Salomon Ledezma-Cosino v. Eric Holder, Jr.

Filing

FILED OPINION (SIDNEY R. THOMAS, ALEX KOZINSKI, SUSAN P. GRABER, M. MARGARET MCKEOWN, RICHARD R. CLIFTON, CARLOS T. BEA, SANDRA S. IKUTA, MARY H. MURGUIA, MORGAN B. CHRISTEN, PAUL J. WATFORD and JOHN B. OWENS) DENIED. Opinion by Judge Graber; Concurrence by Judge Kozinski; Concurrence by Judge Watford; Dissent by Chief Judge Thomas. FILED AND ENTERED JUDGMENT. [10451312]

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Technical Instructions for Panel Physicians and Civil Surgeons
CDC > Immigrant and Refugee Health > Technical Instructions > For Civil Surgeons

Technical Instructions for Physical or Mental Disorders with
Associated Harmful Behaviors and Substance-related
Disorders for Civil Surgeons

CDC has updated the 2010 Technical

On This Page

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Disorders with Associated Harmful
PrefaceRole of the Civil Surgeon
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Behaviors and Substance-related
Key ConceptsMental Health Examination
ma-C d on Ma
dez hi Screening ResultsWaivers
Disorders
[PDF – 38 pages] for Civil in Le
Mental Healthve
9 arc
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Mental Health and Substance
Surgeons. This is also known asc
Mental 7328
12- Abuse/Addiction Classifications and
Health Technical InstructionsNo.
(MH
Instructions for Physical or Mental

TIs).
The diagnosis of mental disorders and
substance-related disorders is made
using the current American Psychiatric
Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM)
criteria. Therefore, the 2010 MH TIs
have been modified to reflect the

Descriptions
Documentation
Appendix A: Glossary of Abbreviations
Appendix B: Useful Resources
Appendix C: Controlled Substances
Appendix D: Summary of Mental Health
Examination
FiguresTables

current fifth edition, DSM-5, which
was released in the spring of 2013.

Important changes in the DSM-5 that affect the 2010 MH TIs
Deletion of the terms “substance abuse,” “substance dependence,” and “substance
addiction.”
Division of substance-related disorders into the following two groups:

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1. 1. Substance use disorders

2. 2. Substance-induced disorders
For additional information about the changes please refer to page 5, 6, and 11 of the updated
MH TIs PDF.
All civil surgeons should be using the updated MH TIs no later than January 1, 2014.

Preface
Medical screening for physical and mental disorders with associated harmful behaviors and
substance-related disorders among persons applying for adjustment of status to permanent
resident and other persons required by law to have a medical examination, hereafter referred
to as applicants, is an essential component of the immigration-related medical evaluation.
Because these conditions are challenging to diagnose and treat, these technical instructions
provide a method for recording findings from the medical examination and additional guidance
for the civil surgeon in classifying applicants. The new technical instructions use uniform
criteria and diagnosis consistent with current medical knowledge and classification connected
with legal definitions.

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The required examination includes evaluation of physical and mental disorders 2
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potentially harmful behavior.te
12No. (INA) provides three grounds of inadmissibility related to
The Immigration and Nationality Act
substance addiction or abuse, or physical or mental disorders that affect behavior. They are –
Current physical or mental disorder with associated harmful behavior.
Past physical or mental disorder with associated harmful behavior if the harmful behavior
is likely to recur or to lead to other harmful behavior in the future.
Drug (substance) abuse or addiction (medically called dependence). Dependence on or
abuse of any of the substances listed in Section 202 of the Controlled Substances Act
(Appendix C). (The term addiction corresponds with the medical term dependence).
The instructions in this document supersede all previous Technical Instructions, Updates to the
Technical Instructions, memoranda and letters to civil surgeons relating to substance abuse or
addiction and mental or physical disorders with associated harmful behavior (whether past or
present). These new instructions are to be followed when determining whether an applicant is
afflicted with physical and mental disorders with associated harmful behaviors and substancerelated disorders among all applicants.
For any questions about these Technical Instructions, please contact the Immigrant, Refugee,

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and Migrant Health Branch of the Division of Global Migration and Quarantine (DGMQ),

Centers for Disease Control and Prevention (CDC), at [e-mail] or 404-498-1600.
These Technical Instructions and other information pertinent to them and the medical
examination for applicants for U.S. immigration can be found online at
https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civilsurgeons.html.

Role of the Civil Surgeon
The purpose of the immigration examination is to identify health-related conditions that
render an applicant inadmissible, and also to identify and inform the applicant of
conditions possibly needing follow-up care.

As part of the medical evaluation and physical examination of the applicant, the civil surgeon
will carry out or obtain a mental health evaluation –
To identify and diagnose any physical or mental disorder (including alcohol-related
disorders).
To identify any harmful behavior associated with a disorder.

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To determine the remission status of any disorder previously on
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To identify the use of drugs, other than those required for medical reasons, and diagnose

For most applicants, the civil surgeon’s examination will require only one appointment.
However, for some applicants multiple appointments or specialist consultations may be
required to make an accurate diagnosis of whether the applicant is afflicted with a Class A or
Class B condition as it relates to physical or mental disorders with associated harmful behavior
or substance abuse and addiction (dependence).

Key Concepts
A harmful behavior is defined as an action associated with a mental or physical disorder
that is or has caused –
Serious psychological or physical injury to the applicant or to others (e.g., a suicide
attempt or pedophilia)
A serious threat to health or safety (e.g., driving while intoxicated or verbally
threatening to kill someone)
Major property damage.

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An applicant who has exhibited harmful behavior not associated with a specific mental or

physical disorder is not considered inadmissible under health-related grounds, but may be
inadmissible under criminal grounds as determined by DHS/USCIS.

The Diagnostic and Statistical Manual of Mental Disorders' (DSM) diagnosis for
substance-related disorders is used in this examination to determine "drug abuse" and
"drug addiction" which are listed as a medical ground of inadmissibility in the Immigration
and Nationality Act.

Alcohol dependence or abuse alone is not considered a Class A condition. It is considered
the same as any other mental disorder, and requires associated harmful behavior to be
classified as a medically inadmissible condition.

Physical Disorder
A physical disorder is a clinically diagnosed medical condition where the focus of attention is
physical manifestations. Only physical conditions that are included in the current version of the

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be considered for the purpose of this examination.
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Mental disorders are health conditions that328
21
or behavior (or some combination .
No thereof). The current version of the American Psychiatric
World Health Organization’s Manual of the International Classification of Diseases (ICD) will

Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is an authoritative
source on the classification of mental disorders and should be considered for the purpose of
this examination.

“V” Coded Condition
“V” coded conditions listed in the DSM are not diagnoses, but are used in clinical practice
settings when the focus of clinical attention is on a behavior that is not due to a mental disorder.
Because these “V” conditions are not mental disorders, they cannot be used in determining if a
person has an inadmissible (Class A) health-related condition, regardless of whether there is an
associated harmful behavior. However, behaviors associated with “V” coded conditions might
require treatment.

Harmful Behavior
The civil surgeon is to identify any harmful behavior that is associated with an applicant’s
physical or mental disorder.

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Only harmful behavior that is associated with a physical or mental disorder is relevant for the
classification of U.S. medical eligibility; neither harmful behavior by itself nor the physical or

mental disorder by itself makes an applicant medically inadmissible. People can have multiple
harmful behaviors that are not associated with a physical or mental disorder. Repetitive
antisocial activities and harmful acts may warrant evaluation for personality disorders
according to DSM criteria, and eventually provide a basis for the conclusion of inadmissibility.
Because of the complexity of this issue, the civil surgeon might feel that a more specialized
psychiatric examination is indicated. (Table 4)

Substance-Related Disorders
To establish any substance-related disorder diagnosis, the examining physician must document
the pattern of use and behavioral, physical, and psychological effects associated with the use or
cessation of use of that substance. Diagnoses of substance-related disorders are to be made in
accordance with existing medical standards as determined by the current edition of the DSM. In
the current DSM, substance-related disorders are divided into the following two groups:
1. Substance use disorders
2. Substance-induced disorders

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For purposes of this evaluation, substances are divided into two groups, controlled substances

taken in accordance with a prescription do not amount to a substance use disorder. However,
abuse of prescription drugs could be a substance-related disorder. This requires a full
evaluation by the examining physician to determine whether illicit drugs are being used,
because use of illicit drugs is a risk factor for the misuse of prescribed, controlled substances.

Substance Use Disorders
The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and
physiological symptoms indicating that the individual continues using the substance despite
significant substance-related problems.
The DSM criteria for substance use disorders fit within overall groupings of impaired control,

social impairment, risky use, and pharmacological criteria. Pharmacological criteria include
tolerance and withdrawal.
Drug (substance) abuse or addiction (medically called dependence) is listed as a medical ground
of inadmissibility by the Immigration and Nationality Act (INA). An applicant will be barred from
admission if he or she

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Uses a controlled substance
AND
Meets DSM criteria for a substance use disorder.
The DSM uses the following criteria to determine the severity of a substance use disorder:
The presence of 2-3 symptoms (this suggests a mild substance use disorder)
The presence of 4-5 symptoms (this suggests a moderate substance use disorder)
The presence of 6 or more symptoms (this suggests a severe substance use disorder)
If an applicant’s substance use meets criteria for either a mild, moderate, or severe substance
use disorder, and involves a controlled substance, the applicant is considered Class A for drug
abuse/addiction.
If an applicant’s substance use meets the criteria for either a mild, moderate, or severe
substance use disorder but involves a non-controlled substance, the civil surgeon should
determine whether harmful behavior is present or if there is a history of harmful behavior that
is judged likely to recur. If harmful behavior is present or is judged likely to recur, then the
applicant is considered Class A for a physical or mental disorder. If the applicant does not

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recur, the applicant is considered Class B for a physical or mental disorder. S
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currently have harmful behavior or does not have a history of harmful behavior judged likely to

intoxication, withdrawal, and other substance/medication-induced mental disorders (psychotic
disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessivecompulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and
neurocognitive disorders/substance-induced psychotic disorder, and substance-induced
depressive disorder).
If an applicant’s substance use meets the DSM criteria for a substance-induced disorder, and
involves the use of a controlled substance, the applicant is considered Class A for drug
abuse/addiction.
If an applicant’s substance use meets the criteria for a substance-induced disorder but involves
a non-controlled substance, the civil surgeon should determine whether harmful behavior is
present or if there is a history of harmful behavior that is judged likely to recur. If harmful
behavior is present or is judged likely to recur, then the applicant is considered Class A for a
physical or mental disorder. If the applicant does not currently have harmful behavior or a
history of harmful behavior judged likely to recur, the applicant is considered Class B for a
physical or mental disorder.

