USCIS – Form I-693 – Report of Medical Examination and Vaccination Record by Department of Homeland Security – U.S. Citizenship and Immigration Services

USCIS – Form I-693 – Report of Medical Examination and Vaccination Record by Department of Homeland Security – U.S. Citizenship and Immigration Services

 

https://www.uscis.gov/i-693

I-693, Report of Medical Examination and Vaccination Record

If you are applying for adjustment status to become a lawful permanent resident, use this form to establish that you are not inadmissible to the United States on public health grounds.

A list of those health grounds can be found in section 212(a)(1) of the Immigration and Nationality Act. For more information on the validity of Form I-693, see the USCIS Policy Manual Volume 8, Part B, Chapter 4.

Instructions for 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 07/31/2022

 

 

Form I-693 reports results of a medical examination to U.S. Citizenship and Immigration Services (USCIS). USCIS requires the examination to establish that applicants who are seeking immigration benefits are not inadmissible to the United States on public health grounds. You can find a list of those health-related grounds in section 212(a)(1) of

the Immigration and Nationality Act (INA). The list is also available in these Instructions in the Frequently Asked Questions section, Item Number 9.

The results of your medical examination are confidential, and USCIS uses them rimarily for immigration purposes. When required by law, the civil surgeon may share your results with public health authorities. USCIS will generally not discuss your medical issues with other individuals, such as your attorney or BIA-accredited representative, immigration officers, or other government officials, unless they have a need to know the information.

NOTE: If you are applying for adjustment of status as a refugee, a derivative of an asylee, or a K or V nonimmigrant visa holder, before reading any further, see section entitled Frequently Asked Questions, Item Numbers 2. – 5., of these Instructions.

 

 

 

  How Do I File Form I-693?

 

You must submit a separate Form I-693 for each applicant. There is no filing fee for this form.

  1. Carefully read all these instructions, including the Frequently Asked Questions
  2. Contact a doctor who is designated as a civil surgeon by USCIS to make an

3.                         Fill out Part 1. Information About You of Form I-693. Do not sign the form until the civil surgeon tells you to sign it. You must sign in the presence of the civil surgeon.

  1. Attend your medical examination appointment and all follow-up examinations, as required. If you have any medical records, including vaccination records, take them with you to the initial
  2. The civil surgeon must give you the completed Form I-693 in a sealed envelope for you to submit to USCIS. Do not accept the form from the civil surgeon unless it is in a sealed envelope. USCIS will return your Form I-693 to you if it is not in a sealed envelope or if the envelope is opened or altered in any The civil surgeon should also give you a copy of the completed Form I-693 for your records.
  3. Submit your completed Form I-693 in the sealed envelope to USCIS. Please see our website at uscis.gov/I-693. The Form I-693 must be dated no earlier than 60 days before you filed your underlying application. A properly and timely completed Form I-693 remains valid for two years from the date of the civil surgeon’s signature.
    1. If you are applying for adjustment of status, Form I-485: Submit Form I-693 according to the instructions on Form I-485, Application to Register for Permanent Residence or Adjust

 

 

  1. For all other applicants: Follow the application’s instructions, follow the instructions that the office requesting the medical examination gave you, or visit the USCIS Contact Center at uscis.gov/contactcenter to learn more, including where to file this application. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

NOTE: The civil surgeon will ask you to verify your identity. Bring a valid government-issued form of photo identification to your appointment (for example, your unexpired passport or driver’s license). If you are under 14 years of age, acceptable documents for proof of identity must show your name, date and place of birth, parents’ full names, and any other identifying information about you. Acceptable documents include birth certificates (with a translation, if necessary) or affidavits.

 

 

To find a designated civil surgeon in your area, visit the USCIS website at www.uscis.gov. (Select “TOOLS,” choose “Find a Doctor,” enter your ZIP Code or address, and click “Search.”)

 

USCIS provides forms free of charge through our website. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have internet access, you may order USCIS forms by calling the USCIS Contact Center at 1-800-375-5283. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

 

Signature. Each Form I-693 must be properly signed and filed. In general, USCIS will not accept a stamped or typewritten name in place of a signature. If you are under 14 years of age, your parent or legal guardian may sign the form on your behalf. A legal guardian may also sign for a mentally incompetent person.

There are special rules for blanket designated health departments or military physicians. Refer to these Instructions for additional information on how blanket designated civil surgeons may sign the form. (See section entitled How Do I, as a Civil Surgeon, Fill Out My Portion of This Form I-693?, subsection “Military physicians performing the

medical examination for members and veterans of the U.S. Armed Forces or U.S. Coast Guard and certain eligible

dependents”.)

 

Filing Fee. There is no filing fee for this form.

 

Evidence. At the time of filing, you must submit all evidence and supporting documentation listed in the Specific

Instructions section of these Instructions.

 

Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you must submit an original document. USCIS may request an original document at the time of filing or at any time during processing of an application, petition, or request. If USCIS requests an original document from you, it will be returned to you after USCIS determines it no longer needs your original.

NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be

immediately destroyed upon receipt.

 

Translations. If you submit a document with information in a foreign language, you must also submit a full English translation. The translator must sign a certification that the English language translation is complete and accurate, and that he or she is competent to translate from the foreign language into English. The certification must include the translator’s signature, should contain the translator’s printed name and the date, and it may also contain the translator’s contact information.

 

 

How To Fill Out Form I-693

  1. Type or print legibly in black
  2. If you (the applicant or the civil surgeon) need extra space to complete any item within this application, use the space provided in Part Additional Information or attach a separate sheet of paper. Type or print the applicant’s name and Alien Registration Number (A-Number) (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
  3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been married and the question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many children do you have” or “How many times have you departed the United States”), type or print “None” unless otherwise directed.

 

Form I-693 is divided into 11 parts. These instructions will help you and the civil surgeon complete Form I-693.

