Chapter 9 - Vaccination Requirement

A. Vaccination Requirements for Immigrants

Some vaccines are expressly required by statute. Others are required because the Centers for Disease Control and Prevention (CDC) have determined they are in the interest of public health.^[1]

The Immigration and Nationality Act (INA)^[2] specifies the following vaccinations:

• Mumps, measles, rubella;

• Polio;

• Tetanus and diphtheria toxoids;^[3]

• Pertussis;

• Haemophilius influenza type B; and

• Hepatitis B.

CDC requires the following additional vaccines for immigration purposes:

• Varicella;

• Influenza;

• Pneumococcal pneumonia;

• Rotavirus;

• Hepatitis A;

• Meningococcal; and

• COVID-19.

If the applicant has not received any of the listed vaccinations and the vaccinations are age appropriate and medically appropriate, the applicant has a Class A condition and is inadmissible. Generally, all age appropriate vaccine rows of the vaccination assessment must have at least one entry before the assessment can be considered to have been properly completed. However, the COVID-19 vaccination (required as of October 1, 2021) differs in that the applicant must complete the entire vaccine series (one or two doses depending on formulation).^[4]

B. Blanket Waiver if Vaccine is “Not Medically Appropriate”

1. Definition of “Not Medically Appropriate”

The term “not medically appropriate” applies to:^[5]

• Vaccinations that are not required based on the applicant’s age at the time of the medical exam (“not age appropriate”);^[6]

• Vaccinations that cannot be administered on account of a medical contraindication(“contraindication”);

  • A contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine is given.

  • Examples of contraindications include a severe allergic reaction to a vaccination that was previously given, or pregnancy.

• Vaccinations that are administered as a series in intervals, but there is insufficient time to complete the entire vaccination series at the time of the medical examination (“insufficient time interval”);^[7] or

• The influenza vaccine if it is not the flu season, or if the vaccine for the specific flu strain missing is no longer available (“not flu season”).

If receiving the vaccine is not medically appropriate, the civil surgeon should indicate this medical finding on the Report of Immigration Medical Examination and Vaccination Record (Form I-693) in the appropriate boxes. USCIS will then waive that vaccine(s).^[8] A separate waiver application is not required for an officer to grant a waiver of the vaccination requirement as “not medically appropriate.”

The officer should generally accept a finding by the civil surgeon that a vaccine is not medically appropriate unless that finding is clearly wrong. For example, if a vaccine was age appropriate at the time of the medical exam based on the vaccination chart,^[9] but the civil surgeon marked that the vaccine is not medically appropriate because it is not age appropriate, then it is clear that the civil surgeon’s mark is incorrect. The same is true for a finding that a vaccine is not medically appropriate because it is not flu season; the officer should be able to clearly see whether the finding is correct based on the date of the medical examination.

An officer, however, should usually defer to a civil surgeon’s finding that a vaccine is not medically appropriate because of a contraindication. This is because such a finding involves medical judgment.

As indicated in the previous section, generally all age appropriate vaccine rows of the vaccination assessment must have at least one entry before the assessment can be considered to have been properly completed. However, if the officer can see from the record that the age appropriate vaccine was not required because, for instance, “it is not the flu season” but the civil surgeon failed to mark this on the vaccination assessment, then the officer may grant a blanket waiver despite the omission. In such cases, the officer should annotate in the “For USCIS Use Only” Remarks box in the vaccination record that a blanket waiver was granted.

2. Pregnancy or an Immuno-Compromised Condition^[10]

Some vaccines are, in general, not medically appropriate during pregnancy. These vaccines will likely be marked as contraindicated on Form I-693 if the applicant was pregnant at the time of the medical examination.^[11]

The civil surgeon may annotate in the remarks section that the applicant did not receive one or more vaccines because of a contraindication that is based on pregnancy or a condition other than pregnancy. The reason for the contraindication may be annotated by the civil surgeon on the Form I-693; however, if it is omitted, the officer does not need to issue a Request for Evidence (RFE) solely for that omission as long as the contraindication is marked in the vaccine chart.

An officer should also never issue an RFE for additional vaccines if the applicant is no longer pregnant at the time of the adjudication of the adjustment of status. As long as the vaccination assessment was properly completed by the civil surgeon at the time of the examination, the vaccination assessment can be accepted. In other words, if a woman did not receive certain required vaccines because she was pregnant at the time of the medical examination, and the contraindication box is marked by the civil surgeon, the applicant is not required to get those vaccines later at the time of the adjudication.