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Class A and Class B Medical Conditions
Class A medical conditions are inadmissible conditions and include an applicant who is
determined to have –
A current physical or mental disorder with associated harmful behavior
A past physical or mental disorder with associated harmful behavior if the harmful behavior
is likely to recur or to lead to other harmful behavior in the future
Drug (substance) abuse or addiction (dependence)
Class B medical conditions are not inadmissible medical conditions and include any applicant

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who is determined to have a physical or mental abnormality, disease, or disability serious in

Random screening for drugs is not part of the routine medical evaluation of applicants for
U. S. admission.

If the civil surgeon is unable to determine whether an applicant has a diagnosis of a
physical or mental disorder, or substance abuse or dependence for a substance listed in
Section 202 of the Controlled Substances Act, diagnosis and classification may be deferred
in order to obtain additional medical evidence.

Record DSM diagnoses for mental disorders and substance-related disorders on the I-693
Form under Part 2, in the Remarks for Number 3 and Number 4.

The civil surgeon can recognize that an applicant with a physical or mental disorder might have
an associated harmful behavior during any point of the examination.
While taking the medical history of a mental disorder,

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While taking history of harmful behavior, or

While observing for current abnormal behavior during the physical examination.

Medical History
The civil surgeon should begin by asking questions about the past medical history of the
applicant. To fully investigate the applicant’s past medical history, the civil surgeon, when
possible, should –
Obtain other relevant records, such as police, military, school, and employment, that might
provide a history of harmful behavior associated with physical or mental disorders.
Ask about mental disorders in the family and, when appropriate, about signs of mental
problems or odd behaviors.
Ask about any use of drugs and medicines.
Ask about harmful behaviors.
When a civil surgeon defers diagnosis and classification, the civil surgeon should explain to the
applicant what the civil surgeon would like to see during the next 3-6 months (in order to
classify the applicant) to show abstinence (see Figure 2). This may include but is not limited to
requiring clinical reports from health care professionals for applicants with possible substance-

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with deferred diagnosis and classification, the civil surgeon should
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statement signed by the applicant the information he or
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7328
abstinence.
12No.
related disorders to demonstrate participation in a drug treatment program. For applicants

Psychiatric Evaluation
The civil surgeon should conduct an activities assessment and mental status examination that
assesses, at a minimum –
orientation,
mood and affect,
speech and language,
anxiety,
thought processes and content, and
behavior.
The civil surgeon may estimate the degree of cognitive impairment in dementia or mental
retardation by assessing the applicant’s (1) level of knowledge, and (2) ability to carry out
functions of daily living (e.g., learning, communication, and routine activities).
Any available reports of cognitive, development, or intelligence testing, or neuropsychological
testing in the medical record are welcome and may be included with the civil surgeon’s report.

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However, the civil surgeon is not asked to routinely send applicants for additional psychological
tests.
Under most circumstances, the civil surgeon or consultant will not need to provide additional
psychological or neuropsychological testing. Use of projective instruments, such as Rorschach
test, may not be useful given the added administrative burden involved. No psychological or
neuropsychological testing is a substitute for the civil surgeon’s or consultant’s history and
examination of the applicant. However, for certain cases, these tests may aid in making a
diagnosis.

Laboratory Testing
Random screening for drugs is not part of the routine medical examination for applicants for
U.S. admission. The civil surgeon needs to evaluate the applicant’s history, behavior and
physical appearance when determining if drug screening should be performed.
Whole populations of applicants should not routinely be subject to random laboratory
screening. The civil surgeon should make an individual decision based on the indications for
drug screening (see Table 1).

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applicants.
. 12Nosupport depend on the availability of such laboratory services
Other possible uses of laboratory
Laboratory testing to identify underlining medical conditions that might be causing psychiatric

and the clinical judgment of the civil surgeon as to their usefulness in classification of the
individual applicant. For example, therapeutic levels of prescribed anticonvulsant medications,
antipsychotic medications, or other medicines used in psychiatry (such as lithium levels) might
be of value to the civil surgeon in –
Determining the applicant’s adherence to a prescribed course of treatment.
Possibly changing or adjusting the applicant’s medications, and therefore contributing to
remission of illness and reduction of associated harmful behavior.
Random screening for drugs on short notice to the applicant can provide additional evidence to
aid in diagnosis and classification. For example, the civil surgeon might request that three
random screenings for drugs within a 3- to 6-month period be done with only 24- to 48-hour
notification to the applicant. The period of advance notification should be the minimum
practical time for the applicant to arrive at the screening facility, preferably 24 or 48 hours
after notification.
It is the civil surgeon’s responsibility to know the reliability and validity of the laboratory tests

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and laboratory methods used during the medical evaluation. All drug testing is to be done by
using materials licensed by the U.S. Food and Drug Administration or by the equivalent

licensing office in other countries. Rapid testing or semi-quantitative testing may be used for
the screening test; however, gas chromatography/mass spectrometry (GC/MS), performed at a
reference laboratory, needs to be used as the confirmatory test. Positive and negative controls
must be used with any testing and only test kits that are for medical diagnosis and treatment
must be used. Forensic testing is minimally regulated and will be labeled “not for medical
diagnosis and treatment” and, therefore, should not be used because it is not sensitive enough
for medical purposes.

Mental or Physical Disorders With Associated Harmful Behavior
Only mental or physical disorders during which the applicant engages in or has engaged in
harmful behavior that is associated with (due to) the mental or physical disorder will make an
applicant inadmissible. As previously stated, no diagnosis of a mental or physical disorder by
itself provides a basis for inadmissibility. There must also be a determination made regarding
current harmful behavior or a history of harmful behavior, associated with or caused by the
disorder, and the likelihood of associated harmful behavior to recur, in order to provide basis

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Thus, when evaluating an applicant for possible mental disorders, itna v to assess for the
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be helpful to first look for the harmful behavior when
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assessing an applicant for a possible
-7 disorder. (See
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for inadmissibility.

Mental disorders most frequently associated with harmful behavior include –
major depression,
bipolar disorder,
schizophrenia, and
mental retardation.

These disorders occur within broader categories of disorders that can be grouped as –
Mood disorders that include major depression and bipolar disorders and can be associated
with high rates of suicide and aggression.
Anxiety disorders that include post-traumatic stress disorder, panic disorders, phobias, and
anxiety disorders and can be associated with harmful behavior.
Personality disorders that include antisocial, paranoid, and borderline personality
disorders and can be associated with impulsive acts of violence.
Sexual disorders that include paraphilias.
Schizophrenia and other psychotic disorders that can be associated with delusions,
paranoia, suicide, and aggressive acts.

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Disorders usually first diagnosed in childhood that include mental retardation and conduct
disorder and are often associated with harmful behaviors. In addition, other cognitive
disorders, such as dementia, can be associated with harmful behaviors.
Substance-related disorders that include substance dependence or abuse. For specific
substances listed in Schedule I-V of Section 202 of the Controlled Substances Act (see
Appendix C), no associated harmful behavior is required for the applicant to have a
medically inadmissible condition based on substance abuse/dependence (please see above
for the determination of substance abuse/dependence). The civil surgeon is reminded that
for substances not listed in Schedule I-V (such as alcohol), that abuse or dependence is
evaluated as a mental disorder and determination of associated harmful behavior is

required for applicant to have a medically inadmissible condition. With alcohol dependence
or abuse there is often associated harmful behavior during periods of intoxication and
withdrawal.

Physical Disorder
Physical disorders are rarely associated with harmful behavior. It may happen in delirious or
confused states due to metabolic disturbances, hypoglycemia; and some psychomotor

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disorders. When evaluating an applicant for a physical disorder with associated
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epilepsies and in the aftermath of generalized seizure disorders and various forms of seizure

If the applicant is currently engaging in harmful behavior, that is, harmful behavior (see
definition above) that has continuously occurred and seems ongoing, the civil surgeon must
evaluate whether the actions may be indicative of a mental disorder.

Future Harmful Behavior
If the applicant presently is or in the past has engaged in harmful behavior associated with a
physical or mental disorder, the civil surgeon must evaluate whether the harmful behavior is
likely to recur. Many factors enter into this determination of classification, and the decision
requires clinical judgment. At a minimum, the underlying physical or mental disorder must be
either in remission or reliably controlled by medication or other effective treatment.
As a general guideline, when a mental or physical disorder has a favorable prognosis and is in
remission or under control but there was associated harmful behavior, if it has been 12 months
since the harmful behavior occurred, the harmful behavior is less likely to recur (see Table 3).

Remission

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The current version of the DSM defines sustained, full remission as a period of at least 12

months during which no substance use or mental disorder-associated behaviors have occurred.
These new technical instructions reflect the current medical knowledge and standards of the
DSM. The panel physician and his or her consultant must use their clinical judgment in
determining if 12 months is an acceptable period of time for the individual applicant to
demonstrate sustained, full remission. This time period must be based on the reliability of the
evidence provided, such as clinical reports of participation in a program, such as a drug
treatment program.
Remission must also be considered in two contexts: (1) general mental disorders and (2)
substance-related disorders.
For general mental disorders, the determination of remission must be made based on the
assessment of associated harmful behavior, either current or history of judged likely to recur
and DSM criteria. This includes substance-related disorders for those substances, including
alcohol, not listed in Schedules I through V of Section 202 of the Controlled Substances Act.
For substance-related disorders for those substances listed in Schedule I through V of Section
202 of the Controlled Substances Act, the determination of remission must be made based on

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The practical significance for diagnosis of remission is that applicantsa are or24, been
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determined to be Class A for abuse or addiction for z
those
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complete the time period for sustained, full remission before reapplying for admission.
12No.
applicant’s substance use and DSM criteria.

