Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 11
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12Physical Address
Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
4.a.
Street Number
Regulations)
and Name
4.b.
Apt.
Ste.
Flr.
To be completed for applicants with a Class A Tuberculosis
Condition (as defined by HHS Regulations).
4.c. City or Town
Statement by Applicant
4.d. State
4.e. ZIP Code
Upon admission to the United States, I will go directly to the
health department named in the section below; present all X-rays
Physician's Certification
used in the visa medical examination to substantiate diagnosis;
submit to such examinations, treatment, isolation, and medical
5.a.
Signature of Physician (sign in ink)
regimen as may be required; and remain under the prescribed
treatment or observation, whether on an inpatient or outpatient
basis, until discharged.
5.b. Date of Signature (mm/dd/yyyy)
1.a.
Signature of Applicant (sign in ink)
5.c. Physician's Family Name (Last Name)
1.b.
Date of Signature (mm/dd/yyyy)
5.d.
Physician's Given Name (First Name)
Statement by Local (City or County) Health
Department
Physician's Contact Information
NOTE: The physician at the local health department in the area
6.
Daytime Telephone Number
where the alien plans to reside should complete this statement.
I agree to supply any treatment or observation necessary for the
proper management and continued care of the alien's
7.
Email Address (if any)
tuberculosis condition.
Within 30 days of the alien reporting for care, I agree to submit
a summary of my initial evaluation of the alien's condition,
Arrangement for Medical Care by the Applicant or
indicate presumptive diagnosis, and provide test results and
His or Her Sponsor
plans for future care of the alien to the State Health Department
Official named in the Endorsement of State Health
Arrange for medical care (of the applicant) and have the
Department Official section and to the Division of Global
appropriate health departments complete Statement by Local
Migration and Quarantine (E03), Centers for Disease
(City or County) Health Department and Endorsement of
Control and Prevention (CDC), Atlanta, Georgia 30333.
State Health Department Official sections.
I also agree to report the alien if the alien has not reported
Provide the following information:
within 30 days after receiving notice from the Division of
Address where you (the sponsor) or the applicant plan to reside
Global Migration and Quarantine, CDC.
in the United States:
Satisfactory financial arrangements have been made. (This
8.a.
Street Number
statement does not relieve the alien from submitting evidence,
and Name
as required by a U.S. Consulate, to establish that the alien is not
8.b.
Apt.
Ste.
Flr.
likely to become a public charge.)
I represent (select the appropriate box and give the complete
8.c. City or Town
name, address, certification, and contact information of the
health department):
8.d. State
8.e. ZIP Code
2.a.
City Health Department
2.b.
County Health Department
3.
Name of Health Department
Form I-601 08/21/17 N
Page 11 of 12
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