Only complete Part 1. of Form I-693 and the identifying information at the top of each page. The civil surgeon and any other doctors, clinics, or health departments that you are referred to will complete the remaining parts of Form I-693.

 

Part 1. Information About You

Complete this part before your medical examination appointment. Fill out your name and A-Number (if any) at the top of each page of Form I-693. The civil surgeon will check that this information matches Part 1.

 

Item Number 1. Your Full Name. Use your legal name, which is the name that appears on your birth certificate, unless it was changed after birth by a legal action such as marriage or a court order. If you do not have and cannot obtain your birth certificate, use your full legal name as it appears on government issued identity documents such as a passport, refugee travel document, or similar official record. Do not provide a nickname. If you have two last names, include both and use a hyphen (-) between the names, if appropriate.

 

Item Number 2. Physical Address. Provide your physical street address. This must include a street number and name

or a rural route number. Do not provide a post office box (PO Box) number here.

 

Item Number 3.A. Gender. Select the box that indicates whether you are male or female.

 

Item Number 3.B. Date of Birth. Use eight numbers to show your date of birth in mm/dd/yyyy format (for example, type or print May 1, 1979 as 05/01/1979).

 

Item Number 3.C. City/Town/Village of Birth. Provide the name of the city, town, or village where you were born.

 

Item Number 3.D. Country of Birth. Provide the name of the country where you were born.

 

Item Number 3.E. Alien Registration Number (A-Number) (if any). This is your alien registration file number.  If you are not sure if you have one, look at any letters or notices that you have received from the Department of Homeland Security (DHS). Look for a number that begins with a letter “A” followed by 8 or 9 digits (for example: A 000 000 000). If you do not have one, or if you cannot remember what it is, leave this space blank.

 

 

Item Number 3.F. USCIS Online Account Number (if any). If you have previously filed an application, petition, or request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)), provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions, or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The USCIS Online Account Number is not the same as an A-Number.

 

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

Item Numbers 1. – 6. Select the appropriate box to indicate that you either read this application yourself or whether you had an interpreter assist you. If someone assisted you in completing the application, select the box indicating that you used a preparer. Further, you must sign and date your Form I-693 in front of the civil surgeon, and provide your daytime telephone number, mobile telephone number (if any), and email address (if any). Every Form I-693 MUST contain

the signature of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

Note Regarding Applicant’s Signature: The civil surgeon must witness you signing Form I-693. The civil surgeon will type or print the form of applicant identification document presented, and the identification number from your identification document.

 

Part 3. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1. – 7. If you used anyone as an interpreter to read the Instructions and questions on this application to you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number (if any), and his or her email address (if any). The interpreter must sign and date Form I-693. A stamped or typewritten name in place of a signature is not acceptable.

 

Part 4. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than

the Applicant

Item Numbers 1. – 8. This section must contain the signature of the person who completed your application, if other than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete both Part 3. and Part 4. If the person who completed this application is associated with a business or organization, that person should complete the business or organization name and address information. Anyone who helped you complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative, he or she may also need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, along with your application.

 

 

 

 

 

  1. Truthfully and accurately report the results. You are responsible for reporting the results of the medical examination and all laboratory reports on Form I-693 where indicated, and for signing the civil surgeon’s certification provided on the form.

You must take reasonable steps to ensure that the person appearing for the medical examination is the same person applying for the requested immigration benefit. All applicants must present a valid government-issued form of photo identification or another form of government-recognized identity documentation. You must note in Part 5.,

Applicant’s Identification Information, Item Numbers 1. – 2., the form of identification presented and identification number, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a material fact or using any false documents in connection with this medical examination.

You should direct the applicant to complete and sign in Part 2., Item Numbers 1. – 5., in your presence. You should also ensure that the applicant’s name and A-Number (if any) are at the top of each page of the Form I-693 and match the information provided in Part 1.

  1. Follow U. S. Department of Health and Human Services (HHS) regulations and Centers for Disease Control and Prevention (CDC) guidelines. As a USCIS-designated civil surgeon, you are required to perform the medical examination according to HHS regulations. These regulations include the specific guidelines found in the Technical Instructions for the Medical Examination of Aliens in the United States, published by the CDC. The Technical Instructions (including periodic updates posted by the CDC) are available at cdc.gov/immigrantrefugeehealth/ exams/ti/civil/technical-instructions-civil-surgeons.html.
  2. Make referrals and file case reports, as required. According to the CDC’s Technical Instructions, you are required to:
    1. Refer the applicant to the local health department if a chest X-ray suggests TB or other circumstances described in the CDC’s Technical Instructions.
    2. Ensure that any applicant diagnosed with syphilis is treated with the standard treatment regimen described in the CDC’s Technical Instructions.
    3. Ensure that the applicant is tested for gonorrhea and given therapy, if
    4. Refer the applicant to a Hansen’s disease specialist for evaluation to confirm a suspected diagnosis of Hansen’s

disease (leprosy).

  1. File a case report with the appropriate public health authorities if a case report is required by local laws or

regulations. You must also advise the applicant that a case report is being filed.

 

 

You, as the civil surgeon, are responsible for ensuring that Form I-693 is completed and signed as follows.

  1. Part 5. Applicant’s Identification Information. You are responsible for verifying the identity of the applicant and noting in Part 5., Applicant’s Identification Information, Item Numbers 1. – 2., the form of identification that the applicant presents to you and the identification number, if applicable. You are also required to check the top of each page of Form I-693 to make sure the name and A-Number (if any) are correct. Finally, you must require the applicant to sign the Applicant’s Certification in Part 2. in your presence. The applicant should not sign Part 2. until the medical examination is completed and all health-related follow-up requirements, if any, are

 

 

  1. Part 6. Summary of Overall Findings. After the medical examination and any required follow-up, summarize the results in Part 6.
  2. Part 7. Civil Surgeon’s Contact Information, Certification, and Signature. You must sign the certification after the medical examination is complete. Fill out your identifying information in this part before referring an applicant for further tests or evaluation. Do not sign and date this part until the referral or follow-up evaluation (if required) is completed and the applicant is medically cleared. Your signature must be original. Stamped signatures or typewritten names are not acceptable (except for blanket-designated health department or military physicians as described below).

