CDC Requirements for Immigrant Medical Examinations: COVID-19 Technical Instructions for Civil Surgeons

Overview

The current pandemic of COVID-19 has been determined by the World Health Organization (WHO) to be a public health emergency of international concern (PHEIC) under the International Health Regulations, and it creates unique challenges for the immigration-related medical evaluation.  COVID-19 meets the definition of a quarantinable communicable disease under 42 USC 264 and Executive Order 13295, as amended by Executive Order 13375 and 13674. Specifically, COVID-19 meets the definition of severe acute respiratory syndromes as specified by Presidential Executive Order 13674external icon (issued July 31, 2014), thus making it a Class A Inadmissible Condition.

Applicants, defined in these Technical Instructions as people applying for adjustment of status for US permanent residence, are medically screened well in advance of adjustment of status. Thus, a negative screening for COVID-19 at the time of the medical evaluation does not guarantee the applicant will not have COVID-19 at the time the applicant becomes a Lawful Permanent Resident.

A combination of vaccination and routine infection control practices will provide the best protection from COVID-19 for applicants and US communities. These instructions provide information about COVID-19 vaccination for applicants.  The instructions in this document are to be followed for COVID-19 vaccination among applicants from all countries and are effective as of October 1, 2021.

Visit the Technical Instructions for Civil Surgeons webpage for more information about the medical examination for applicants for US immigration.

COVID-19 Vaccination Requirement

The Advisory Committee on Immunization Practices (ACIP) has recommended COVID-19 vaccination for the age-appropriate, general US population. Therefore, COVID-19 vaccination now meets the criteria for required vaccinations and is a requirement for applicants eligible for the vaccine.

The applicant must complete the COVID-19 vaccine series and provide documentation of vaccination to the civil surgeon in person before completion of the medical examination.  The COVID-19 vaccination requirement will differ from previous requirements in that the entire vaccine series (1 or 2 doses depending on formulation) must be completed in addition to the other routinely required vaccines. COVID-19 vaccinations can now be given at any time, without regard to the timing of other vaccinations.  Some example timelines for the Pfizer-BioNTech, Moderna, and Janssen (Johnson & Johnson) COVID-19 vaccines and other required vaccinations are illustrated in Figure 1.

Figure 1

Day 0

Day 21

Day 21

Day 0

First dose of Pfizer-BioNTech COVID-19 Vaccine

Day 21

Second dose of Pfizer-BioNTech COVID-19 Vaccine

Day 21

Other routine vaccinations

Day 0

Day 28

Day 28

Day 0

First dose of Moderna COVID-19 Vaccine

Day 28

Second dose of Moderna COVID-19 Vaccine

Day 28

Other routine vaccinations

Day 0

Day 0

Day 0

First dose of Janssen COVID-19 Vaccine

Day 0

Other routine vaccinations

Although the vaccine schedules cannot be shortened and must follow the ACIP’s recommendations, the other components of the medical examination can be scheduled at the discretion of the applicant and the civil surgeon. The civil surgeon must confirm in person documentation that the applicant received all doses of COVID-19 vaccine, and if applicants want to complete the remaining components of the exam after they are fully vaccinated against COVID-19, civil surgeons should accommodate them.

The applicant should be vaccinated in accordance with the specific instructions for the formulation used. Civil surgeons are expected to remain informed about changing recommendations, such as expansion of recommendations to include younger children and any new contraindications or precautions. As new COVID-19 formulations are recommended by ACIP, they can be used to fulfill this requirement. As with all vaccinations, there are specific blanket waivers that cover reasons why an applicant did not receive the required vaccination. Given the special circumstances, the blanket waivers to be used for COVID-19 vaccination are further defined below to include information specific to this vaccination.

Blanket Waivers Applicable to COVID-19 vaccinations:

  • Not age-appropriate
    For COVID-19 vaccines, the age for which a particular vaccine can be administered differs by formulation. If the applicant is younger than the lowest age limit for the formulations in use, this blanket waiver should be documented.
  • Contraindication
    If an applicant has a contraindication or precaution to the COVID-19 vaccine formulation available, the “Contraindicated” reason should be documented, and the vaccine should not be administered. If the applicant has had a severe reaction to the first dose that is considered a contraindication to receiving a second dose, the first dose should be documented in addition to the blanket waiver.  Please refer to Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States for COVID-19 specific information about contraindications and precautions.
  • Not routinely available
    If no COVID-19 vaccine is routinely available in the state where the Civil Surgeon practices, the “Not routinely available” reason should be documented.  If vaccine is available to the applicant but due to limited supply, it would cause significant delay for the applicant to receive their vaccination, then this situation would also be considered “Not routinely available.”

Other reasons why an applicant does not complete a COVID-19 vaccine series:

  • Applicant may request a waiver based on religious or moral convictions.
    If an applicant objects to vaccination based on religious or moral convictions, it must be documented that the applicant is requesting an individual waiver based on religious or moral convictions. This is not a blanket waiver, and the applicant will have to submit a waiver request to US Citizenship and Immigration Services (USCIS). USCIS will determine if this type of waiver is granted, not the civil surgeon or CDC.
  • Applicant refuses a COVID-19 vaccine series in part or entirety
    If an applicant refuses one or more doses of a COVID-19 vaccine series that is medically appropriate for the applicant, it should be documented that the vaccine requirements are not complete and that the applicant refuses vaccination. This applicant is Class A and is inadmissible to the United States.

Review of Vaccination Records

  • The civil surgeon should instruct the applicant to submit documentation of receiving the COVID-19 vaccine series. Acceptable vaccination documentation must come from a vaccination record, either an official vaccination record or a copy of a medical chart with entries made by a physician or other appropriate medical personnel. If COVID-19 vaccine is available to civil surgeons, the civil surgeon may vaccinate applicants and document the doses.
  • Civil surgeons must be familiar with the COVID-19 vaccination documentation and use their judgement to evaluate the validity of these documents. Only those records of vaccine doses that include the dates of receipt (month, day, and year) are acceptable. The name or manufacturer and lot number should be included if available. The document must not appear to have been altered, and dates of vaccinations should seem reasonable. Self-reported vaccine doses without written documentation are not acceptable. 
  • Civil surgeons must document all acceptable vaccination history on the I-693 Form, which will become the applicant’s permanent vaccination record. If the COVID-19 formulation is a two-dose series, both doses must be documented.

Laboratory Confirmation of Immunity

  • Laboratory tests for COVID-19 immunity must not be used for the civil surgeon exam. The applicant is required to receive the vaccine series regardless of evidence of immunity or prior COVID-19 infection. The duration of immunity due to natural infection is still being investigated and might not protect the applicant throughout the immigration process.

Glossary of Abbreviations

Acronym

Full Phrase

Acronym

ACIP

Full Phrase

Advisory Committee on Immunization Practices

Acronym

CDC

Full Phrase

Centers for Disease Control and Prevention

Acronym

USCIS

Full Phrase

United States Citizenship and Immigration Services