

 

 

 

 

Back to top ^

Vaccination Requirements for Adjustment of Status Applicants

All adjustment of status applicants must be assessed for vaccination requirements.  The required vaccines are those listed on the age-based immunization schedules recommended by ACIP and available at:  http://www.cdc.gov/vaccines/recs/schedules/.  The civil surgeon must review all vaccination records presented by the applicant during this process and record the vaccination assessment results on Form I-693, Report of Medical Examination and Vaccination Record.  Those vaccines required based on the applicant’s age must be administered.  If the applicant had previously received a dose or doses of a required vaccine but had not completed the series, then the next required dose should be administered according to standard recommendations.
 
The civil surgeon may refer the applicant to another health-care provider to have the required vaccinations administered.  In such a case, the civil surgeon must not complete the form until the applicant returns with a written record from the referral health-care provider that notes the vaccines administered and the dates of administration.

If the civil surgeon administers the vaccines, he/she must screen the applicant for contraindications and discuss with the applicant any potential adverse reactions.  After administering any needed vaccines, the civil surgeon must complete Form I-693 and give the form to the applicant in a sealed envelope, which the applicant will present to U.S. Citizenship and Immigration Services (USCIS).  A copy of the completed vaccination record in Part 2, Section 5, must also be provided to the applicant for his or her personal records.  After the applicant has received the required vaccinations and Form I-693 has been completed, the applicant has fulfilled the vaccination requirements for adjustment of status to permanent residence.

Because completion of the vaccine series often requires several months, applicants are not required to have received all doses of the ACIP-recommended vaccines to fulfill the vaccination requirements for adjustment of status to U.S. permanent residence.  Rather, they are required to have received at least one dose of each recommended vaccine, and they are encouraged to follow up with their primary health-care provider to complete the series.

Back to top ^

Vaccination Requirements for Refugees and Procedure for Determining Refugee Status

The USCIS, formerly the Immigration and Naturalization Services (INS), has determined that the vaccination requirements do not apply to refugees at the time of their initial admission to the United States.  However, refugees must meet the vaccination requirements when they apply for adjustment of status or permanent resident status in the United States (one year or more after arrival).  For a refugee, the adjustment of status application includes the medical examination report issued by a panel physician overseas and Form I-693, indicating the vaccination assessment performed by a civil surgeon or designated health department in the United States.
  
All refugees must be assessed for vaccination requirements only.  A civil surgeon must obtain the applicant’s I-94 form (arrival/departure record) to determine whether the applicant was admitted to the United States as a refugee pursuant to Section 207 of the INA.  The civil surgeon must verify that the I-94 form belongs to the applicant by comparing it with other identification documents, keeping in mind that many refugees might not have passports.

Once it is determined that an applicant is a refugee applying for adjustment of status in the United States, the civil surgeon must review all vaccination records presented by the applicant during this process and record the vaccination assessment results on Form I-693.  Those vaccines determined to be required must be administered.

Health Departments Acting as Civil Surgeons for Refugees

In 1998, USCIS provided a blanket designation for health departments to function as civil surgeons for refugees adjusting their status.  This blanket designation to health departments applies only to the vaccination assessment of refugees.  To act as a civil surgeon, a health department must have a physician or physicians who meet the legal definition of a civil surgeon.  The terms of the blanket civil surgeon designation do not apply to the vaccination assessment of an applicant who has been granted asylum.  Such an applicant must schedule an appointment with a physician who has been designated as a civil surgeon under the usual procedure and complete the full health assessment.

Records in Languages Other Than English

Although some civil surgeon offices might have the ability to translate records into English, the responsibility lies with the applicant to provide reliable English translations of all records.

Vaccination Documentation

Acceptable vaccination documentation must come from a vaccination record, either a personal vaccination record or a copy of the medical chart record with entries made by a physician or other appropriate medical personnel.  Self-reported doses of vaccines without written documentation are not acceptable.  Only those records of doses of vaccines that include the dates of receipt (month, day, and year) are acceptable.  The document must not appear to have been altered, and dates of vaccinations should seem reasonable.

Vaccinations Received Outside the United States

Most vaccines used worldwide are from reliable local or international manufacturers; it is reasonable, therefore, to assume that any vaccine received by an applicant was of adequate potency.  However, the vaccination schedules should be consistent with those recommended in the United States. 