The civil surgeon must exercise judgment in reevaluating applicants with a previous Class A

determination who are reapplying for admission. If the disorder is in the past, the decision is
whether to classify the applicant as Class A or B. If the disorder is current, the decision becomes
whether the applicant is still Class A or is in a period of remission sufficient to lend confidence
that remission is sustained and full. In other words, if the applicant is currently in remission,
what is the likelihood that the remission will be sustained? (See Table 2)

Sexually Dangerous People
Not all sexually dangerous people have behaviors attributable to a psychiatric or general
medical disorder. For instance, rapist is not a psychiatric diagnosis. However, people diagnosed
with paraphilias might commit rape when their intense sexual fantasy, urge, or fetish is enacted
with a child or other non-consenting person. People who have harmful behaviors associated
with sexual acts, whether reported as a criminal act or psychiatric disorder, have been shown
not to benefit reliably from treatment programs. Documented or acknowledged episodes of
paraphilia might represent only a fraction of the sexually dangerous person’s history of related
harmful behaviors. Given the pattern of recurring harmful behaviors in paraphilia and the high

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relapse rate of sexual offenders, applicants with a history of harmful behavior associated with
sexual acts are almost always likely to have a recurrence of harmful behavior and therefore
remain medically classifiable as a Class A mental disorder with associated harmful behavior.

Referring the Applicant to a Specialist for Psychiatric Examination
After reviewing the applicant’s available records (such as medical, psychiatric, police, military,
school, and employment) and performing mental status and physical examinations (including an
Activities Assessment and Mental Status Assessment), the civil surgeon may feel that a more
specialized psychiatric examination is indicated. (See Table 4)
If an applicant has been referred to a specialist for psychiatric evaluation and the civil surgeon
still needs guidance and assistance in determining the diagnosis and classification of a Class A
or Class B or No Class A or Class B condition, DGMQ may be consulted to provide additional
assistance.
A copy of all the pertinent medical information may be faxed to 404-639-4441, sent via secure
files to [e-mail], or mailed to the following address:
Quality Assessment Program

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Centers for Disease Control and Prevention, Mailstop E-03
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1600 Clifton Road, Atlanta, Georgia 30333, USA
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Mental Health Screening Results
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o. 12
Nis complete when all required aspects of the medical
The mental health screening
Division of Global Migration and Quarantine

examination have been finalized, including if indicated, the report of the specialist and
laboratory test results. At this time, the civil surgeon should be able to assign to the
applicant a classification regarding a physical or mental disorder or substance-related
disorder.

For physical or mental disorders with associated harmful behavior (past and present), or
substance-related disorders, the civil surgeon should use the below outlined screening results
to classify applicants as Class A or Class B.
Pertinent information relating to physical or mental disorders, and substance related disorders
should be indicated on the I-693.

Screening Results
Applicants without findings suggestive of mental or physical disorders, or substance abuse
or addiction. (No Class A or B Physical or Mental Disorder, No Class A or B Drug
Abuse/Addiction).

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Applicants with physical and mental disorders that affect behavior but no associated

harmful behavior, and who do not have substance abuse or addiction. (No Class A or B
Physical or Mental Disorder, No Class A or B Drug Abuse/Addiction).
Applicants with “addiction” (dependence) or abuse of any of the substances listed in
Schedule I-V of Section 202 of the Controlled Substances Act (see Appendix C) with or
without associated harmful behavior. (Class A Substance (Drug) Use, Listed in Section 202
of the Controlled Substance Act.). Applicants may not apply for a waiver of eligibility.
Applicants with a diagnosis of a current physical or mental disorder (including other
substance-related disorders such as alcohol-related disorders) with associated harmful
behavior. (Class A, Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with a history of a physical or mental disorder (including other substancerelated disorders, such as alcohol-related disorders) with associated harmful behavior and
whose harmful behavior is likely to recur or lead to other harmful behavior. (Class A,
Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with a history of alcohol-related arrests or convictions (e.g., driving under the
influence [DUI]) who currently continues to drink alcohol and who meets DSM criteria for
alcohol abuse. (Class A, Physical/Mental Disorder with Associated Harmful Behavior).

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efor alcohol17
or more arrests or convictions within the last ten years should be evaluated
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Applicants who meet DSM criteria for mood disorders or schizophrenic disorders with
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2 or
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Physical/Mental Disorder with Associated
No.
Applicants with single alcohol related arrest or conviction within the last five years, or two

Applicants with sustained, full remission of “addiction” (dependence) or abuse of any of the
specific substances listed in Schedule I-V of Section 202 of the Controlled Substances Act
(see Appendix C) may be assigned a Class B, Prior Substance (Drug) Use in Remission.
Applicants with a history of a diagnosable physical or mental disorder (including other
substance-related disorders, such as alcohol-related disorders) with associated harmful
behavior when the harmful behavior is judged unlikely to recur or lead to other harmful
behavior may be assigned a Class B, Physical/Mental Disorder without Associated Harmful
Behavior.
Applicants who are diagnosed with a physical disorder that affects behavior or a mental
disorder (including substance-related disorders) that is significant enough to require
clinical attention but who have has had no associated harmful behavior (such as those with
seizure disorders, mental retardation, or schizophrenia without associated harmful
behavior) may be assigned a Class B, Physical/Mental Disorder without Associated Harmful
Behavior.
Applicants with history of alcohol related arrests or convictions that currently meets DSM
criteria for full, sustained remission, may be assigned a Class B Physical/Mental Disorder

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Without Associated Harmful Behavior.
Applicant with a current or past history of mood disorders or schizophrenic disorders
without associated harmful behavior may be assigned a Class B Physical/Mental Disorder
Without Associated Harmful Behavior.
Applicants with history of non-medical use of specific categories of substances that
currently meets DSM criteria for full, sustained remission may be assigned a Class B, Prior
Substance (Drug) Use in Remission.

Waivers
A provision allows applicants diagnosed with a mental or physical disorder with associated
harmful behavior to apply for a Class A waiver.

Most applicants diagnosed with substance abuse or addiction are not eligible to apply for a
Class A waiver.

Applicants diagnosed with substance abuse or addiction who are subsequently found to be
in remission and reclassified as Class B do not need to apply for a waiver.

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A provision allows applicants with a Class A physical disorder or s
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associated harmful behavior to petition for a Class A waiver. Form on or
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immigrants or refugees, respectively) must be completed. These
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Department of Homeland Security (DHS), U.S. Citizenship and Immigration Services (USCIS) on
12No.
an individual basis. DGMQ also reviews the waivers and supporting medical examination to

provide an opinion regarding the case to the requesting entity (DOS or DHS, USCIS). DGMQ’s
review of the waiver and supporting medical examination documentation is to ensure that the
applicant has been classified properly and that an appropriate U.S. health care provider is
identified for the applicant. DHS, USCIS has the final authority to adjudicate the waiver
request.
Most applicants diagnosed with substance abuse or addiction (dependence) for specific
substance categories based on current DSM criteria and classified as Class A are not eligible for
a waiver.
Applicants who were previously diagnosed as Class A for substance abuse or addiction and
subsequently found to be in remission and reclassified as Class B do not require a waiver.

Mental Health and Substance Abuse/Addiction
Applicants may be assigned one or more mental or physical disorders with associated

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harmful behavior and substance-related disorders classification on the I-693 Form.

The physical and mental disorders with associated harmful behaviors and substance related
disorders are listed below. Applicants may have more than one classification. However,
applicants cannot be classified as both Class A and Class B for the same physical or mental
disorder, or substance related disorder.

Applicants with no diagnosis of physical or mental disorder, or substance related disorder.
Applicants diagnosed with physical and mental disorders based on current DSM criteria
that affect behavior but do not meet criteria for Class A or Class B.

Class A Physical or Mental Disorder with Associated Harmful
Behavior
Applicants diagnosed with current physical or mental disorder based on current DSM
criteria with associated harmful behavior.
Applicants diagnosed with history of physical or mental disorder based on current DSM

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behaviors.
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Applicants with non medical substance use for non specific substance categories (including
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Controlled Substances Act)
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current DSM criteria with current associated harmful behavior or history of associated
criteria with associated harmful behavior judged likely to recur or lead to other harmful

harmful behavior judged likely to recur.

provided in Schedule I-V of Section 202 of the Controlled
Substances Act
Applicants with non medical substance use for specific substances provided in Schedule I-V of
Section 202 of the Controlled Substances Act (see Appendix C), and diagnosed with substance
abuse or dependence based on current DSM criteria with or without associated harmful
behavior.

Class B Current Physical or Mental Disorder with No Associated
Harmful Behavior
Applicants with current diagnosable physical or mental disorder (including alcohol related
and other non specific substance categories disorders) based on current DSM criteria with
no associated harmful behavior.

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Class B History of Physical or Mental Disorder with Associated
Harmful Behavior Unlikely to Recur
Applicants with history of diagnosable physical or mental disorder (including alcohol
related or other non specific substance categories) based on current DSM criteria with
associated harmful behavior when the harmful behavior is judged unlikely to recur or lead
to other harmful behavior.

Class B Substance Abuse or Dependence in Full Remission
Applicants diagnosed with full, sustained remission of substance abuse or dependence
based on current DSM criteria.

Documentation
The I-693 Medical Examination form must be completed in entirety including diagnosis
and classification of mental or physical disorders and substance related disorders.

The original I-693, Report of Medical Examination and Vaccination Record, must be completed

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Homeland Security (DHS), Citizenship and Immigration Servicessina
(CIS) office. This includes
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assigning a classification on the I-693 if an applicantz Class A Class for a
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mental disorder or substance related disorder.
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2For applicants who are referred o.a1
N to specialist for further evaluation, the civil surgeon is
in entirety, signed, and placed in a sealed envelope for submission to the Department of

required to retain a copy of the specialist’s report along with the I-693 form for their records.
For applicants who are referred for psychological or laboratory testing, the civil surgeon is

required to complete Part 3 of the I-693 form. The civil surgeon must also ensure that Part 4 is
completed and provides sufficient information to make a diagnosis and classification of a
physical or mental disorder, or substance related disorder. The civil surgeon should provide
pertinent information regarding referral in the appropriate remarks section in Part 2 or the I693 form.
A copy of any other documents provided for review regarding the diagnosis or classification of
a physical or mental disorder, or substance related disorder for an applicant should be retained
by the civil surgeon.