In signing the Form I-693 in this part, you certify under penalty of perjury that you have a valid, unrestricted license in the jurisdiction in the United States in which you are conducting immigration related medical examinations. You also certify under penalty of perjury that no other jurisdiction in the United States in which you conduct immigration- related medical examinations has revoked or placed restrictions on your license to practice medicine in that jurisdiction.

For health departments performing the vaccination assessment for refugee adjustment applicants ONLY: You must complete Part 7. Civil Surgeon’s Contact Information, Certification, and Signature of Form I-693. The original or stamped signature of the physician on staff at the health department must be present in Part 7. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed

physicians. Health departments must also place either the official stamp or raised seal, whichever is customarily used,

in Part 7. where indicated.

Military physicians performing the medical examination for members and veterans of the U.S. Armed Forces or U.S. Coast Guard and certain eligible dependents must also complete Part 7. The original or stamped signature of the military physician operating under the blanket civil surgeon designation must appear in Part 7. USCIS will reject signatures by attending nurses, physician assistants, or other medical professionals who are not licensed physicians. Military treatment facilities must also place either their official stamp or raised seal in Part 7. where indicated.

  1. Part 8. Civil Surgeon Worksheet and Part 10. Vaccination Record. You must fill out this worksheet and provide the results of each component of the medical examination relating to: communicable diseases of public health significance, physical or mental disorders with associated harmful behavior, drug abuse or drug addiction, and vaccinations. You must also include the results of any lab work or other studies required to determine whether the applicant is inadmissible on health-related grounds.
  2. Part 9. Referral Evaluation. If you refer the applicant to a local health department or to another physician or clinic, you must also fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 8. Civil Surgeon Worksheet in Form I-693. The health care professional receiving the referral must fill out and sign Part 9. Referral Evaluation. Do not complete Item Number 5. in Part 8. if the referral is recommended and not

 

 

Advise applicants that they must complete all health-related follow-up requirements before you can certify Form I-693. You must fill out Item Number 5. Required Referral to Health Department or Other Doctor in Part 8. Civil Surgeon Worksheet with the contact information of the physician or public health facility that will conduct further evaluation or provide treatment. You should also specify the type of examination and additional tests or treatment that the applicant should receive in the Remarks section of Item Number 5. The health care professional receiving the referral must fill out and sign Part 9. Referral Evaluation. Complete your identifying information in Part 7., but do not sign or date the application. Make a copy of the Form I-693 for your records and give the original to the applicant in a sealed envelope. (See the next section for additional instructions for sealing the envelope.)

 

 

After the medical examination and any health-related required follow-up is complete, summarize the results in Part 6. of Form I-693. Do not sign Form I-693 until the applicant has met all health-related follow-up requirements. After that, sign the civil surgeon’s certification in Part 7., Item Number 8.

 

Make two copies of the completed and signed Form I-693 and any supporting documents. Keep one copy for your records. Give the other copy to the applicant. The vaccination portion of Form I-693 will serve as the applicant’s official vaccination record for future use (for example, school or employment purposes.)

 

Prepare the original of the completed and signed Form I-693 for submission to USCIS.

Follow these steps:

  1. Place the Form I-693 and any supporting documentation into an
  2. Seal the
  3. On the front, write in capital letters: “DO NOT OPEN. FOR USCIS USE ”
  4. On the back, write your initials across the seal where the flap meets the
  5. Seal the entire flap with clear tape. Make sure the tape covers your initials as well as the
  6. Give the sealed envelope to the

 

 

1.                         Who must submit Form I-693?

Most applicants filing for adjustment of status to become a lawful permanent resident must submit Form I-693 completed by a designated civil surgeon. Certain other applicants may also be required to submit Form I-693 completed by a civil surgeon.

2.                         What if I am a refugee and already had a medical examination overseas?

If you are now applying for adjustment of status under INA section 209 one year after your first admission, you only need to repeat the entire examination if the panel physician found a class A medical condition during your overseas examination.

If you do not have a Class A medical condition and therefore do not need to repeat the full medical examination, you must still comply with the vaccination requirements. This means you only need to submit Part 10. Vaccination

Record and Parts 1. – 5., and Part 7. of Form I-693. Contact your state or local refugee health coordinator to find out whether a state or local health department can complete the Part 10. of Form I-693. The health department must also complete Part 7. of the benefit request.

3.                         What if I am a K nonimmigrant visa holder and already had a medical examination overseas?

 

 

If you were admitted as a:

  1. K-1 fiancé(e) or a K-2 child of a K-1 fiancé(e); or
  2. K-3 spouse of a U.S. citizen or a K-4 child of a K-3 spouse of a U.S. citizen; and
  3. You received a medical examination prior to admission, then:
    • You are not required to have another medical examination as long as you file your Form I-485 within one year

of an overseas medical examination; and

  • The panel physician did not find a class A medical condition during your overseas examination; or
  • The panel physician did find a class A medical condition, you received a waiver of inadmissibility, and

you have complied with the terms and conditions of the waiver.

  • Even if a new medical examination is not required, you must still show proof that you complied with the vaccination requirements. If the vaccination record (DS 3025) was not properly completed and included as part of the original overseas medical examination report, you will need to have the Part 10. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1. – 5., 7., and

of Form I-693.