Back to top ^

Identify Any Past or Present Condition That Might Be a Contraindication or Precaution to Vaccination

 

 

The civil surgeon should identify any condition that might be a contraindication or precaution for the administration of a vaccine.  A contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine is given.  A precaution is a condition in a recipient that might increase the chance of a serious adverse reaction if the vaccine is administered, or a condition that might compromise the ability of the vaccine to produce immunity. 

General contraindications for the administration of a vaccine:

• Severe (anaphylactic) allergic reaction to a vaccine component or following a prior dose of a vaccine
• Severely immunocompromised conditions  are a contraindication for receiving live attenuated vaccines:  measles-mumps-rubella (MMR), varicella, zoster, influenza
• Pregnancy is a contraindication for receiving live attenuated vaccines:  MMR, varicella, zoster,  influenza
• Encephalopathy not due to another identifiable cause is a contraindication for administration of DTaP if it occurred within 7 days of a previous dose of DTP or DTaP

The following conditions are not contraindications for the administration of a vaccine:

• Mild to moderate local reactions to a previous dose of vaccine
• Mild acute illness (e.g., low-grade fever, upper respiratory infection, diarrhea)
• Recovering from an illness
• Pregnancy, for receiving inactivated virus or bacterial vaccines or toxoids
• Breastfeeding
• Antimicrobial therapy
• Tuberculin skin testing 

Some precautions to vaccination include:

• Any of the following after a previous dose of DTP/DTaP:
• Fever ≥40.5°C (≥105°F) that is not attributed to another identifiable cause and occurs within 48 hours after vaccination
• Collapse or shock-like state (that is, a hypotonic-hyporesponsive episode) occurring within 48 after vaccination
• Persistent, inconsolable crying lasting 3 hours or more and occurring within 48 hours after vaccination
• Convulsions with or without fever occurring within 3 days after vaccination
• Moderate to severe acute illness with or without fever

In general, vaccines are deferred when a precaution condition is present.  If the decision to defer a vaccine is made, the precaution condition should be recorded as a medical condition on Form I-693. Contraindications and precautions to specific vaccines are shown at― http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm . For pregnant women, contraindications and precautions are shown at― http://www.cdc.gov/vaccines/pubs/preg-guide.htm.

Back to top ^

Laboratory Evidence of Immunity

 

The civil surgeon should obtain a good history of acute, vaccine-preventable diseases, including measles, mumps, rubella, and varicella, from the applicant to identify any naturally acquired diseases for optional laboratory confirmation.  An applicant who provides a reliable written or oral history of varicella disease does not require laboratory confirmation or further vaccination.

Laboratory evidence of immunity is acceptable for the following diseases:  measles, mumps, rubella, hepatitis A, hepatitis B, polio, and varicella (normally not necessary unless a history of varicella disease is questionable).

Acceptable tests for the presence of antibodies are U.S. Food and Drug Administration (FDA)-approved kits or Clinical Laboratory Improvement Amendments (CLIA)-certified kits.  In the use of any approved kits, the manufacturer’s guidelines or instructions must be followed, including not using a kit which is past its expiration date or which has not been maintained according to the manufacturer’s directions.  Standard precautions in drawing blood (e.g., use of disposable gloves and sterile needles) and appropriate needle disposal must also be followed.

Procedure for Completing Form I-693, Report of Medical Examination and Vaccination Record

The civil surgeon is responsible for―

• Completing the applicant’s identification information.
• Copying the dates of all acceptable documented vaccinations from written records and any vaccines administered by the panel physician at the time of the overseas assessment in the appropriate “Date Received” box in Part 2 (Medical examination), Section 5 (Vaccinations). Any vaccine administered by the civil surgeon is to be indicated in the “Vaccine Given/Date Given by Civil Surgeon” box of Form I-693.
  • Doses should be recorded chronologically (month, day, and year as numbers corresponding to mm/dd/yyyy), from left to right.

•  Filling the form for additional vaccines.
  • Names of additional required vaccines not listed on Form I-693 (e.g., rotavirus, hepatitis A, meningococcal, human papillomavirus, zoster) must be written in the “Other Vaccine (specify below)” box.