APPENDIX A: GLOSSARY OF ABBREVIATIONS
CDC – Centers for Disease Control and Prevention, United States
DGMQ – Division of Global Migration and Quarantine

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DHS – Department of Homeland Security
DOS – Department of State

DSM – Diagnostic and Statistical Manual of Mental Disorders
FDA – Food and Drug Administration
ICD – Manual of the International Classification of Diseases
WHO – World Health Organization

APPENDIX B: USEFUL RESOURCES
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition.
World Health Organization: Manual of the International Classification of Diseases.

APPENDIX C: CONTROLLED SUBSTANCES
Schedules I through V of Section 202 of the Controlled Substances Act are available at the
following location: http://www.gpo.gov/fdsys/pkg/CFR-2001-title21-vol9/pdf/CFR-2001-

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APPENDIX D: SUMMARY OF MENTALo on Ma
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EXAMINATION
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12Summary
No.
title21-vol9-part1308-subjectgroup-id175.pdf

[PDF – 4 pages]

.

The purpose of the examination is to identify health-related conditions that render an
applicant inadmissible and conditions that will need follow-up care.
Health-related conditions that render an applicant inadmissible are –
Dependence on (addiction) or abuse of a specific substance provided in Schedule I-V of
Section 202 of the Controlled Substances Act.
A physical or mental disorder (including alcohol-related disorders) that might cause or
has caused harmful behavior.
History of physical or mental disorder that has caused harmful behavior and is likely to
recur.
Mental disorders are characterized by alterations in thinking, mood, or behavior.
Substance dependence and abuse are determined by DSM criteria.
Indicated medical use of a substance is not substance abuse.
General mental disorders are determined by DSM criteria.
“V” coded conditions are not mental disorder diagnoses.
Harmful behavior is –

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Serious psychological or physical injury to others or to the applicant.
A serious threat to health or safety.
Major damage to property.

Harmful behavior alone (without mental or physical disorder) or a mental or physical
disorder alone is not a health-related condition that renders an applicant inadmissible.
Any antisocial act requires further investigation, but mental disorder diagnoses involve
patterns of behavior, not single events.
The classification (A or B) is used to determine admissibility and the need for follow-up
care.
Remission is determined by DSM criteria.
Sustained, full remission for substance-related disorders is at least 12 months.
Sustained, full remission is dependent on clinical judgment but requires reliable
evidence.
A statement signed by the applicant is helpful in documenting –
The applicant’s understanding of his or her condition, and
Requirements to demonstration remission, such clinical reports.
Harmful behavior unlikely to recur includes the following factors –

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External circumstances influencing that behavior have changed.v. S
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The eligibility to apply for a waiver is determined by law. DHS, USCIS has the final authority
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to adjudicate the waiver request.
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Figures
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Remission or control of the mental disorder for at least 12 months.

Figure 1. For Applicant With Medical History of a Physical or
Mental Disorder, Next Determine:

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Figure 2. Identifying and Classifying Applicantsna v. Possible
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Tables
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12Table 1. Indications for Laboratory Drug Screening
No.
Include (but are not limited to) –
History of any substance abuse or dependence with a specific substance listed in
Schedules I through V of Section 202 of the Controlled Substances Act. (See Appendix
C)
Applicant-provided information that appears to contradict information provided by
family members or from other records, such as police, military, school, and employment.
Unexplained gaps of time in the applicant's past schooling or employment.
Evidence of unreliable or false information given during the interview or examination.
Any demeanor, presentation, or findings that the examining physician associates with
substance abuse or dependence, such as motor ability and interpersonal skills;
deepened skin coloring, needle scarring, or skin ulcers along the veins in the arms or
legs; or a hard, bumpy, or shrunken liver.
Evidence or appearance of intoxication with any substance during the examination.
Disturbed behavior that might be associated with a substance-related disorder.

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Follow-up of an initial positive drug screen or a history of a positive drug-screening test.

Table 2. Sustained, Full Remission During the Most Recent 12 Months
Before Reexamination
Means that during that interval –
The civil surgeon has received reliable evidence of the applicant’s remission for that
time period.
The applicant did not meet DSM criteria (no behavior) for dependence or abuse.
The general mental disorder (non-substance related) is under control (by medication or
by the natural history of the disorder) and recurrence of specific life events or unusual
circumstances that precipitated an episode(s) of illness are judged unlikely to recur.
The applicant was not in a controlled environment where access to alcohol or drugs was
restricted, such as a treatment facility, jail, or halfway house.

Table 3. Factors Affecting the Applicant's Likelihood of Maintaining
Remission of a Mental Disorder or Having a Disorder Under Control
s

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The availability of effective treatments.
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treatment, and his or her insight into disorder. Herchi stating in writing a willingness
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to continue medication or other effective treatment to control the disorder can help
2-73
1
No.
demonstrate this.
The natural history of the disorder (for instance, bipolar mood disorders without
ongoing treatment are characterized by multiple episodes of illness and remission).
The number of and interval between previous episodes of illness (for instance, episodes
of schizophrenia with prominent psychotic symptoms were 3 years apart at the
beginning of the illness but are now happening every year).
Any trend towards increasing severity of episodes of illness or emergence of treatmentresistant symptoms.
The likelihood of recurrence of specific life events that precipitated previous episodes
of illness or likelihood of severe life stresses that might precipitate further episodes of
illness (for instance, postpartum depression in a young woman).
Unusual circumstances that precipitated a single episode of illness judged unlikely to
recur.

Table 4. Referring Applicant to a Specialist Consultant

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The Civil Surgeon may refer the applicant to a specialist consultant if after interview,
review of records, and examination, he or she is unable to –

Arrive at a probable psychiatric diagnosis for purposes of the determination of a mental
disorder with associated harmful behavior (past or present)
Arrive at a probable diagnosis of substance-related disorder according to DSM criteria.
Arrive at a probable diagnosis for past episodes of mental disorder according to current
DSM criteria, or determine that previous difficulties in functioning were the result of a
mental disorder.
Rule out the presence of a mental disorder.
Determine if harmful behavior has been associated with a physical or mental disorder.
Determine if any associated harmful behavior is likely to recur.
Determine if any diagnosed physical or mental disorders that affect behavior are in
remission or under control.
Determine the likelihood of maintaining remission or effective control of diagnosed
physical or mental disorders that affect behavior.

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Related Links
dez
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Immigrant and Refugee Health
12No.
Panel Physicians Portal

Travelers' Health

Animal Importation
Nonpharmaceutical Interventions (NPIs)
United States–Mexico Public Health
Quarantine
Division of Global Migration and Quarantine

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Page last reviewed: December 18, 2013
Page last updated: December 18, 2013
Content source: Content source: Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
Division of Global Migration and Quarantine (DGMQ)

ABOUT
About CDC

Jobs

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Policies

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FOIA

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1600 Clifton Road Atlanta, GA 30329-4027 USA

OIG

U.S. Department of Health & Human Services

800-CDC-INFO (800-232-4636), TTY: 888-232-6348
Email CDC-INFO

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12No.

HHS/Open
USA.gov

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CDC IMMIGRATION REQUIREMENTS:
TECHNICAL INSTRUCTIONS FOR PHYSICAL OR MENTAL
DISORDERS WITH ASSOCIATED HARMFUL BEHAVIORS AND
SUBSTANCE-RELATED DISORDERS
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious Diseases

Division of Global Migration and Quarantine
s

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18, 2013 y 24, 2
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12No.

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CDC IMMIGRATION REQUIREMENTS:
Technical Instructions for
Physical or Mental Disorders with Associated
Harmful Behaviors and
Substance-Related Disorders
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12No.

1

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Table of Contents
Preface ................................................................................................................................................................. 3
Role of the Civil Surgeon ................................................................................................................................. 4
Key Concepts ..................................................................................................................................................... 5
Mental Health Examination ............................................................................................................................. 9
Mental Health Screening Results ................................................................................................................... 19
Waivers .............................................................................................................................................................. 21
Mental Health and Substance Abuse/Addiction Classifications and Descriptions ............................... 22
Documentation ................................................................................................................................................ 24
APPENDIX A GLOSSARY OF ABBREVIATIONS ......................................................................................... 25
APPENDIX B USEFUL RESOURCES ............................................................................................................ 26
APPENDIX C CONTROLLED SUBSTANCES ............................................................................................... 27
APPENDIX D SUMMARY OF MENTAL HEALTH EXAMINATION............................................................ 35
Index .................................................................................................................................................................. 36

Figures
Figure 1. For Applicant With Medical History of a Physical or Mental Disorder,s
n Next Determine:
essio 17 or Abuse
Figure 2. Identifying and Classifying Applicants With Possible Substance Dependence
v. S

20
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osin May 24,
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in Le 9 arch
cited 7328
12Table 1. Indications for o.
N Laboratory Drug Screening

Table 2. Sustained, Full Remission During the Most Recent 12 Months Before Reexamination
Table 3. Factors Affecting the Applicant’s Likelihood of Maintaining Remission of a Mental
Disorder or Having a Disorder Under Control
Table 4. Referring Applicant to a Specialist Consultant

2

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Preface
Medical screening for physical and mental disorders with associated harmful behaviors and substancerelated disorders among persons applying for adjustment of status to permanent resident and other
persons required by law to have a medical examination, hereafter referred to as applicants, is an
essential component of the immigration-related medical evaluation. Because these conditions are
challenging to diagnose and treat, these technical instructions provide a method for recording findings
from the medical examination and additional guidance for the civil surgeon in classifying applicants.
The new technical instructions use uniform criteria and diagnosis consistent with current medical
knowledge and classification connected with legal definitions.
The required examination includes evaluation of physical and mental disorders with
associated harmful behaviors and substance-related disorders. Inadmissibility based on a
physical or mental disorder is limited to applicants with associated harmful behavior or
potentially harmful behavior.
The Immigration and Nationality Act (INA) provides three grounds of inadmissibility related to
substance addiction or abuse, or physical or mental disorders that affect behavior. They are Current physical or mental disorder with associated harmful behavior.
Past physical or mental disorder with associated harmful behavior if the harmful behavior is
likely to recur or to lead to other harmful behavior in the future. ons
si
Drug (substance) abuse or addiction (medically called dependence). Dependence on or abuse
. Ses , 2017
v
of any of the substances listed in Section 202 osina
of the Controlled 24
y Substances Act (Appendix C).
aC
(The term addiction corresponds with the-medical termMa
dependence).
m
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Lede r
n supersedeaallchive Technical Instructions, Updates to the
i
The instructions in this document
89 previous
cited 73and letters to civil surgeons relating to substance abuse or addiction
Technical Instructions, memoranda 2
12and mental or physical disorders with associated harmful behavior (whether past or present). These new
No.
instructions are to be followed when determining whether an applicant is afflicted with physical and
mental disorders with associated harmful behaviors and substance-related disorders among all
applicants.