4.                         What if I am a V nonimmigrant visa holder and already had a medical examination overseas?

If you were admitted to the United States or obtained status while in the United States as a:

  1. V-1 spouse of a lawful permanent resident or are waiting for a V-1 visa; or
  2. V-2 child of a V-1 spouse of a lawful permanent resident; or
  3. V-3 child of a V-2 unmarried son or daughter of a V-1 spouse of a lawful permanent resident; and
  4. You received a medical examination prior to admission or obtaining V status, then:
    • You are not required to have another medical examination as long as you file your Form I-485 within one year

of an overseas examination, and:

  • The panel physician did not find a class A medical condition; or
  • The panel physician did find a class A medical condition, you received a waiver of inadmissibility, and

you have complied with the terms and conditions of the waiver.

  • Even if a new medical examination is not required, you still must show proof that you complied with the vaccination requirements. If the vaccination record was not properly completed and included as part of the original medical examination report, you will need to have the Part 10. Vaccination Record completed by a designated civil surgeon. In this case, you must submit Parts 1. – 5., 7., and of Form I-693.

5.                         What if I am an asylee derivative applying for adjustment of status and already had a medical examination overseas?

If you were admitted to the United States as an asylee derivative, you generally do not need to repeat, at the time you submit Form I-485, the entire medical examination you had overseas, provided that:

  1. The panel physician found no class A condition during your overseas examination; and
  2. You are applying for adjustment of status within one year of becoming eligible to file.

You must, however, comply with the vaccination requirement and submit Part 10. Vaccination Record and

Parts 1. – 5., and 7. of Form I-693 with your Form I-485.

6.                         May any doctor perform the required medical examination?

Only a doctor who was designated by USCIS as a civil surgeon may perform the medical examination. USCIS will not accept a Form I-693 completed by a doctor who is not a currently designated civil surgeon.

 

 

7.                         How do I know if a doctor is a designated civil surgeon?

Doctors found through the USCIS website at www.uscis.gov or through the USCIS Contact Center are generally current in their designation as civil surgeons. Applicants who are unsure should ask doctors to confirm their status as a civil surgeon.

8.                         Who pays for the medical examination?

You, the applicant, must pay all costs of the medical examination, including the cost of any follow-up tests or treatment that is required. Make payments directly to the civil surgeon or other health care provider.

9.                         What are the health-related grounds of inadmissibility?

U.S. immigration law divides the health-related grounds of inadmissibility into the following four general categories:

  1. Communicable diseases of public health significance;
  2. Lack of proof of having received required vaccinations;
  3. Physical or mental disorders with associated harmful behavior or a history of associated harmful behavior; and
  4. Drug abuse or

See INA section 212(a)(1)(A). HHS regulations classify these and other medical conditions into class A or B conditions. Class A conditions result in inadmissibility while class B conditions do not. See 42 CFR 34.2(d) – (e).

 

1.  Communicable Diseases of Public Health Significance

The civil surgeon is required to perform specific tests for tuberculosis, syphilis, and gonorrhea. The medical examination also requires the civil surgeon to evaluate for other sexually transmitted diseases and Hansen’s disease (leprosy).

If you have a communicable disease of public health significance, the civil surgeon will advise you on how to obtain treatment. USCIS will inform you of whether you also need to apply for a waiver of inadmissibility. To learn more about this waiver, visit the USCIS website at www.uscis.gov.

A.          Testing for Tuberculosis

All applicants two years of age and older must be tested for tuberculosis (TB) with an initial screening test. Civil surgeons may require an applicant younger than two years of age to undergo testing if there is evidence of contact with a person known to have TB or other reasons to suspect TB. Testing must be completed per CDC guidelines, which can found at the CDC’s website at https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/ technical-instructions-civil-surgeons.html.

B.          Testing for Syphilis

All applicants 15 years of age and older must have a blood test for syphilis. Civil surgeons may require testing for applicants under 15 years of age if there is reason to suspect the possibility of infection.

Civil surgeons should consult the latest version of CDC’s Technical Instructions to ensure they are using an approved type of test and following appropriate screening and testing procedures: https://www.cdc.gov/ immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

C.          Testing for Gonorrhea

All applicants 15 years of age and older must be tested for gonorrhea. Civil surgeons may require testing for applicants under 15 years of age if there is reason to suspect the possibility of infection.

 

 

Civil surgeons should consult the latest version of CDC’s Technical Instructions to ensure they are using an approved type of test and following appropriate screening and testing procedures: https://www.cdc.gov/ immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.

2.  Physical or Mental Disorders

This category of physical or mental disorders includes any diagnosis of substance-related disorders that involve any substance that is not listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act (for example, diagnosis of an alcohol-related disorder). Mental disorders are diagnosed according to the diagnostic criteria in the most recent edition of the Diagnostic and Statistical Manual (DSM) or by another authoritative source as determined by the CDC director.  Physical disorders are diagnosed according to the diagnostic criteria in the most recent edition of the World Health Organization’s Manual of the International Classification of Diseases, Injuries, and Causes

of Death (ICD) or by another authoritative source as determined by the CDC director. See the CDC’s Technical Instructions for more information.

The presence of a physical or mental disorder alone does not make you inadmissible on health-related grounds. The civil surgeon must also determine that there is behavior associated with the disorder that is harmful to you, to others, or to property. USCIS will only consider you inadmissible if there is a current associated harmful behavior or a history of associated harmful behavior that is likely to recur.

The civil surgeon will ask you general questions during the medical examination to determine whether you have such a condition. The civil surgeon may refer you to a specialist for further evaluation, if necessary.

If the civil surgeon finds that you have a physical or mental disorder with associated harmful behavior, you may apply for a waiver. If the waiver is granted, you may be subject to terms, conditions, and controls as determined by USCIS in consultation with HHS. For more information about these waivers, visit the USCIS website at www.uscis.gov.

3.  Drug Addiction and Drug Abuse

HHS sets the medical guidelines for determining drug abuse and drug addiction. The terms are defined at 42 CFR 34.2(h) and (i). The civil surgeon will review your medical history during the medical examination and ask you questions necessary to determine whether you are currently using any drugs or other psychoactive substances or have used them in the past.

