Vaccination Technical Instructions for Civil Surgeons

Overview of Vaccination Technical Instructions

The Centers for Disease Control and Prevention (CDC) has specific criteria to determine which vaccines people applying for adjustment of status for US permanent residence (hereafter referred to as applicants) are required to show proof of having received.

The criteria are as follows:

1. The vaccine must be an age-appropriate vaccine, as recommended by the Advisory Committee on Immunization Practices (ACIP) for the general US population
   AND
2. At least one of the following:
   1. The vaccine must protect against a disease that has the potential to cause an outbreak. An outbreak is defined as the occurrence of more cases of disease than expected in a given area or among a specific group of people, over a given period of time. For endemic diseases, an outbreak occurs when incidence rises above the normally expected level. For diseases with seasonal variation, the average incidence rates over particular weeks or months of previous years, or average high or low levels over a period of years, may be used as baselines.
   2. The vaccine must protect against a disease that has been eliminated in the United States or is in the process of being eliminated in the United States.

Therefore, the vaccines required for applicants do not include all the vaccines recommended by the ACIP and CDC for routine US domestic use, and are limited to vaccination for the following diseases:

• Diphtheria
• Tetanus
• Pertussis
• Polio
• Measles
• Mumps
• Rubella
• Rotavirus
• Haemophilus influenzae type b (Hib)
• Hepatitis A
• Hepatitis B
• Meningococcal disease
• Varicella
• Pneumococcal disease
• Influenza

The vaccines from the list above that are required for a given applicant are defined in Table 1. Vaccine series have minimum age requirements and typically require months to years to complete. Therefore, it is usually not possible for applicants to receive all vaccinations for the diseases listed above prior to adjustment of status, and they are instead required to receive from the civil surgeon at least one dose of each age-appropriate vaccine listed in Table 1 for which the applicant is not currently up to date. If the applicant is up to date on the required vaccines listed in Table 1, no additional vaccines are required to be given at the time of the medical exam. The civil surgeon should counsel the applicant about the importance of completing the series of vaccines according to the recommended schedule.

The civil surgeon must review all vaccination records presented by the applicant and, if documentation appears valid, record the vaccination history and vaccines given during the medical exam on Form I-693 (Report of  Medical Examination and Vaccination Record), according to the instructions provided by the US Citizenship and Immigration Services (USCIS). After administering any needed vaccines, the civil surgeon must complete Form I-693 and give it to the applicant in a sealed envelope, which the applicant will present to USCIS. A copy of the completed vaccination record in Part 2, Section 5, must also be provided to the applicant for his or her personal records.

CDC and ACIP are excellent sources for other vaccine information, such as vaccine handling, storage and administration, spacing of doses, precautions, contraindications, and adverse reactions. Another excellent resource is Epidemiology and Prevention of Vaccine-Preventable Diseases, also called the “Pink Book,” a comprehensive, up-to-date resource about all aspects of vaccines and vaccine-preventable diseases. The Pink Book and additional information involving vaccine storage and handling and how to administer vaccines, including dosage and site, can be found on CDC’s website. Vaccine Information Statements (VISs) for patients are available in many languages and must be used to provide vaccine information to applicants.

The instructions in this document supersede all previous vaccination-related “Technical Instructions,” “Updates to the Technical Instructions,” and memoranda or letters to civil surgeons. These instructions are to be followed as the vaccination requirements for all status adjustment applicants.

Further information on vaccination criteria is available in the Notice of Revised Vaccination Criteria for US Immigration on CDC’s website. Questions from civil surgeons regarding vaccination requirements for status adjustment may be sent to CDC’s Division of Global Migration and Quarantine (DGMQ) at: cdcqap@cdc.gov.

Procedures for the Vaccination Portion of the Medical Exam

The following instructions and accompanying tables describe the procedures that should be followed by civil surgeons performing the vaccination portion of the medical examination for any person who seeks adjustment of status for US permanent residence.

• Review the applicant’s medical history and vaccination records.
• Assess the applicant’s needs, if any, for laboratory confirmation of immunity.
• Determine the vaccines the applicant needs based on his or her age, records, documented immunity, and information provided in Table 1.
• Assess for contraindications and precautions that might apply to the applicant.
• Administer vaccines, if indicated.
• Complete the applicant’s Form I-693 and give it to the applicant in a sealed envelope for USCIS, in addition to a copy for the applicant to keep.