For any questions about these Technical Instructions, please contact the Immigrant, Refugee, and
Migrant Health Branch of the Division of Global Migration and Quarantine (DGMQ), Centers for
Disease Control and Prevention (CDC), at [e-mail] or 404-498-1600. These Technical
Instructions and other information pertinent to them and the medical examination for applicants for
U.S. immigration can be found online at
http://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civilsurgeons.html.

3

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Role of the Civil Surgeon
The purpose of the immigration examination is to identify health-related conditions
that render an applicant inadmissible, and also to identify and inform the applicant of
conditions possibly needing follow-up care.

As part of the medical evaluation and physical examination of the applicant, the civil surgeon will carry
out or obtain a mental health evaluation To identify and diagnose any physical or mental disorder (including alcohol-related disorders).
To identify any harmful behavior associated with a disorder.
To identify the use of drugs, other than those required for medical reasons, and diagnose any
substance-related disorder.
To determine the remission status of any disorder previously diagnosed.
To determine the likelihood of recurrence of harmful behaviors associated with a physical or mental
disorder.
For most applicants, the civil surgeon’s examination will require only one appointment. However, for
ns
some applicants multiple appointments or specialist consultations may ssrequired 7 make an accurate
e be io 01 to
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diagnosis of whether the applicant is afflicted with a Classna v.
i A or ClassyB24, 2 as it relates to
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Key Concepts
A harmful behavior is defined as an action associated with a mental or physical
disorder that is or has caused Serious psychological or physical injury to the applicant or to others (e.g., a
suicide attempt or pedophilia)
A serious threat to health or safety (e.g., driving while intoxicated or verbally
threatening to kill someone)
Major property damage.

An applicant who has exhibited harmful behavior not associated with a specific mental
or physical disorder is not considered inadmissible under health-related grounds, but
may be inadmissible under criminal grounds as determined by DHS/USCIS.

The Diagnostic and Statistical Manual of Mental Disorders’ sions
s(DSM) diagnosis for
substance-related disorders is used in this examinationSe
. to determine1“drug abuse”
20 7
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and “drug addiction” which are listed as a medical ground of 4,
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Immigration andC
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1 Alcohol dependence 2 abuse alone is not considered a Class A condition. It is
No. asor other mental disorder, and requires associated harmful
considered the same
any
behavior to be classified as a medically inadmissible condition.

Physical Disorder
A physical disorder is a clinically diagnosed medical condition where the focus of attention is physical
manifestations. Only physical conditions that are included in the current version of the World Health
Organization’s Manual of the International Classification of Diseases (ICD) will be considered for the purpose
of this examination.
Mental Disorder
Mental disorders are health conditions that are characterized by alterations in thinking, mood, or
behavior (or some combination thereof). The current version of the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is an authoritative source on the
classification of mental disorders and should be considered for the purpose of this examination.
5

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“V” Coded Condition
“V” coded conditions listed in the DSM are not diagnoses, but are used in clinical practice settings
when the focus of clinical attention is on a behavior that is not due to a mental disorder. Because these
“V” conditions are not mental disorders, they cannot be used in determining if a person has an
inadmissible (Class A) health-related condition, regardless of whether there is an associated harmful
behavior. However, behaviors associated with “V” coded conditions might require treatment.
Harmful Behavior
The civil surgeon is to identify any harmful behavior that is associated with an applicant’s physical or
mental disorder.
Only harmful behavior that is associated with a physical or mental disorder is relevant for the
classification of U.S. medical eligibility; neither harmful behavior by itself nor the physical or mental
disorder by itself makes an applicant medically inadmissible. People can have multiple harmful
behaviors that are not associated with a physical or mental disorder. Repetitive antisocial activities and
harmful acts may warrant evaluation for personality disorders according to DSM criteria, and eventually
provide a basis for the conclusion of inadmissibility. Because of the complexity of this issue, the civil
surgeon might feel that a more specialized psychiatric examination is indicated. (Table 4)

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Substance-Related Disorders
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use of that substance. Diagnoses 732
are to
2- of substance-related disorders of the be made in accordance with
existing medical standards.as determined by the current edition
DSM. In the current DSM,
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substance-related disorders are divided into the following two groups:
1)
2)

Substance use disorders
Substance-induced disorders

For purposes of this evaluation, substances are divided into two groups, controlled substances and noncontrolled substances. Controlled substances are any substance listed in Schedules I through V of
Section 202 of the Controlled Substances Act. (See Appendix C.) Non-controlled substances include
alcohol and all other substances.
Substances used for clinical care in medical practice are not prohibited. Prescription drugs taken in
accordance with a prescription do not amount to a substance use disorder. However, abuse of
prescription drugs could be a substance-related disorder. This requires a full evaluation by the
examining physician to determine whether illicit drugs are being used, because use of illicit drugs is a
risk factor for the misuse of prescribed, controlled substances.
Substance Use Disorders

6

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The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological
symptoms indicating that the individual continues using the substance despite significant substancerelated problems.
The DSM criteria for substance use disorders fit within overall groupings of impaired control, social
impairment, risky use, and pharmacological criteria. Pharmacological criteria include tolerance and withdrawal.
Drug (substance) abuse or addiction (medically called dependence) is listed as a medical ground of
inadmissibility by the Immigration and Nationality Act (INA). An applicant will be barred from
admission if he or she
Uses a controlled substance
AND
Meets DSM criteria for a substance use disorder.
The DSM uses the following criteria to determine the severity of a substance use disorder:
The presence of 2-3 symptoms (this suggests a mild substance use disorder)
The presence of 4-5 symptoms (this suggests a moderate substance use disorder)
The presence of 6 or more symptoms (this suggests a severe substance use disorder)

ns
essio 01substance use
If an applicant’s substance use meets criteria for either a mild, moderate, or severe 7
.S
2
ina v y 2 Class
disorder, and involves a controlled substance, the applicant is considered 4, A for drug
-Cos n Ma
a
abuse/addiction.
dezm hived o
in Le criteria
c
If an applicant’s substanceed meets the 9 ar for either a mild, moderate, or severe substance use
use
cit
28
-73
disorder but involves a non-controlled substance, the civil surgeon should determine whether harmful
o. 12 a history of harmful behavior that is judged likely to recur. If harmful
behavior is present orN there is
if

behavior is present or is judged likely to recur, then the applicant is considered Class A for a physical or
mental disorder. If the applicant does not currently have harmful behavior or does not have a history of
harmful behavior judged likely to recur, the applicant is considered Class B for a physical or mental
disorder.
Substance-Induced Disorders
In addition to substance use disorders, the DSM has a separate category called substance-induced
disorders. The DSM list of substance-induced disorders includes but is not limited to intoxication,
withdrawal, and other substance/medication-induced mental disorders (psychotic disorders, bipolar and
related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders,
sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders/substance-induced
psychotic disorder, and substance-induced depressive disorder).
If an applicant’s substance use meets the DSM criteria for a substance-induced disorder, and involves
the use of a controlled substance, the applicant is considered Class A for drug abuse/addiction.
If an applicant’s substance use meets the criteria for a substance-induced disorder but involves a noncontrolled substance, the civil surgeon should determine whether harmful behavior is present or if there
is a history of harmful behavior that is judged likely to recur. If harmful behavior is present or is judged
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likely to recur, then the applicant is considered Class A for a physical or mental disorder. If the
applicant does not currently have harmful behavior or a history of harmful behavior judged likely to
recur, the applicant is considered Class B for a physical or mental disorder.
Summary of Substance Use Disorders and Substance-Induced Disorders
DSM Diagnosis

Involving Controlled
Substance?

Harmful Behavior
Associated with Disorder
(Current, or History
Likely to Recur)?

Classification for
Immigration Purposes

Substance use disorder
(mild, moderate, or
severe)
Substance use disorder
(mild, moderate, or
severe)
Substance use disorder
(mild, moderate, or
severe)

Yes

N/A- Does not apply

Class A, Drug
Abuse/Addiction

No

Yes

No

No

Substance-induced
disorder
Substance-induced
disorder

Yes

N/A-Does not apply

No

Yes

Class A, Physical/Mental
Disorder with Associated
Harmful Behavior
Class B, Physical/Mental
Disorder without
Associated Harmful
Behavior
Class A, Drug
Abuse/Addiction
Class A, Physical/Mental
Disorder with Associated
Harmful Behavior
Class B, Physical/Mental
Disorder without
Associated Harmful
Behavior

Substance-induced
disorder

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essio 017
.S
No
No ina v
4, 2
-Cos n May 2
a
dezm hived o
Le
ed in 289 arc
cit
-73
o. 12
N

Class A and Class B Medical Conditions
Class A medical conditions are inadmissible conditions and include an applicant who is determined to
have A current physical or mental disorder with associated harmful behavior
A past physical or mental disorder with associated harmful behavior if the harmful behavior
is likely to recur or to lead to other harmful behavior in the future
Drug (substance) abuse or addiction (dependence)
Class B medical conditions are not inadmissible medical conditions and include any applicant who is
determined to have a physical or mental abnormality, disease, or disability serious in degree or nature
amounting to a substantial departure from well-being.