“Drug abuse” is “current substance use disorder or substance-induced disorder, mild,” but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. The diagnosis is made according to the diagnostic criteria in the most current edition of the DSM or by another authoritative source as determined by the CDC director.

“Drug addiction” is “current substance use disorder or substance-induced disorder, moderate or severe,” but only with respect to substances listed in Schedule I, II, III, IV, or V of section 202 of the Controlled Substances Act. The civil surgeon will make a diagnosis according to the diagnostic criteria in the most current edition of the DSM or by another authoritative source as determined by the CDC director. See the CDC’s Technical Instructions for more information.

If the civil surgeon determines you have a substance-related disorder, you are not eligible to apply for a waiver unless

you are applying for adjustment of status one year after you were admitted as a refugee or granted asylum.

You will no longer be inadmissible based on drug abuse or drug addiction if, after a later medical examination by a civil surgeon, the civil surgeon finds your drug abuse or addiction is in remission. The diagnosis of remission is made according to the diagnostic criteria in the most current edition of the DSM or another authoritative source as determined by the CDC director.

 

 

All applicants for adjustment of status must present documents showing they were vaccinated against a broad range of vaccine-preventable diseases. The civil surgeon will review your vaccination history with you to determine whether you have had all the required vaccinations. Make sure you take your vaccination records with you to your appointment with the civil surgeon.

NOTE: Do not attempt to meet the requirements before the civil surgeon evaluates you, in case any of the required vaccines are not medically appropriate for you.

You can find a list of the required vaccines at

www.cdc.gov/immigrantrefugeehealth/exams/medical-examination-faqs.html#6.

If you never received certain vaccines, or you are unable to prove you received them, the civil surgeon can provide them to you. You also have the option to ask your family doctor to administer those vaccines to you after your evaluation by the civil surgeon. If you choose that option, show the records to the civil surgeon to note on Form I-693.

If you initially did not have documents proving you received all the required vaccines, but later submit those documents, USCIS may grant you a waiver based on the civil surgeon’s certification on Part 10. Vaccination Record of Form I-693. USCIS may also grant you a waiver if the civil surgeon certifies that it is not medically appropriate for you to have one or more of the required vaccines.

HHS has determined that a vaccine is “not medically appropriate” if:

  1. The vaccine is not recommended for your specific age group;
  2. There is a medical reason why it would not be safe to have the vaccine (for example, you are allergic to eggs and/or yeast or you had bad reactions to prior vaccines);
  3. You are unable to complete the entire series of a required vaccine within a reasonable amount of time; or
  4. For the influenza vaccine, it is not the flu

If you object to required vaccinations because of sincerely held religious beliefs or moral convictions, you may apply for a waiver of these requirements. If you hold these objections, inform the civil surgeon that you will apply for a waiver.

If USCIS denies the waiver application, we may also deny the immigration benefit that you are seeking. For more

information about these waivers, visit the USCIS website at www.uscis.gov.

 

An applicant or petitioner who is not a U.S. citizen must notify USCIS of his or her new address within 10 days of moving from his or her previous residence. For information on filing a change of address, go to the USCIS website at www.uscis.gov/addresschange or reach out to the USCIS Contact Center at www.uscis.gov/contactcenter for help.

The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call:

1-800-767-1833.

NOTE: Do not submit a change of address request to the USCIS Lockbox facilities because the Lockbox does not process change of address requests.

 

To ensure you (the applicant or the civil surgeon) are using the latest version of this form, visit the USCIS website at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have internet access, you may order USCIS forms by calling the USCIS Contact Center at 1-800-375-5283. The USCIS Contact Center provides information in English and Spanish. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

 

 

Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at www.uscis.gov. Select “Tools,” then under “Self Service Tools,” select “Appointments” and follow the screen prompts to set up your appointment. Once you finish scheduling an appointment, the system will generate an appointment notice for you.

 

If you (the applicant or the civil surgeon) knowingly and willfully falsify or conceal a material fact or submit a false document with the Form I-693, you will face severe penalties provided by law and may be subject to criminal prosecution.

 

 

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act section 212(a)(1)(a).

 

PURPOSE: The primary purpose for providing the requested information on this form is to report results of a medical examination and provide vaccination records to USCIS. DHS uses the information to assist with determining eligibility for the immigration benefit you are seeking.

 

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your Social Security number (if applicable), and any requested evidence, may delay a final decision or result in denial of your form.

 

ROUTINE USES: DHS may share the information you provide on this form and any additional requested evidence with other Federal, state, local, and foreign government agencies and authorized organizations in accordance with approved routine uses described in the associated published system of records notices [DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System and DHS/USCIS-007 Benefits Information System] and the published privacy impact assessments [DHS/USCIS/PIA-003 Integrated Digitization Document Management Program (IDDMP) and DHS/USCIS/PIA-067 Civil Surgeon Designation] which you can find at www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law enforcement purposes or in the interest of national security.

 

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public reporting burden for this collection of information is estimated at 2 hours and 30 minutes per response, including the time for reviewing instructions, gathering the required documentation and information, completing the form, preparing statements, attaching necessary documentation, and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0033. Do not mail your completed Form I-693 to this address.

STATEMENT OF NON-IMPEDEMENT TO MARRIAGE – BẢN XÁC NHẬN KHÔNG CẢN TRỞ KẾT HÔN

STATEMENT OF NON-IMPEDEMENT TO MARRIAGE
Mr/Miss………………………………………………………………, a U.S. citizen/ a Legal Permanent Resident, born

on………………………………….in………………………………….,     Passport     No/     Permanent     Resident   Card

No:…………………………….. , has confirmed that he/she is entitled for legal marriage to a Vietnamese/U.S.

citizen and requested a “Certificate of Non-Impedement to Marriage” in relation to his/her proposed marriage in Viet Nam to Mr/Miss…………………………………………………………, a Vietnamese/U.S. citizen born on………………………………., in………………………….., Passport/ ID number: ………………………………….