Review of Vaccination Records

The civil surgeon should instruct the applicant to submit all available written records of vaccination history for review. Acceptable vaccination documentation must come from a vaccination record, either a personal vaccination record or a copy of a medical chart with entries made by a physician or other appropriate medical personnel. Only those records of vaccine doses that include the dates of receipt (month, day, and year) are acceptable. The document must not appear to have been altered, and dates of vaccinations should seem reasonable. Self-reported vaccine doses without written documentation are not acceptable.  Civil surgeons must document all acceptable vaccination and relevant immunity on the Form I-693 according to USCIS instructions.

Records in Languages Other than English

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

Vaccinations Received Outside the United States

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

Laboratory Confirmation of Immunity

The civil surgeon should obtain a good history of vaccine-preventable diseases, including measles, mumps, rubella, and varicella, from the applicant to identify any naturally acquired diseases for optional laboratory confirmation.

An applicant who provides a reliable written or oral history of varicella disease does not require laboratory confirmation or further vaccination. To verify a history of varicella, civil surgeons should inquire about: 1. an epidemiologic link to another typical varicella case or to a laboratory-confirmed case or 2. evidence of laboratory confirmation, if testing was performed at the time of acute disease.  Persons who meet neither of these criteria should not be considered as having a valid history of disease and should be tested for immunity or vaccinated.

Acceptable tests for the presence of antibodies are US Food and Drug Administration (FDA)-approved kits or Clinical Laboratory Improvement Amendments (CLIA)-certified kits. When using any approved kits, the manufacturer’s guidelines or instructions must be followed.

Determining the Vaccines the Applicant Needs

The following is a list of diseases for which applicants must show proof of having age-appropriate vaccinations or immunity for adjustment of status for US permanent residence:

• Diphtheria
• Tetanus
• Pertussis
• Polio
• Measles
• Mumps
• Rubella
• Rotavirus
• Haemophilus influenzae type b (Hib)
• Hepatitis A
• Hepatitis B
• Meningococcal disease
• Varicella
• Pneumococcal disease
• Influenza

The civil surgeon should use the applicant’s age at the time of the medical evaluation and information in Table 1 to determine which diseases the applicant must be vaccinated against. If the disease is not on this list, vaccination to prevent the disease is not required for the purposes of status adjustment.

If the applicant had previously received a dose, or doses, of a required vaccine and is due for the next dose in the series, then the next required dose should be administered at the medical examination visit.  If the applicant has not received any of the doses of a vaccine required for his or her age, the first dose in the series should be given at the visit.  In order to determine the number of doses and spacing for each vaccine, the civil surgeon should refer to the standard ACIP recommendations.

In addition to standard vaccination recommendations for children and adults, ACIP provides recommendations that are specific for medical conditions or other situations, such as pregnancy or travel.  These additional vaccines are not required for status adjustment.  For example, Hib vaccine doses are recommended for adults with sickle cell disease.  Since the ACIP does not routinely recommend Hib vaccine for adults, an adult with sickle cell disease would not be required to receive this vaccine for status-adjustment purposes.

Vaccination Requirements for Refugees and Procedure for Determining Refugee Status

Although refugees are not required to receive vaccinations before entering the United States, they must meet the vaccination requirements when applying for adjustment of status to permanent resident status in the United States. For a refugee, the adjustment of status application includes the medical examination report issued by a panel physician overseas and Form I-693, indicating a vaccination assessment performed by a civil surgeon or designated health department in the United States.

Refugees adjusting status must be assessed for vaccination requirements only. A civil surgeon must obtain the applicant’s I-94 Form (Arrival-Departure Record) to determine whether the applicant was admitted to the United States as a refugee pursuant to the Immigration and Nationality Act (INA) Section 207. The civil surgeon must verify that the I-94 Form belongs to the applicant by comparing it with other identification documents, keeping in mind that many refugees might not have passports.

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

Health Departments Acting as Civil Surgeons for Refugees

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

Identifying Potential Contraindications and Precautions to Vaccination

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

Civil surgeons must be aware of all contraindications and precautions for the vaccines they administer as described in the ACIP immunization schedules’ footnotes. The Pink Book’s chapter on General Recommendations on Immunization gives a helpful summary of ACIP’s contraindications, precautions, and misconceptions about contraindications, and a list of screening questions that civil surgeons can use. This chapter also gives detailed, concise information about vaccinating pregnant women, people with immunosuppression, and general considerations about giving multiple vaccines at one time.