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Mental Health Examination
Observation alone is not sufficient to assess an applicant.

Random screening for drugs is not part of the routine medical evaluation of applicants
for U. S. admission.

If the civil surgeon is unable to determine whether an applicant has a diagnosis of a
physical or mental disorder, or substance abuse or dependence for a substance listed
in Section 202 of the Controlled Substances Act, diagnosis and classification may be
deferred in order to obtain additional medical evidence.

Record DSM diagnoses for mental disorders and substance-related s
disorders on the
I-693 Form under Part 2, in the Remarks for Number 3 and Number 4.
ssion
e

17
.S
ina v y 24, 20
os
ma-C d on Ma
z with
The civil surgeon can recognize that ande
hi
n Le applicantthevea physical or mental disorder might have an
associated harmful behaviord i
point of
e during any89 arc examination.
cit
32
While taking the medical history of a mental disorder,
12-7
.
N of
While taking historyo harmful behavior, or
While observing for current abnormal behavior during the physical examination.

Medical History
The civil surgeon should begin by asking questions about the past medical history of the applicant. To
fully investigate the applicant’s past medical history, the civil surgeon, when possible, should Obtain other relevant records, such as police, military, school, and employment, that might provide
a history of harmful behavior associated with physical or mental disorders.
Ask about mental disorders in the family and, when appropriate, about signs of mental problems or
odd behaviors.
Ask about any use of drugs and medicines.
Ask about harmful behaviors.

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When a civil surgeon defers diagnosis and classification, the civil surgeon should explain to the
applicant what the civil surgeon would like to see during the next 3-6 months (in order to classify the
applicant) to show abstinence (see Figure 2). This may include but is not limited to requiring clinical
reports from health care professionals for applicants with possible substance-related disorders to
demonstrate participation in a drug treatment program. For applicants with deferred diagnosis and
classification, the civil surgeon should consider documenting in a statement signed by the applicant the
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information he or she is providing to the applicant; the statement should specify what is required
during the next 3 to 6 months (see Figure 2) to show abstinence.
Psychiatric Evaluation
The civil surgeon should conduct an activities assessment and mental status examination that assesses,
at a minimum orientation,
mood and affect,
speech and language,
anxiety,
thought processes and content, and
behavior.
The civil surgeon may estimate the degree of cognitive impairment in dementia or mental retardation by
assessing the applicant's (1) level of knowledge, and (2) ability to carry out functions of daily living (e.g.,
learning, communication, and routine activities).
Any available reports of cognitive, development, or intelligence testing, or neuropsychological testing in
ions
the medical record are welcome and may be included with the civilSess report. However, the civil
surgeon’s
17
.
surgeon is not asked to routinely send applicants for additionalv
ina psychological20
4, tests.
s

2
o
M y
ma-C d on nota to provide additional
Under most circumstances, the civil surgeon or consultant will
need
edez c e
n Ltesting.aUsehivprojective instruments, such as Rorschach test,
i
r of
psychological or neuropsychological
9
cited 7administrative burden involved. No psychological or
may not be useful given the added 328
2substitute for the civil surgeon’s or consultant’s history and examination
1
neuropsychological testing is a
No.
of the applicant. However, for certain cases, these tests may aid in making a diagnosis.
Laboratory Testing
Random screening for drugs is not part of the routine medical examination for applicants for U.S.
admission. The civil surgeon needs to evaluate the applicant’s history, behavior and physical
appearance when determining if drug screening should be performed.
Whole populations of applicants should not routinely be subject to random laboratory screening. The
civil surgeon should make an individual decision based on the indications for drug screening (see Table
1).
Laboratory testing to identify underlining medical conditions that might be causing psychiatric
manifestations may be necessary before making any mental disorder diagnoses. However, specialized
laboratory testing, such as dexamethasone suppression tests or challenge administration of various
pharmaceuticals, is usually not indicated in the diagnosis of applicants.

Other possible uses of laboratory support depend on the availability of such laboratory services and the
clinical judgment of the civil surgeon as to their usefulness in classification of the individual applicant.
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For example, therapeutic levels of prescribed anticonvulsant medications, antipsychotic medications, or
other medicines used in psychiatry (such as lithium levels) might be of value to the civil surgeon in Determining the applicant’s adherence to a prescribed course of treatment.
Possibly changing or adjusting the applicant’s medications, and therefore contributing to remission
of illness and reduction of associated harmful behavior.
Random screening for drugs on short notice to the applicant can provide additional evidence to aid in
diagnosis and classification. For example, the civil surgeon might request that three random screenings
for drugs within a 3- to 6-month period be done with only 24- to 48-hour notification to the applicant.
The period of advance notification should be the minimum practical time for the applicant to arrive at
the screening facility, preferably 24 or 48 hours after notification.

Table 1. Indications for Laboratory Drug Screening
Include (but are not limited to) History of any substance abuse or dependence with a specific substance listed in Schedules I
through V of Section 202 of the Controlled Substances Act. (See Appendix C)
Applicant-provided information that appears to contradict information provided by family
members or from other records, such as police, military, school, and employment.
Unexplained gaps of time in the applicant’s past schooling or employment.
Evidence of unreliable or false information given during the interview ns
or examination.
ssioassociates with
Any demeanor, presentation, or findings that the examining Se
. physician 2017
a vinterpersonal skills; deepened skin
substance abuse or dependence, such as motor ability and
in
4,
a arms
-Cos nin the y 2 or legs; or a hard, bumpy,
coloring, needle scarring, or skin ulcers along the veins M
a
dezm hived o
or shrunken liver.
Le
Evidence or appearance of intoxication with any substance during the examination.
ed in 289 arc
cit
-7 be
Disturbed behavior that might3 associated with a substance-related disorder.
o. 12 drug screen or a history of a positive drug-screening test.
Follow-up of an N
initial positive

It is the civil surgeon’s responsibility to know the reliability and validity of the laboratory tests and
laboratory methods used during the medical evaluation. All drug testing is to be done by using
materials licensed by the U.S. Food and Drug Administration or by the equivalent licensing office in
other countries. Rapid testing or semi-quantitative testing may be used for the screening test; however,
gas chromatography/mass spectrometry (GC/MS), performed at a reference laboratory, needs to be
used as the confirmatory test. Positive and negative controls must be used with any testing and only
test kits that are for medical diagnosis and treatment must be used. Forensic testing is minimally
regulated and will be labeled “not for medical diagnosis and treatment” and, therefore, should not be
used because it is not sensitive enough for medical purposes.

Mental or Physical Disorders With Associated Harmful Behavior
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Only mental or physical disorders during which the applicant engages in or has engaged in harmful
behavior that is associated with (due to) the mental or physical disorder will make an applicant
inadmissible. As previously stated, no diagnosis of a mental or physical disorder by itself provides a
basis for inadmissibility. There must also be a determination made regarding current harmful behavior
or a history of harmful behavior, associated with or caused by the disorder, and the likelihood of
associated harmful behavior to recur, in order to provide basis for inadmissibility.
Thus, when evaluating an applicant for possible mental disorders, it is vital to assess for the likelihood
of harmful behavior. Because there are mental disorders that are commonly associated with harmful
behavior, it may be helpful to first look for the harmful behavior when assessing an applicant for a
possible mental disorder. (See Figure 1)
Mental disorders most frequently associated with harmful behavior include major depression,
bipolar disorder,
schizophrenia, and
mental retardation.
These disorders occur within broader categories of disorders that can be grouped as Mood disorders that include major depression and bipolar disorders and can be associated with
ns
high rates of suicide and aggression.
essio 017
.S
2
Anxiety disorders that include post-traumatic stress a v
indisorder,ypanic ,disorders, phobias, and
os behavior. 4
-Charmfuln Ma 2
anxiety disorders and can be associated with
zma paranoid,
d antisocial,ved o and borderline personality disorders and
Personality disorders that includee
Le
hi
can be associated ted impulsive 9 aof violence.
with in
acts rc
8
ci
Sexual disorders that include 2
2-73 paraphilias.
1
No.
Schizophrenia and other psychotic disorders that can be associated with delusions, paranoia,
suicide, and aggressive acts.
Disorders usually first diagnosed in childhood that include mental retardation and conduct
disorder and are often associated with harmful behaviors. In addition, other cognitive
disorders, such as dementia, can be associated with harmful behaviors.
Substance-related disorders that include substance dependence or abuse. For specific
substances listed in Schedule I-V of Section 202 of the Controlled Substances Act (see
Appendix C), no associated harmful behavior is required for the applicant to have a medically
inadmissible condition based on substance abuse/dependence (please see above for the
determination of substance abuse/dependence). The civil surgeon is reminded that for
substances not listed in Schedule I-V (such as alcohol), that abuse or dependence is evaluated as
a mental disorder and determination of associated harmful behavior is required for applicant to
have a medically inadmissible condition. With alcohol dependence or abuse there is often
associated harmful behavior during periods of intoxication and withdrawal.
Physical Disorder
Physical disorders are rarely associated with harmful behavior. It may happen in delirious or confused
states due to metabolic disturbances, hypoglycemia; and some psychomotor epilepsies and in the
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aftermath of generalized seizure disorders and various forms of seizure disorders. When evaluating an
applicant for a physical disorder with associated harmful behavior, the civil surgeon should diagnosis
physical disorders according to the conventions used in the current edition of the ICD published by the
World Health Organization.
Current Harmful Behavior
If the applicant is currently engaging in harmful behavior, that is, harmful behavior (see definition
above) that has continuously occurred and seems ongoing, the civil surgeon must evaluate whether the
actions may be indicative of a mental disorder.
Future Harmful Behavior
If the applicant presently is or in the past has engaged in harmful behavior associated with a physical or
mental disorder, the civil surgeon must evaluate whether the harmful behavior is likely to recur. Many
factors enter into this determination of classification, and the decision requires clinical judgment. At a
minimum, the underlying physical or mental disorder must be either in remission or reliably controlled
by medication or other effective treatment.
As a general guideline, when a mental or physical disorder has a favorable prognosis and is in remission
ions
ess12 months since the harmful
or under control but there was associated harmful behavior, if it . Sbeen
vhas 4 017
behavior occurred, the harmful behavior is less likely osina (see Table 3)., 2
to recur
2

ay
a-C
ezm ived on M
d
in Le 9 arch
Remission
cited 7328
12The current version of the DSM defines sustained, full remission as a period of at least 12 months
No.