Likewise, some vaccines are not medically appropriate for applicants who have an immuno-compromised condition (such as HIV/AIDS or a weakened immune system because of taking certain medications) and may be marked by the civil surgeon as contraindicated.^[12]

In the case of an immuno-compromised person, the officer should never issue an RFE for additional vaccines even if, at the time of the adjudication of adjustment of status, the applicant is no longer immuno-compromised. As long as the vaccination assessment was properly completed at the time of the examination by the civil surgeon, the vaccination assessment can be accepted. The applicant should not be required to get the missing vaccines later at the time of the adjudication.

3. Blanket Waiver due to Nationwide Vaccination Shortage

USCIS will grant a blanket waiver only in the case of a vaccination shortage if CDC recommends that USCIS should do so based on CDC’s assessment that there is a nationwide shortage.

An officer may only grant a blanket waiver for a vaccine based on a vaccination shortage if the following circumstances are met:

• CDC declares that there is a nationwide vaccination shortage, and issues the appropriate statement on its website for civil surgeons;

• USCIS issues the appropriate statement on uscis.gov; and

• The civil surgeon annotates the medical examination form in compliance with any additional requirements specified by CDC or USCIS.

The grant of this blanket waiver does not differ from the grant of other blanket waivers.

4. Vaccines Not Routinely Available

Civil surgeons should annotate “not routinely available” on Form I-693 if the COVID-19 vaccine is not routinely available in the state where the civil surgeon practices. In addition, if the vaccine is available to the applicant but due to limited supply, it would cause significant delay for the applicant to receive the vaccination, then the civil surgeon should also annotate “not routinely available” on Form I-693.^[13] USCIS may grant a blanket waiver in these cases.

Generally, “national vaccination shortage” principles do not apply overseas. In the context of overseas vaccinations, the term panel physicians use to indicate the unavailability of a vaccine is “not routinely available.” Therefore, if the adjustment applicant is permitted to use the vaccination assessment completed overseas,^[14] then officers should not find the applicant inadmissible solely based on the lack of the vaccine(s) that is “not routinely available.” Officers should also not issue an RFE for corrective action. USCIS may grant a blanket waiver in these cases.

C. Adjudication Steps

Vaccination Requirement: Adjudication Steps
Step 1	Determine which vaccination(s) were age appropriate for the applicant to receive based on the applicant’s age on the date the medical exam was completed.[15]
Step 2	Verify that any vaccine that was required (age appropriate)[16] as of the date of the medical exam is marked as: Received by the applicant; or  “Not medically appropriate” because of contraindication, inappropriate time interval, or not flu season.
Step 3	If the required (age appropriate) vaccinations were not received or not marked as “not medically appropriate” as of the date the medical exam was completed, determine whether the missing vaccinations would still be required as of the date of adjudication.  Vaccinations missing at the time of the medical exam may no longer be required as of the date of adjudication if, for example, the applicant has aged out, or it is not the flu season, or a vaccine is no longer required by law.
Step 4	If the missing vaccinations are no longer required as of the date of the adjudication, the vaccination requirements have been met.
Step 5	If the missing vaccinations would still be required, the officer should send an RFE for an updated Form I-693 showing the applicant has received those vaccinations.

D. Vaccination Chart

USCIS officers should consult the chart in the Vaccination Technical Instructions to determine inadmissibility based on failure to meet the vaccination requirements. 

E. Special Vaccination Considerations

Additionally, officers should pay special attention to the following developments.

1. Human Papillomavirus (HPV) Vaccination

From August 1, 2008 through December 13, 2009, human papillomavirus (HPV) vaccination was required for female applicants ages 11 years through 26 years. The requirement was eliminated on December 14, 2009, and affects any admissibility determination under INA 212(a)(1)(A)(ii) on that date or thereafter. Therefore, for adjudications taking place on or after December 14, 2009, officers should disregard any annotation of the HPV vaccine, or the lack thereof, on Form I-693 or U.S. Department of State’s Vaccination Documentation Worksheet (Form DS-3025), when determining whether the vaccination requirements are met.

2. Zoster Vaccination

From August 1, 2008 through December 13, 2009, the zoster vaccination was required for applicants ages 60 years or older unless the applicant had received the varicella vaccine.

The zoster vaccine, however, was not available in the United States due to a nationwide shortage from the time it became mandatory. Therefore, even though the vaccine was missing, the Form I-693 could be accepted if the physician was unable to obtain the vaccine.