Contraindications and precautions to specific vaccines are available on CDC’s ACIP site.

For pregnant women, contraindications and precautions on CDC’s Pregnancy and Vaccination site.

In general, civil surgeons should defer vaccines when a precaution or contraindication is present. If the decision is made to defer a vaccine, the “contraindication” reason for a Blanket Waiver (see below) should be documented for the vaccine dose not given, and the specific type of contraindication or precaution should be documented on the Form I-693.

Waivers and Documenting Reasons for Not Giving a Vaccine

For all applicants, it will not be appropriate to administer a dose of one or more of the required vaccines due to the applicant’s age, or one of the other reasons listed below. However, the applicant can still be considered to have completed the US status adjustment vaccination requirements by means of a Blanket Waiver.  The civil surgeon needs to document the appropriate Blanket Waiver reason for each vaccine not given on the Form I-693, and the waiver will be granted to the applicant if documented correctly.  The applicant does not need to apply for a Blanket Waiver. There are four acceptable reasons why a vaccine should be considered “Not Medically Appropriate” that qualify for Blanket Waivers.

The four “Not Medically Appropriate” reasons for Blanket Waivers are:

• Not age-appropriate
  For each vaccine for which administration is not age-appropriate, the “Not age appropriate” reason should be documented. For all applicants, this reason will need to be documented for at least one vaccine. For example, if adults did not receive Hib or rotavirus vaccine as a child, they are not required to receive these vaccines as adults for status adjustment purposes, according to Table 1 and these vaccines should be documented as “Not age appropriate.”
• Contraindication
  If an applicant has contraindications or precautions to specific vaccines, the “Contraindication” reason should be documented for each vaccine not administered.
• Insufficient time interval between doses
  If the minimum time interval between the last documented dose and the next required dose has not passed, the “Insufficient time interval” reason should be documented.
  If administration of a single dose of vaccine at the time of the medical examination does not complete the series for that vaccine, the “Insufficient time interval to complete series” reason should be documented to indicate that additional doses will be needed to complete the series for that vaccine.  This reason can also be used if a live vaccine has recently been administered and another live vaccine is needed, but sufficient time has not passed.

• Influenza vaccine not available
  Influenza vaccine is required when available in the United States. The influenza vaccine is usually given from fall through early spring in temperate areas and is often not available in the summer months in these regions. If influenza vaccine is not available because it is not vaccination season in the United States, document the “Not flu season” reason.

Non-medical reasons why vaccines are not given:

• Applicant may request a waiver based on religious or moral convictions
  If an applicant objects to vaccination based on religious or moral convictions, it must be documented that applicant is requesting an individual waiver based on religious or moral convictions. This is not a Blanket Waiver, and the applicant will have to submit a waiver request to USCIS.
• Applicant refuses a vaccine
  If an applicant’s vaccine history is incomplete and the applicant refuses a single dose of any required vaccine that is medically appropriate for the applicant, it should be documented that the vaccine requirements are not complete and that the applicant refuses vaccination.

Vaccine Resources for Civil Surgeons

Handling, Storage, and Administration

Proper handling and storage of vaccines are important to ensure their efficacy. If vaccines are not properly handled or stored, their potency is reduced and they may not produce immunity. Guidance on the storage and handling of vaccines is available in the Pink Book chapter on Vaccine Storage and Handling, CDC’s Vaccine Storage and Handling website, and the vaccine package inserts are available on the Immunization Action Coalition site (immunization.org).

Vaccine Adverse Event Reporting System (VAERS)

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

Vaccine Information Statements

The National Childhood Vaccine Injury Act requires all healthcare providers in the United States who administer vaccines to provide a copy of the relevant Vaccine Information Statement (VIS) to either the adult receiving a vaccine or, in the case of a minor, to the parent or legal representative. In addition to the VIS, healthcare providers should give visual and oral explanations of each vaccine. Civil surgeons can find patient vaccine information sheets in many languages on CDC’s webpage for Vaccine Information Statements.

ACIP Schedules and Updates

ACIP immunization schedules for children and adults are updated annually, and ACIP vaccine-specific updates are also posted online periodically and can be found on CDC’s website.