• Completing the vaccination series.
  • If the applicant has completed the vaccination series, the “Completed Series” box for each vaccine must be checked on Form I-693.
  • If as a result of a laboratory test, the applicant is identified as fully immune, the month, date, and year of the test must be written in the “Completed Series” box for each applicable vaccine.
  • If a reliable written or oral history of varicella disease is given, “VH” (varicella history) must be written in the “Completed Series” box for varicella.

• Reviewing any incomplete vaccination series to determine if eligible for a blanket waiver.

  A blanket waiver is a waiver that is applied uniformly to a group of conditions and does not require a separate waiver application or fee to be filed with USCIS.  In many cases, it might not be medically appropriate to administer a dose of a particular vaccine.  Four “Not Medically Appropriate” categories are acceptable when determining an applicant’s eligibility for a blanket waiver. 

  The four “Not Medically Appropriate” categories are―

  • Not age appropriate

    For each vaccine for which administration is not age appropriate, the “Not age appropriate” waiver box must be checked.  For all applicants, this box will need to be checked for at least one vaccine.  For example, infants and adults do not need
    meningococcal vaccine, and adults do not need Haemophilus influenzae type b vaccine. 

  • Contraindication

    If an applicant has contraindications to specific vaccines, the “Contraindication” waiver box for that vaccine must be checked.

  • Insufficient time interval between doses

    If the minimum time interval between the last documented dose and the next required dose has not passed, the “Insufficient time interval” waiver box for that vaccine must be checked. 

    If administration of the single dose of a vaccine at the time of the medical examination does not complete the series for that vaccine, the “Insufficient time interval” waiver box must be checked to indicate that additional doses will be needed to complete the series for that vaccine.

  • Not flu season

    Influenza vaccine is required during the influenza (flu) season.  The flu season usually begins in the fall and continues through early spring.  In general, influenza activity peaks from December to March.  The vaccine should be offered beginning in September and throughout the influenza season.  The “Not fall (flu) season” waiver box must be checked at other times of the year.

Back to top ^

• Completing “Results” section

  After reviewing entries in Section 5 (Vaccinations) for all the vaccines, only one appropriate box under “Results” must be checked.

  • Applicant may be eligible for blanket waiver(s).

    Completion of a vaccine series is not required to conclude the medical examination because such a requirement would require multiple visits to a civil surgeon and could lead to unnecessary delay in the immigration process.  If any of the boxes under the “Not Medically Appropriate” heading was checked, the “Applicant may be eligible for blanket waiver(s) as indicated above” box must also be checked.  This box will probably always be checked because some vaccines may not be age appropriate for the applicant.

  • Applicant will request an individual waiver based on religious or moral convictions.

    If an applicant objects to vaccination based on religious or moral convictions, the “Applicant will request an individual waiver based on religious or moral convictions” box must be checked.  This is not a blanket waiver, and the applicant will have to submit a waiver request to USCIS.

  • Vaccine history complete for each vaccine.

    If the applicant has met the vaccination requirements, i.e., completed the series for all required vaccines, the “Vaccine history complete for each vaccine, all requirements met” box must be checked.

  • Applicant does not meet immunization requirements.

    If an applicant’s vaccine history is incomplete and the applicant refuses administration of a single dose of any required vaccine that is medically appropriate for the applicant, the “Applicant does not meet immunization requirements” box must be checked.

The civil surgeon should review the entire Form I-693 for completeness and accuracy before signing the document.  The document must be legible, and all names and dates must be either printed or typed.  The civil surgeon’s signature on this document signifies the reliability of the document to the best of the physician’s knowledge.

The primary intent of this document is for presentation to USCIS to meet immigration vaccination requirements.  However, an extra copy of the vaccination section should be provided to the applicant since it is an important vaccination record that may be used later by other health-care providers, schools, and other institutions.

Back to top ^

Infection Control and Safety Issues

Proper handling and storage of vaccines are important to ensure the potency of vaccines.  If vaccines are not properly handled or stored, their potency is reduced, and they may not produce immunity.

Information on storage and handling of vaccines can be found in the CDC/NCIRD website:  http://www.cdc.gov/vaccines/pubs/vac-mgt-book.htm.