This is to certify that there is no U.S. law that prohibits a US citizen or a person residing in the US from marrying a citizen of Vietnam/ U.S. in Vietnam. The marriage between a US citizen or a person residing in the U.S. and a citizen of Vietnam/U.S. would normally be recognized as valid in the United States.
Mr/Miss……………………………………………………………… has stated that information provided above is true and correct. The U.S. government is unable to verify this information, but on the legal basis, there is no reason why this U.S. citizen/permanent resident can not marry a Vietnamese citizen, according to the U.S. law.
BẢN XÁC NHẬN KHÔNG CẢN TRỞ KẾT HÔN
Ông/Bà……………………………………………………………………………..là  công  dân/Thường  trú  nhân  Hoa  Kỳ,

sinh ngày………………………………………, tại………………………………………., Hộ chiếu/Thẻ thường trú nhân số………….. , đã xác nhận rằng đương sự có đủ điều kiến để kết hôn với công dân Việt

Nam/Hoa Kỳ và yêu cầu cấp giấy chứng nhận “Không cản trở kết hôn” đối với việc dự kiến kết hôn của đương sự tại Việt Nam với Ông/Bà………………………………………………… là công dân Việt Nam/Hoa Kỳ, sinh ngày…………………………….., tại……………………………….., Hộ chiếu/CMND số…………………………………..

Giấy này để chứng nhận rằng luật pháp Hoa Kỳ không ngăn cấm công dân Hoa Kỳ hoặc người cư trú tại Hoa Kỳ kết hôn với công dân Việt Nam/Hoa Kỳ. Hôn nhân giữa một công dân Hoa Kỳ hoặc người cư trú tại Hoa Kỳ với công dân Việt Nam/Hoa Kỳ thông thường sẽ được công nhận hợp pháp tại Hoa Kỳ.
Ông/Bà……………………………………………………………………………… cam đoan rằng những thông tin được

cung cấp như trên là chính xác và trung thực. Chính phủ Hoa Kỳ không thể xác minh tính xác thực của những thông tin này; tuy nhiên dựa trên thông tin do đương sự cung cấp như trên thì không có lý do pháp lý nào cho thấy công dân/thường trú nhân Hoa Kỳ này không thể kết hôn với công dân Việt Nam theo luật pháp Hoa Kỳ.

Signature of Affiant…………………………………………..

 

Full name in Print:……………………………………………..

 

Người tuyên thệ ký và ghi đầy đủ họ tên

For the Notary Public –

Phần dành cho Công chứng viên Sworn to and subcribed before me on

………………………………………………

Tuyên thệ và ký trước mặt tôi ngày…………………………………..

Hồ sơ Công hàm Độc thân

HỒ SƠ CÔNG HÀM ĐỘC THÂN ĐỂ ĐĂNG KÝ KẾT HÔN VỚI CÔNG DÂN VIỆT NAM

https://vietnamconsulate-sf.org/vi/2017/05/05/ho-so-cong-ham-doc-than/

Hồ sơ bao gồm:

Hồ sơ Công hàm Độc thân /đăng ký kết hôn gửi đến Tổng lãnh sự quán Việt Nam để hợp pháp hóa và dịch thuật theo quy định, trước khi mang về Việt Nam làm thủ tục kết hôn, gồm:

  1. Tuyên thệ độc thân (Affidavit of Single Status)
  2. Giấy chứng nhận chưa kết hôn (Certificate of Non-marriage/Certificate of No Record): Do Lục sự quận (County Clerk) hoặc cơ quan tương đương của địa phương Hoa Kỳ cấp, sau đó được Đổng lý Tiểu bang (Secretary of State) xác thực: chứng nhận đương sự không có vợ/chồng bắt đầu từ khi đủ tuổi kết hôn (nam 20, nữ 18) hoặc từ khi ly hôn hoặc khi vợ/chồng chết cho tới nay.
  3. Giấy xác nhận tình trạng hôn nhân  do Tổng Lãnh sự quán cấp (theo Thông tư số 22/2013/TT-BTP, hiệu lực từ ngày 17/02/2014) nhằm chứng nhận người Việt Nam định cư ở nước ngoài chưa từng đăng ký kết hôn tại Tổng Lãnh sự quán.

Quý vị lưu ý:

+ Đối với người xuất cảnh khi đã đủ tuổi kết hôn (nam từ 20 tuổi, nữ từ 18 tuổi trở lên): Khai từ thời điểm bắt đầu định cư ở Hoa Kỳ.

+ Đối với người xuất cảnh khi chưa đủ tuổi kết hôn (nam dưới 20 tuổi, nữ dưới 18 tuổi): Khai thời điểm khi đủ tuổi kết hôn (nam từ 20 tuổi, nữ từ 18 tuổi trở lên).

  1. Tờ khai đăng ký kết hôn (Application for Marriage Registration)
  2. Lý lịch cá nhân (Biographic Information Sheet)
  3. Giấy xác nhận sức khỏe của bác sĩ hoặc tổ chức y tế có thẩm quyền cấp, xác nhận hiện tại đương sự không mắc bệnh tâm thần hoặc không mắc bệnh khác mà không thể nhận thức, làm chủ được hành vi của mình. Chữ ký của bác sỹ phải được Công chứng viên chứng thực và Đổng lý văn phòng tiểu bang xác nhận chữ ký và thẩm quyền của Công chứng viên (Pre-marital Examination of Mental Health).
  4. Bản xác nhận không cản trở kết hôn,
  5. Bản sao hộ chiếu (Passport) hoặc Thẻ xanh (Green card)
  6. Phán quyết ly hôn của tòa án (đối với người đã ly hôn): Phải có chứng thực của Lục sự tòa (Court Clerk) hoặc Thẩm phán (Judge) và xác nhận của Đổng lý văn phòng tiểu bang nơi có tòa án đó (đối với con dấu, chữ ký và thẩm quyền của Lục sự tòa hoặc Thẩm phán).
  7. Bản sao giấy chứng tử (nếu vợ hoặc chồng đã chết): Phải có xác nhận của Hộ tịch viên/Lục sự…và xác nhận của Đổng lý văn phòng tiểu bang (đối với con dẫu, chữ ký và thẩm quyền của Hộ tịch viên/ Lục sự…).
  8. Giấy ủy quyền: Nếu chưa thể về Việt Nam nộp hồ sơ và để tránh mất thời gian chờ đợi ngày ký giấy đăng ký kết hôn tại Việt Nam,  quý vị vị cần làm giấy ủy quyền cho vị hôn thê/hôn phu ở Việt Nam thay mặt mình nộp các giấy tờ xin đăng ký kết hôn tại Sở Tư pháp tỉnh/thành phố ở Việt Nam.