Epidemiology and Prevention of Vaccine-Preventable Diseases “Pink Book”

The Pink Book, Epidemiology and Prevention of Vaccine-Preventable Diseases, provides an overview of vaccine-preventable infectious diseases and the corresponding vaccines. It serves as a useful companion to the ACIP schedules and provides appendices that identify search tools and other useful resources.

Table 1: Vaccine Requirements According to Applicant Age

Vaccines by applicant age	Birth-1 Month	2-11 Months	12 Months-6 Years	7-10 Years	11-17 Years	18-64 Years	≥ 65 Years
DTP/DTaP/DT	NO	YES		NO
Td/Tdap	NO			Sometimes*	YES (substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 years)
Polio** (IPV/OPV)	NO	YES				NO
Measles, Mumps, and Rubella	NO		YES, if born in 1957 or later				NO
Rotavirus***	NO	YES, 6 weeks to 8 months old	NO
Hib	NO	YES, 2 through 59 months old		NO
Hepatitis A	NO		YES, 12 through 23 months old	NO
Hepatitis B	YES, through 18 years old					NO
Meningococcal (MenACWY)	NO				YES, 11 through 18 years old	NO
Varicella	NO		YES
Pneumococcal	NO	YES, 2 through 59 months old (administer PCV)		NO			YES (administer either PCV or PPSV depending on vaccination history)
Influenza	NO, if less than 6 months		YES, ≥ 6 months (annually when flu vaccine is available in country of exam)

Print only version [PDF – 1 page]

* Children 7-10 years old sometimes need a dose of Tdap depending on their vaccine history. See Diphtheria, Tetanus and Pertussis-Containing Vaccines Catch-Up Guidance[PDF – 4 pages] on CDC’s website for additional information.

** Please see posted Addendum to Technical Instructions for Panel Physicians for Vaccinations on CDC’s website for changing guidance about polio vaccine.

*** Rotavirus vaccination should not be initiated for infants aged 15 weeks 0 days or older.

DTP=pediatric formulation diphtheria and tetanus toxoids and pertussis vaccine; DTaP=pediatric formulation diphtheria and tetanus toxoids and acellular pertussis vaccine; DT=pediatric formulation diphtheria and tetanus toxoids; Td=adult formulation tetanus and diphtheria toxoids; Tdap=adolescent and adult formulation tetanus and diphtheria toxoids and acellular pertussis vaccine (IPV=inactivated poliovirus vaccine (killed); OPV=oral poliovirus vaccine (live); Hib=Haemophilus influenzae type b conjugate vaccine; MenACWY=quadravalent meningococcal conjugate vaccine; PCV=pneumococcal conjugate vaccine; PPSV=pneumococcal polysaccharide vaccine.

This table describes vaccine requirements for U.S. immigrant visa and status adjustment applicants only and does not include recommendations for other clinical purposes. See the Immunization Schedules on CDC’s website for number and spacing of doses for required vaccines.

Requirements for United States status adjustment applicants adapted from ACIP recommendations.

Glossary of Abbreviations

• ACIP – Advisory Committee on Immunization Practices
• CDC – Centers for Disease Control and Prevention
• CLIA – Clinical Laboratory Improvement Amendments
• DGMQ – Division of Global Migration and Quarantine
• DT – Diphtheria and tetanus toxoids
• DTaP – Diphtheria and tetanus toxoids and acellular pertussis vaccine
• DTP – Diphtheria and tetanus toxoids and pertussis vaccine
• FDA – Food and Drug Administration
• Hib – Haemophilus influenzae type b conjugate vaccine
• INA – Immigration Nationality Act
• IPV – Inactivated poliovirus vaccine
• MCV – Meningococcal conjugate vaccine
• MMR – Measles, mumps, and rubella vaccine
• MMRV – Measles, mumps, rubella, and varicella vaccine
• OPV – Oral poliovirus vaccine
• PCV – Pneumococcal conjugate vaccine
• PPSV – Pneumococcal polysaccharide vaccine
• Td – Tetanus and diphtheria toxoids
• Tdap – Tetanus and diphtheria toxoids and acellular pertussis vaccine
• USCIS – United States Citizenship and Immigration Services
• VAERS – Vaccine Adverse Event Reporting System
• VIS – Vaccine Information Statement