Medical Certification For Disability Exceptions {N-648}

OMB No. 1615-0060; Expires 03/31/2019 Department of Homeland Security U.S. Citizenship and Immigration Services Form N-648, Medical Certification for Disability Exceptions ALL parts of this form, except the "APPLICANT ATTESTATION" and "INTERPRETER'S CERTIFICATION" must be certified by a licensed medical professional as provided in the instructions for Form N-648. Before certifying this form, the medical professional must conduct an in-person examination of the applicant. (See instructions for Form N-648 for additional information which is also located in the "FORMS" section at www.uscis.gov.) Reminder About Eligibility Requirements This form is intended for an applicant who seeks an exception to the English and/or civics requirements due to a physical or developmental disability or mental impairment that has lasted, or is expected to last, 12 months or more. An applicant who with reasonable accommodations provided under the Rehabilitation Act of 1973 can satisfy the English and civics requirements does not need to submit this form. Reasonable accommodations include, but are not limited to, sign language interpreters, extended time for testing, and off-site testing. Type or print clearly in black ink. Completing and Certifying This Form All questions or items must be answered fully and accurately. Responses should utilize common terminology, without abbreviations, that a person without medical training can understand. U.S. Citizenship and Immigration Services (USCIS) recommends that the certifying medical professional use the electronic Form N-648 located in the "FORMS" section www.uscis.gov. If the medical professional completes the form by hand, then responses must be legible and appear in black ink. Part 1. APPLICANT INFORMATION I certify that I have examined: Last Name First Name Middle Name USCIS A-Number USCIS USE ONLY This N-648 is: Sufficient Insufficient Continued/RFE Reviewer AAddress (Street Number and Name) U.S. Social Security Number City State or Province Zip Code or Postal Code Location & Date Telephone Number E-Mail Address (if any) Date of Birth Gender Male Female Part 2. MEDICAL PROFESSIONAL INFORMATION Type or print clearly in black ink. If you need more space to complete an answer, use a separate sheet of paper. Type or print the applicant's name and Alien Registration Number (A-Number), at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. You must sign and date each continuation sheet. You must answer and complete each question since USCIS will not accept an incomplete Form N-648. You may, but are not required to, attach to this completed form supportive medical diagnostic reports or records regarding the applicant. NOTE: Only medical doctors, doctors of osteopathy, or clinical psychologists licensed to practice in the United States (including the U.S. territories of Guam, Puerto Rico, and the Virgin Islands) are authorized to certify the form. While staff of the medical practice associated with the medical professional certifying the form may assist in its completion, the medical professional is responsible for the accuracy of the form's content. Last Name First Name Middle Name Business Address (Street Number and Name) City State or Province Zip Code or Postal Code Telephone Number License Number Licensing State E-Mail Address (if any) 1. Currently licensed as a (Select all that apply): 2. Medical practice type: Medical Doctor Doctor of Osteopathy Clinical Psychologist Form N-648 03/21/17 Y Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number A- Part 3. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT(S) 1. Provide the clinical diagnosis of the applicant's disability and/or impairment, that form the basis for seeking an exception to the English and/or civics requirements. If applicable, please provide the relevant medical code as accepted by the Department of Health and Human Services (HHS). This includes the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). For example, DSM-V 318.1 Intellectual Disability (Severe) or 2015/16 ICD-10-CM F72 Severe intellectual disabilities. 2. Provide a basic description of the disability and/or impairments, for example, Intellectual Disability (Severe) is a genetic disorder that causes lifelong intellectual disability, developmental delays, and other problems. 3. Date you first examined the applicant regarding the conditions listed in number 1. Date (mm/dd/yyyy) Location (if different from business address on Page 1; otherwise type or print "same as business address") 4. Date you last examined the applicant regarding the conditions listed in number 1, if different from above. Date (mm/dd/yyyy) Location (if different from business address on Page 1; otherwise type or print "same as business address") 5. Are you the medical professional regularly treating this applicant for the conditions listed in Item Number 1? Yes (If "Yes," indicate duration of treatment.) Years Months No (If "No," provide the name of the applicant's regularly treating medical professional on the next page and explain why you are certifying this form instead of the regularly treating medical professional.) Form N-648 03/21/17 Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Applicant's Name USCIS A-Number AName of Regularly Treating Medical Professional and Address Last Name First Name Middle Name Business Address (Street Number and Name) City State or Province Zip Code or Postal Code Telephone Number Explanation 6. Has the applicant's disability and/or impairments lasted, or do you expect it to last, 12 months or more? Yes (If "Yes,"continue to complete this form.) No (If "No," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.") 7. Is the applicant's disability and/or impairments the result of the applicant's illegal use of drugs? Yes (If "Yes," the applicant is not eligible for this exception and you need not complete the remainder of the questions. Please go directly to the "Medical Professional's Certification.") No (If "No," continue to complete this form.) 8. What caused this applicant's medical disability and/or impairments listed in number 1, if known? Form N-648 03/21/17 Y Page 3 www.FormsWorkFlow.com Applicant's Name USCIS A-Number A9. What clin