 

* LƯU Ý:

 

– Các giấy tờ nêu tại Mục 1, 2, 3, 4, 5, 6, 11, phải được cấp hoặc chứng thực không quá 06 tháng, tính đến ngày nộp hồ sơ tại Sở tư pháp Việt Nam.

 

– Trước khi gửi đến Tổng Lãnh sự quán, các Giấy tờ có chữ ký của Đương đơn (nêu tại Mục 1,4,5,7,11 ) và bản sao Hộ chiếu hoặc thẻ xanh (nêu tại Mục 8) phải được Công chứng viên (Notary Public) tại địa phương chứng thực và Văn phòng Đổng lý tiểu bang (State- Level Secretary of State) xác nhận chữ ký, thẩm quyền của Công chứng viên.

 

– Nếu các giấy tờ trong hồ sơ được công chứng bởi cùng 1 công chứng viên, thì đương sự chỉ cần xin 01 bản xác nhận của Đổng lý văn phòng đối với chữ ký và thẩm quyền của công chứng viên đó.

 

 

* Lệ phí : có thể trả bằng tiền mặt nếu hồ sơ được nộp trực tiếp; hoặc bằng Money Order hoặc Cashier’s Check  cho “Vietnam Consulate” nếu hồ sơ được gửi qua đường bưu điện.

 

-Nếu muốn nhận kết quả qua đường bưu điện, Quý vị cần gửi kèm theo 01 bì thư đảm bảo (certified mail) có ghi rõ địa  chỉ người nhận và đã trả cước phí. Để tránh mất mát trong quá trình vận chuyển, đề nghị Quý vị sử dụng các dịch vụ chuyển phát bảo đảm của FEDEX hoặc UPS và ghi lại tracking number để theo dõi việc chuyển phát thư (Lưu ý KHÔNG sử dụng FEDEX Ground và UPS Ground – là bì thư không đảm bảo). Tổng Lãnh sự quán không chịu trách nhiệm trong trường hợp hồ sơ của Quý vị bị thất lạc do Quý vị dùng bì thư không đảm bảo.

 

Thời gian xử lý hồ sơ:

Tổng Lãnh sự quán xử lý hồ sơ và trả kết quả trong vòng 5-7 ngày làm việc. Nếu có yêu cầu làm gấp, Tổng Lãnh sự quán có thể trả hồ sơ trong vòng 1-2 ngày làm việc kể từ ngày nhận được hồ sơ hợp lệ.

@ Để biết thêm thông tin, Quý vị có thể liên với Bộ phận Hợp pháp hóa của Tổng Lãnh sự quán:

  • Địa chỉ: 1700 California Street, Suite 580, San Francisco, CA 94109
  • Giờ làm việc: 8.30 am – 12.00pm và 2.30pm – 4.30pm, Thứ hai tới Thứ sáu
  • Điện thoại: +1 415 922 1707 ; 415 922 0707; 415 922 1238;
  • Fax: +1 415 922 1757
  • Email: legalization@vietnamconsulate-sf.org
  • Website: www.vietnamconsulate-sf.org

📌🇺🇸📑 DỊCH VỤ CÔNG CHỨNG 📌🇺🇸📑

Bộ phận dịch vụ công dân Hoa Kỳ thực hiện nhiều thể loại dịch vụ công chứng, bao gồm:

Để đặt cuộc hẹn cho dịch vụ công chứng, vui lòng truy cập trang Hệ thống đặt hẹn. Sau khi quý vị đặt hẹn thành công, vui lòng in trang xác nhận lịch hẹn để đến văn phòng chúng tôi vào ngày hẹn. Khi đến, quý vị sẽ được hỗ trợ thực hiện dịch vụ công chứng và thời gian thực hiện sẽ kéo dài từ 30 phút đến 1 tiếng.

Nếu quý vị không thấy có ngày hẹn trống trên Hệ thống đặt hẹn, vui lòng quay lại sau. Lịch hẹn thường được mở trước khoảng 2 tuần, và lịch hẹn bổ sung thường được mở thêm, nên chúng tôi khuyến khích quý vị nên thường xuyên kiểm tra hệ thống để theo dõi lịch hẹn.

Thông thường các dịch vụ công chứng đều được xem là không mang tính khẩn cấp. Do đó, nhằm bảo đảm công bằng cho tất cả đương đơn, văn phòng chúng tôi sẽ chỉ xem xét các yêu cầu xin lịch hẹn khẩn nếu quý vị thực sự có trường hợp vô cùng khẩn cấp. Nếu cần lịch hẹn khẩn cấp, trước hết quý vị phải đặt một cuộc hẹn trực tuyến như bình thường.  Sau khi đã đặt hẹn thành công, quý vị phải vào Mẫu đơn Trực tuyến để yêu cầu xin lịch hẹn khẩn.  Khi gửi yêu cầu xin lịch hẹn khẩn, Quý vị phải cung cấp đầy đủ:

1) lý do tại sao trường hợp của quý vị lại là trường hợp vô cùng khẩn cấp và quý vị phải xin lịch hẹn sớm hơn, 

2) ngày giờ cuộc hẹn mà quý vị đã đặt và ngày giờ cuộc hẹn mà quý vị muốn có nếu yêu cầu xin lịch hẹn khẩn được chấp thuận,

3) đính kèm giấy tờ bằng chứng thể hiện tình trạng khẩn cấp của quý vị hoặc lời giải thích rõ ràng tại sao một cuộc hẹn sớm hơn lại có thể giúp quý vị giải quyết được tình huống khẩn cấp của mình.