Vaccine Adverse Event Reporting System (VAERS)

VAERS is a reporting system used by the FDA and CDC to receive and analyze reports about adverse events that might be associated with vaccines identified in the National Childhood Vaccine Injury Act.  VAERS encourages the reporting of all clinically significant adverse events following the administration of any vaccine, whether or not the vaccine is believed to be the cause of the event.  The FDA monitors reports to determine whether any vaccine lot has a higher than expected reporting rate of adverse events.  Anyone can report an adverse event 24 hours a day.  Additional information can be obtained by calling 1-800-822-7967 or checking the VAERS website at http://vaers.hhs.gov/.

Back to top ^

Counseling and Resources

Vaccine Information Statements

The National Childhood Vaccine Injury Act (NCVIA) requires all health-care providers in the United States who administer vaccines to provide a copy of the relevant Vaccine Information Statement (VIS) to either the adult vaccinee or, in the case of a minor, to the parent or legal representative.  In addition to the VISs, health-care providers should give visual and oral explanations on vaccines.  Camera-ready copies of VISs can be obtained from a local or state health department’s immunization program.  To determine if the VIS is the most up-to-date version, the VIS section website at http://www.cdc.gov/vaccines/pubs/vis/ should be checked.

There are no “official” CDC translations of the VISs into other languages.  Several states have provided translations, or providers may translate the VISs into other languages.  These VISs are also available through the Immunization Action Coalition’s website at http://www.immunize.org.

Advisory Committee on Immunization Practices (ACIP) Statements

ACIP statements are published in the Morbidity and Mortality Weekly Report (MMWR) periodically.  Copies of specific articles can be obtained by using the CDC/NCIRD website at http://www.cdc.gov/vaccines and selecting “Recommendations & Guidelines”.

Epidemiology and Prevention of Vaccine-Preventable Diseases

The book Epidemiology and Prevention of Vaccine-Preventable Diseases provides an overview of vaccine-preventable infectious diseases and the corresponding vaccines.  It serves as a useful companion to the ACIP statements.  The appendices provide considerable information and are an invaluable aid for identifying search tools and other resources.  This book and other immunization materials are available at http://www.cdc.gov/vaccines/pubs/pinkbook/.

Clinic Assessment Software Application (CASA)

CASA is a menu-driven database developed by CDC as an assessment tool for immunization clinics and providers.  This application is used for data entry and analysis of a clinic assessment and includes many special features.  CASA provides an extensive body of data that can be accessed and organized to suit individual practice needs.  Additional information or a copy of the application can be obtained from the CDC/NCIRD website at http://www.cdc.gov/vaccines/programs/cocasa/.

Back to top ^

 

Appendix A: Glossary Of Abbreviations

• ACIP        Advisory Committee on Immunization Practices
• CASA        Clinic Assessment Software Application
• CDC        Centers for Disease Control and Prevention
• CLIA        Clinical Laboratory Improvement Amendments
• DGMQ        Division of Global Migration and Quarantine
• DT        Diphtheria and tetanus toxoids
• DTaP        Diphtheria and tetanus toxoids and acellular pertussis vaccine
• DTP        Diphtheria and tetanus toxoids and pertussis vaccine
• FDA        Food and Drug Administration
• Hib         Haemophilus influenzae type b conjugate vaccine
• INA        Immigration Nationality Act
• INS        Immigration and Naturalization Services
• IPV        Inactivated poliovirus vaccine
• LAIV        Live attenuated influenza vaccine
• MCV        Meningococcal conjugate vaccine
• MMR        Measles-mumps-rubella vaccine
• MMWR        Morbidity and Mortality Weekly Report
• MPSV        Meningococcal polysaccharide vaccine
• NCIRD        National Center for Immunization and Respiratory Diseases
• NCVIA        National Childhood Vaccine Injury Act
• OPV        Oral poliovirus vaccine
• Td        Tetanus and diphtheria toxoids
• Tdap        Tetanus and diphtheria toxoids and acellular pertussis vaccine
• USCIS        United States Citizenship and Immigration Services
• VAERS        Vaccine Adverse Event Reporting System
• VIS        Vaccine Information Statement

Please also see APPENDIX B I-693 Form, Vaccination Record

Back to top ^