during which no substance use or mental disorder-associated behaviors have occurred. These new
technical instructions reflect the current medical knowledge and standards of the DSM. The panel
physician and his or her consultant must use their clinical judgment in determining if 12 months is an
acceptable period of time for the individual applicant to demonstrate sustained, full remission. This
time period must be based on the reliability of the evidence provided, such as clinical reports of
participation in a program, such as a drug treatment program.
Remission must also be considered in two contexts: (1) general mental disorders and (2) substancerelated disorders.
For general mental disorders, the determination of remission must be made based on the assessment of
associated harmful behavior, either current or history of judged likely to recur and DSM criteria. This
includes substance-related disorders for those substances, including alcohol, not listed in Schedules I
through V of Section 202 of the Controlled Substances Act.
For substance-related disorders for those substances listed in Schedule I through V of Section 202 of
the Controlled Substances Act, the determination of remission must be made based on applicant’s
substance use and DSM criteria.
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The practical significance for diagnosis of remission is that applicants who are or have been determined
to be Class A for abuse or addiction for those substances listed in Schedule I through V of Section 202
of the Controlled Substance Act are not eligible for a waiver and must complete the time period for
sustained, full remission before reapplying for admission.
The civil surgeon must exercise judgment in reevaluating applicants with a previous Class A
determination who are reapplying for admission. If the disorder is in the past, the decision is whether
to classify the applicant as Class A or B. If the disorder is current, the decision becomes whether the
applicant is still Class A or is in a period of remission sufficient to lend confidence that remission is
sustained and full. In other words, if the applicant is currently in remission, what is the likelihood that
the remission will be sustained? (See Table 2)

Table 2. Sustained, Full Remission During the Most Recent 12 Months Before
Reexamination
Means that during that interval The civil surgeon has received reliable evidence of the applicant’ssions for that time
remission
. Ses , 2017
period.
av
24
The applicant did not meet DSM criteria (noCosin for dependence or abuse.
behavior)
a-related)onunder y
Macontrol (by medication or by
The general mental disorder (non-substance
ezm ived is
Ledand recurrence of specific life events or unusual
the natural history of the disorder) arch
n
ted i 3 an 9
ciprecipitated 28episode(s) of illness are judged unlikely to recur.
circumstances that
-7
The applicant was o. 12 controlled environment where access to alcohol or drugs was
not in a
N
restricted, such as a treatment facility, jail, or halfway house.
No use other than indicated medical treatment of any of the substances listed in Schedules IV of Section 202 of the Controlled Substances Act.
Sexually Dangerous People
Not all sexually dangerous people have behaviors attributable to a psychiatric or general medical
disorder. For instance, rapist is not a psychiatric diagnosis. However, people diagnosed with
paraphilias might commit rape when their intense sexual fantasy, urge, or fetish is enacted with a child
or other non-consenting person. People who have harmful behaviors associated with sexual acts,
whether reported as a criminal act or psychiatric disorder, have been shown not to benefit reliably from
treatment programs. Documented or acknowledged episodes of paraphilia might represent only a
fraction of the sexually dangerous person’s history of related harmful behaviors. Given the pattern of
recurring harmful behaviors in paraphilia and the high relapse rate of sexual offenders, applicants with a
history of harmful behavior associated with sexual acts are almost always likely to have a recurrence of
harmful behavior and therefore remain medically classifiable as a Class A mental disorder with
associated harmful behavior.

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Table 3. Factors Affecting the Applicant's Likelihood of Maintaining Remission of a
Mental Disorder or Having a Disorder Under Control The availability of effective treatments.
The applicant's faithfulness with previous treatment, willingness to remain on treatment,
and his or her insight into disorder. He or she stating in writing a willingness to continue
medication or other effective treatment to control the disorder can help demonstrate this.
The natural history of the disorder (for instance, bipolar mood disorders without ongoing
treatment are characterized by multiple episodes of illness and remission).
The number of and interval between previous episodes of illness (for instance, episodes of
schizophrenia with prominent psychotic symptoms were 3 years apart at the beginning of
the illness but are now happening every year).
Any trend towards increasing severity of episodes of illness or emergence of treatmentresistant symptoms.
The likelihood of recurrence of specific life events that precipitated previous episodes of
illness or likelihood of severe life stresses that might precipitate further episodes of illness
(for instance, postpartum depression in a young woman).
Unusual circumstances that precipitated a single episode of illness judged unlikely to recur.

Referring the Applicant to a Specialist for Psychiatric Examination

ns
essio police, military, school,
After reviewing the applicant's available records (such as medical, psychiatric, 17
.S
0
ina v y 24 (including an Activities
and employment) and performing mental status and physical examinations , 2
os may a that a more specialized
Assessment and Mental Status Assessment), ma-Csurgeon M feel
z the civil
deTable 4) ived on
psychiatric examination is indicated. e
L (See
h
ed in 289 arc
t
cireferred 73 specialist for psychiatric evaluation and the civil surgeon still
If an applicant has been
- to a
o. 12 determining the diagnosis and classification of a Class A or Class B or
needs guidance and assistance in
N
No Class A or Class B condition, DGMQ may be consulted to provide additional assistance.

A copy of all the pertinent medical information may be faxed to 404-639-4441, sent via secure files to
[e-mail], or mailed to the following address:
Quality Assessment Program
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention, Mailstop E-03
1600 Clifton Road, Atlanta, Georgia 30333, USA

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Table 4. Referring Applicant to a Specialist Consultant
The Civil Surgeon may refer the applicant to a specialist consultant if after interview, review of
records, and examination, he or she is unable to Arrive at a probable psychiatric diagnosis for purposes of the determination of a mental
disorder with associated harmful behavior (past or present)
Arrive at a probable diagnosis of substance-related disorder according to DSM criteria.
Arrive at a probable diagnosis for past episodes of mental disorder according to current
DSM criteria, or determine that previous difficulties in functioning were the result of a
mental disorder.
Rule out the presence of a mental disorder.
Determine if harmful behavior has been associated with a physical or mental disorder.
Determine if any associated harmful behavior is likely to recur.
Determine if any diagnosed physical or mental disorders that affect behavior are in
remission or under control.
Determine the likelihood of maintaining remission or effective control of diagnosed
physical or mental disorders that affect behavior.

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Mental Health Screening Results
The mental health screening is complete when all required aspects of the medical
examination have been finalized, including if indicated, the report of the specialist and
laboratory test results. At this time, the civil surgeon should be able to assign to the
applicant a classification regarding a physical or mental disorder or substance-related
disorder.

For physical or mental disorders with associated harmful behavior (past and present), or substancerelated disorders, the civil surgeon should use the below outlined screening results to classify applicants
as Class A or Class B.
Pertinent information relating to physical or mental disorders, and substance related disorders should
be indicated on the I-693.
Screening Results
Applicants without findings suggestive of mental or physical disorders, or substance abuse or
addiction. (No Class A or B Physical or Mental Disorder, No Class A ions
s or B Drug
Abuse/Addiction).
. Ses , 2017
av
Applicants with physical and mental disorders that affect behavior but no associated harmful
osin May 24
a-C
behavior, and who do not have substance abuse or addiction. (No Class A or B Physical or Mental
ezm ived on
d
Disorder, No Class A or B in Le
Drug Abuse/Addiction).
rch
Applicants with “addiction” (dependence) or abuse of any of the substances listed in Schedule I-V
cited 73289 a
of Section 202 of the Controlled Substances Act (see Appendix C) with or without associated
12No. A Substance (Drug) Use, Listed in Section 202 of the Controlled
harmful behavior. (Class
Substance Act.). Applicants may not apply for a waiver of eligibility.
Applicants with a diagnosis of a current physical or mental disorder (including other substancerelated disorders such as alcohol-related disorders) with associated harmful behavior. (Class A,
Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with a history of a physical or mental disorder (including other substance-related
disorders, such as alcohol-related disorders) with associated harmful behavior and whose harmful
behavior is likely to recur or lead to other harmful behavior. (Class A, Physical/Mental Disorder
with Associated Harmful Behavior).
Applicants with a history of alcohol-related arrests or convictions (e.g., driving under the influence
[DUI]) who currently continues to drink alcohol and who meets DSM criteria for alcohol abuse.
(Class A, Physical/Mental Disorder with Associated Harmful Behavior).
Applicants with single alcohol related arrest or conviction within the last five years, or two or more
arrests or convictions within the last ten years should be evaluated for alcohol abuse (mental health
classification pending).
Applicants who meet DSM criteria for mood disorders or schizophrenic disorders with associated
harmful behavior, either current or judged likely to recur. (Class A, Physical/Mental Disorder with
Associated Harmful Behavior).
Applicants with sustained, full remission of “addiction” (dependence) or abuse of any of the
specific substances listed in Schedule I-V of Section 202 of the Controlled Substances Act (see
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Appendix C) may be assigned a Class B, Prior Substance (Drug) Use in Remission.
Applicants with a history of a diagnosable physical or mental disorder (including other substancerelated disorders, such as alcohol-related disorders) with associated harmful behavior when the
harmful behavior is judged unlikely to recur or lead to other harmful behavior may be assigned a
Class B, Physical/Mental Disorder without Associated Harmful Behavior.
Applicants who are diagnosed with a physical disorder that affects behavior or a mental disorder
(including substance-related disorders) that is significant enough to require clinical attention but
who have has had no associated harmful behavior (such as those with seizure disorders, mental
retardation, or schizophrenia without associated harmful behavior) may be assigned a Class B,
Physical/Mental Disorder without Associated Harmful Behavior.
Applicants with history of alcohol related arrests or convictions that currently meets DSM criteria
for full, sustained remission, may be assigned a Class B Physical/Mental Disorder Without
Associated Harmful Behavior.
Applicant with a current or past history of mood disorders or schizophrenic disorders without
associated harmful behavior may be assigned a Class B Physical/Mental Disorder
Without Associated Harmful Behavior.
Applicants with history of non-medical use of specific categories of substances that currently meets
DSM criteria for full, sustained remission may be assigned a Class B, Prior Substance (Drug) Use in
Remission.