Nếu quý vị không cung cấp đủ TẤT CẢ các thông tin trên, văn phòng chúng tôi sẽ không xem xét yêu cầu của quý vị.

Phí công chứng là 50 đô la Mỹ cho mỗi con dấu. Để biết thêm thông tin vui lòng xem Bảng phí Dịch vụ Lãnh sự tại đây. Tất cả các phí dịch vụ lãnh sự có thể thanh toán bằng tiền mặt đô la Mỹ, Việt Nam đồng, hoặc bằng các loại thẻ tín dụng/thẻ ghi nợ thanh toán bằng đô la Mỹ như sau:  Visa, MasterCard, Discover và American Express.  Chúng tôi không chấp nhận thanh toán bằng ngân phiếu.  Ngoài ra, chúng tôi chỉ chấp nhận những tờ giấy bạc trong tình trạng còn tốt.  Xin lưu ý rằng những giấy bạc bị dán, phai mờ, rách, hư hại hay có những dấu vết hoặc hoen ố sẽ không được chấp nhận.

Các văn bản của công dân nước ngoài do Hoa Kỳ cấp hoặc để sử dụng ở Hoa Kỳ cũng có thể công chứng.  Để công chứng, yêu cầu quý vị mang theo hộ chiếu của mình hoặc giấy tờ tuỳ thân có dán ảnh dùng để nhận dạng.

Xin lưu ý rằng các văn bản học vị, văn bản thương mại và lý lịch tư pháp của công dân Hoa Kỳ không thể công chứng hoặc hợp pháp hoá tại Đại sứ quán và Lãnh sự quán.  Các loại văn bản này phải được hợp pháp hoá theo thủ tục hợp pháp hoá tại Hoa Kỳ. Tuy nhiên, công dân Hoa Kỳ có thể làm giấy tuyên thệ tại Đại sứ quán / Lãnh sự quán về độ xác thực của giấy tờ. Quý vị nên trao đổi với nơi yêu cầu các giấy tờ này xem họ có chấp nhận hình thức tuyên thệ này hay không và họ cần quý vị nộp loại giấy tờ cụ thể nào (chẳng hạn như bản chính hay bản sao). Quý vị có thể liệt kê nhiều loại giấy tờ trên một mẫu đơn tuyên thệ, và bấm kèm bản chính hoặc bản sao của các giấy tờ này để đóng giáp lai với đơn tuyên thệ.

Chuẩn bị cho cuộc hẹn làm công chứng

  • Vui lòng mang giấy tờ tuỳ thân có dán ảnh do cơ quan có thẩm quyền cấp.
  • Đảm bảo rằng quý vị hiểu rõ nội dung văn bản.  Chúng tôi không được phép giải thích nội dung của văn bản cho quý vị.
  • Xin vui lòng điền đầy đủ thông tin trước khi đến (nhưng không ký; quý vị sẽ ký tại văn phòng của chúng tôi trước mặt viên chức lãnh sự)
  • Nếu văn bản của quý vị cần có người làm chứng bên cạnh công chứng, quý vị phải chuẩn bị người làm chứng và những thông tin hướng dẫn cần thiết.  Nhân viên lãnh sự không thể làm người làm chứng.  Nếu quý vị không thể trả lời những câu hỏi đơn giản liên quan đến việc công chứng văn bản hoặc không hiểu rõ nội dung văn bản, quý vị có thể sẽ phải đặt một cuộc hẹn khác.  Nếu quý vị cần công chứng giấy tờ bản gốc, vui lòng mang theo cả bản gốc và một bản sao. Nếu quý vị không chuẩn bị sẵn bản sao, quý vị có thể phải đóng phí $1.00 cho mỗi trang được sao.

— UNC Tổng hợp —

✨ 🌺 🍀 CÔNG TY TNHH UNIVERSAL NETWORK CONNECTION (VIẾT TẮT LÀ “UNC”) ĐÃ ĐƯỢC THÀNH LẬP, HOẠT ĐỘNG TRONG LĨNH VỰC HỖ TRỢ GIÁO DỤC – TƯ VẤN DU HỌC VÀ ĐỊNH CƯ TRONG HƠN 10 NĂM, VỚI SỰ HIỆN DIỆN THƯƠNG MẠI TẠI NHIỀU QUỐC GIA TRÊN THẾ GIỚI: KOREA, USA, CANADA, AUSTRALIA, VIETNAM, THAILAND.

ĐỊA CHỈ CHI NHÁNH VIỆT NAM

*** Hồ Chí Minh: Tầng 8, Tòa nhà AB, 76A Lê Lai, Phường Bến Thành, Quận 1, HCM

Hotline: 028 38 227 207

Fanpage Hochiminh:

UNC_immigration: https://www.facebook.com/uncvietnam/

Group:

UNC_immigration – Chúng tôi chia sẻ,kết nối “Giấc mơ định cư” cùng các bạn: https://www.facebook.com/groups/2696672960374705/

*** Hà Nội: Tầng 7, Tòa nhà Oriental, 324 Tây Sơn, P.Ngã Tư Sở, Quận Đống Đa, Hà Nội.

Hotline: 024 35 743 666

Fanpage Hanoi:

UNC HANOI_immigration: https://www.facebook.com/UNC-HANOI_immigration-670314116715876/

UNC Hanoi: https://www.facebook.com/UNChanoi/

 


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