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Waivers
A provision allows applicants diagnosed with a mental or physical disorder with
associated harmful behavior to apply for a Class A waiver.

Most applicants diagnosed with substance abuse or addiction are not eligible to apply
for a Class A waiver.

Applicants diagnosed with substance abuse or addiction who are subsequently found
to be in remission and reclassified as Class B do not need to apply for a waiver.

A provision allows applicants with a Class A physical disorder or mental disorder with associated
harmful behavior to petition for a Class A waiver. Form I-601 or I-602 (for immigrants or refugees,
respectively) must be completed. These waivers are submitted to the Department of Homeland
ons
essiindividual basis. DGMQ
Security (DHS), U.S. Citizenship and Immigration Services (USCIS) on an
17
.S
ina v y 24 20
also reviews the waivers and supporting medical examination to provide an,opinion regarding the case
os
to the requesting entity (DOS or DHS, USCIS).aDGMQ’s review a the waiver and supporting medical
m -C d on M of
dez
examination documentation is to ensure that the hive has been classified properly and that an
n Le identifiedapplicant
i
rc
appropriate U.S. health care d
is
cite provider289 a for the applicant. DHS, USCIS has the final
authority to adjudicate the waiver73
12- request.

o.

N
Most applicants diagnosed with substance abuse or addiction (dependence) for specific substance
categories based on current DSM criteria and classified as Class A are not eligible for a waiver.
Applicants who were previously diagnosed as Class A for substance abuse or addiction and
subsequently found to be in remission and reclassified as Class B do not require a waiver.

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Mental Health and Substance
Abuse/Addiction Classifications and
Descriptions
Applicants may be assigned one or more mental or physical disorders with
associated harmful behavior and substance-related disorders classification
on the I-693 Form.

The physical and mental disorders with associated harmful behaviors and substance related disorders
are listed below. Applicants may have more than one classification. However, applicants cannot be
classified as both Class A and Class B for the same physical or mental disorder, or substance related
disorder.
No Class A or Class B Classification

ns
essio related disorder.
Applicants with no diagnosis of physical or mental disorder, . S
or substance 17
ina v y 24, 20
-Cos baseda
Applicants diagnosed with physical andzma disordersn M on current DSM criteria that affect
mental
do
de
behavior but do not meet criteriae Class chive B.
n L for ar A or Class
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Class A Physical or Mental 21Disorder with Associated Harmful Behavior
No.
Applicants diagnosed with current physical or mental disorder based on current DSM criteria with
associated harmful behavior.
Applicants diagnosed with history of physical or mental disorder based on current DSM criteria
with associated harmful behavior judged likely to recur or lead to other harmful behaviors.
Applicants with non medical substance use for non specific substance categories (including alcohol
and other substances NOT provided in Schedule I-V of Section 202 of the Controlled Substances
Act) and diagnosed with substance abuse or dependence based on current DSM criteria with
current associated harmful behavior or history of associated harmful behavior judged likely to recur.

Class A Substance Abuse or Dependence for Specific Substances provided in Schedule I-V of
Section 202 of the Controlled Substances Act
Applicants with non medical substance use for specific substances provided in Schedule I-V of Section
202 of the Controlled Substances Act (see Appendix C), and diagnosed with substance abuse or
dependence based on current DSM criteria with or without associated harmful behavior.
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Class B Current Physical or Mental Disorder with No Associated Harmful Behavior
Applicants with current diagnosable physical or mental disorder (including alcohol related and other
non specific substance categories disorders) based on current DSM criteria with no associated
harmful behavior.
Class B History of Physical or Mental Disorder with Associated Harmful Behavior Unlikely to
Recur
Applicants with history of diagnosable physical or mental disorder (including alcohol related or
other non specific substance categories) based on current DSM criteria with associated harmful
behavior when the harmful behavior is judged unlikely to recur or lead to other harmful behavior.
Class B Substance Abuse or Dependence in Full Remission
Applicants diagnosed with full, sustained remission of substance abuse or dependence based on
current DSM criteria.

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Documentation
The I-693 Medical Examination form must be completed in entirety including diagnosis
and classification of mental or physical disorders and substance related disorders.

The original I-693, Report of Medical Examination and Vaccination Record, must be completed in
entirety, signed, and placed in a sealed envelope for submission to the Department of Homeland
Security (DHS), Citizenship and Immigration Services (CIS) office. This includes assigning a
classification on the I-693 if an applicant is Class A or Class B for a physical or mental disorder or
substance related disorder.
For applicants who are referred to a specialist for further evaluation, the civil surgeon is required to
retain a copy of the specialist’s report along with the I-693 form for their records.
For applicants who are referred for psychological or laboratory testing, the civil surgeon is required to
complete Part 3 of the I-693 form. The civil surgeon must also ensure thatons4 is completed and
Part
si
sa physical 7 mental disorder,
provides sufficient information to make a diagnosis and classificatione
. S of , 201or
or substance related disorder. The civil surgeon shouldsina vpertinent information regarding referral
provide
24
in the appropriate remarks section in Part 2 or the Co form. May
a-I-693

zm
on
Lede rchived
in
cited provided9 areview regarding the diagnosis or classification of a
A copy of any other documents-7328 for
physical or mental disorder, 12
No. or substance related disorder for an applicant should be retained by the
civil surgeon.

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APPENDIX A: GLOSSARY OF ABBREVIATIONS
CDC
DGMQ
DHS
DOS
DSM
FDA
ICD
WHO

Centers for Disease Control and Prevention, United States
Division of Global Migration and Quarantine
Department of Homeland Security
Department of State
Diagnostic and Statistical Manual of Mental Disorders
Food and Drug Administration
Manual of the International Classification of Diseases
World Health Organization

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APPENDIX B: USEFUL RESOURCES
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
World Health Organization: Manual of the International Classification of Diseases.

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APPENDIX C: CONTROLLED SUBSTANCES
Schedules I through V of Section 202 of the Controlled Substances Act are provided below and also
available at the following location: http://www.gpo.gov/fdsys/pkg/CFR-2001-title21-vol9/pdf/CFR2001-title21-vol9-part1308-subjectgroup-id175.pdf

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APPENDIX D: SUMMARY OF MENTAL HEALTH EXAMINATION
Summary
The purpose of the examination is to identify health-related conditions that render an
applicant inadmissible and conditions that will need follow-up care.
Health-related conditions that render an applicant inadmissible are $ Dependence on (addiction) or abuse of a specific substance provided in Schedule I-V
of Section 202 of the Controlled Substances Act.
$ A physical or mental disorder (including alcohol-related disorders) that might cause
or has caused harmful behavior.
$ History of physical or mental disorder that has caused harmful behavior and is likely
to recur.
Mental disorders are characterized by alterations in thinking, mood, or behavior.
$ Substance dependence and abuse are determined by DSM criteria.
Indicated medical use of a substance is not substance abuse.
$ General mental disorders are determined by DSM criteria.
“V” coded conditions are not mental disorder diagnoses.
Harmful behavior is $ Serious psychological or physical injury to others or to the applicant.
ns
$ A serious threat to health or safety.
essio 017
v. S
$ Major damage to property.
,2
ina disorder)24a mental or physical
Harmful behavior alone (without mental -Cos
or physical May or
a
disorder alone is not a health-related conditiond on
dezm hive that renders an applicant inadmissible.
e
$ Any antisocial in Lrequires rfurther investigation, but mental disorder diagnoses
ed actbehavior, not single events.
t
9ac
involveci
patterns-7328
of
12
The classification .(A or B) is used to determine admissibility and the need for follow-up
No
care.
Remission is determined by DSM criteria.
$ Sustained, full remission for substance-related disorders is at least 12 months.
$ Sustained, full remission is dependent on clinical judgment but requires reliable
evidence.
$ A statement signed by the applicant is helpful in documenting The applicant’s understanding of his or her condition, and
Requirements to demonstration remission, such clinical reports.
Harmful behavior unlikely to recur includes the following factors $ Remission or control of the mental disorder for at least 12 months.
$ External circumstances influencing that behavior have changed.
The eligibility to apply for a waiver is determined by law. DHS, USCIS has the final
authority to adjudicate the waiver request.

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Index
Diagnostic and Statistical Manual of Mental Disorders (DSM)
Division of Global Migration and Quarantine
Documentation

p. 5-6, 8, 10, 14-15, 17-22, 24-25, 34

p. 3, 16, 20, 24

p. 20, 23

Harmful Behavior p. 3-10, 12-15, 17-22, 34
Current p. 3, 7, 9, 13-14, 21
Future p. 3, 7, 14
Immigration and Nationality Act (INA)

p. 3

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Substance-Related Disorders p. 3, 6, 8, 11, ma-C
13-15, 18-19, 21, 34 a
dez hived on
Le
ed in 289 arc
cit
Manuel of the International Classification of Diseases (ICD) p. 5, 14, 24
-73
o. 12
N
Laboratory Testing

p. 11-12, 23

Medical History

p. 2, 8-10

Mental Disorder

p. 2-9, 12-25, 34

Mental Health and Substance Abuse/Addiction Classifications

p. 21

Physical Disorder p. 3, 5, 13-14, 18-21, 23, 34
Psychiatric Evaluation
Referral to specialist
Remission

p. 11, 16
p. 2, 4, 16-18, 23

p. 2, 4, 12, 14-20, 22, 34
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Screening Results

p. 18

Section 202 of the Controlled Substance Act
Sexually Dangerous People
“V” Coded Conditions
Waivers

p. 3, 6, 8, 10, 12-13, 15, 18, 21, 26, 34

p. 15

p. 6, 34

p. 20

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