On December 14, 2009, the zoster vaccine was removed from the list of required vaccines for immigration purposes, and the change affects any admissibility determination made on or after that date. Therefore, officers should disregard any annotation of the zoster vaccine, or the lack thereof, on any Form I-693 or U.S Department of State’s Vaccination Documentation Worksheet (Form DS-3025), when determining whether the vaccination requirements are met.

3. Influenza Vaccination

The flu vaccination is only available during the flu season. For purposes of Form I-693, the flu season commences annually on October 1 and runs through March 31.

Over time, CDC has changed the age category of applicants required to obtain the flu vaccine for immigration purposes. As of November 16, 2010, CDC’s Technical Instructions require that all applicants 6 months of age or older receive the flu vaccine during the flu season.

If an applicant was required to obtain the flu vaccine at the time of the medical examination (the date of the civil surgeon’s certification governs) but a flu vaccine annotation is missing, the officer should only issue an RFE if it is still the same flu season and if it is reasonable to expect that the applicant will be able to obtain the flu vaccine within the time frame of the RFE.

This accounts for the fact that the flu vaccine is strain-specific and only available for a limited time each year. The officer should not issue an RFE if the applicant will not be able to obtain the strain-specific flu vaccine that had been required at the time of the medical examination because:

• It is no longer the same flu season; or

• It is not the flu season at all.

4. Vaccination Requirements Prior to August 1, 2008

The following vaccines were NOT required prior to August 1, 2008: Hepatitis A, meningococcal, rotavirus, human papillomavirus (HPV), and zoster.^[17]

F. Completion of the Results Section by the Civil Surgeon

According to the Vaccination Component of the Technical Instructions, the civil surgeon should mark the appropriate results box at the bottom of the vaccination assessment chart. The Technical Instructions direct the civil surgeon to only check one appropriate box.

The officer should be aware that civil surgeons may improperly mark the boxes because they may misunderstand the meaning of these boxes. Therefore, the officer should determine, from the vaccination assessment completed by the civil surgeon, whether the applicant received all vaccines, which blanket waivers should be granted, and whether the applicant requires any other waivers. The officer should exercise discretion in reviewing the vaccination chart and when evaluating the results boxes at the bottom of the vaccination assessment chart.

If the civil surgeon did not check any result boxes, the officer should only return the form for corrective action if he or she is unable to ascertain whether the applicant is admissible. The officer should never alter or complete sections on the medical examination report that are the responsibility of the civil surgeon, such as the results boxes.

The results boxes and their meanings are described below (according to the Vaccination Component of the Technical Instructions).

Vaccination Record: Explanation of Results
Applicant may be eligible for blanket waiver(s) as indicated above	This box will usually be checked because some vaccines may not be age appropriate for the applicant, a vaccination series could not be completed, there was a contraindication, or because of any other condition noted in the “Not Medically Appropriate” heading.
Applicant will request an individual waiver based on religious or moral convictions	If an applicant objects to vaccines based on religious or moral convictions, the "Applicant will request an individual waiver based on religious or moral convictions" box must be checked.[18] This is not a blanket waiver, and the applicant will have to submit a waiver request on Form I-601.  Even if the applicant otherwise requires a blanket waiver(s), the civil surgeon must check this box, and not the box titled “Applicants may be eligible for blanket waivers.” It may be, however, that the civil surgeon checks both boxes, in which case, the officer should just request the waiver documentation that establishes the religious or moral conviction.
Vaccine history complete for each vaccine, all requirements met	If the applicant has met the vaccination requirements, i.e., completed the series for all required vaccines, the "Vaccine history complete for each vaccine, all requirements met" box must be checked.
Applicant does not meet immunization requirements	If an applicant's vaccine history is incomplete and the applicant refuses administration of a single dose of any required vaccine that is medically appropriate for the applicant, the "Applicant does not meet immunization requirements" box must be checked. If this box is checked, the applicant may be inadmissible. Depending on the case, the officer should ask for the reason through an RFE, Notice of Intent to Deny (NOID), or an interview.  If the applicant refused to be vaccinated on account of a religious or moral conviction, the officer should direct the applicant to file a waiver. If the applicant had no religious or moral reason for refusal, the applicant is inadmissible.  The officer should not return the assessment to the civil surgeon if he or she has enough information to determine health-related inadmissibility.

G. Exception for Certain Adopted Children

Some children are not subject to the vaccination requirement^[19] if all of the following conditions are met:

• The child is 10 years of age or younger;

• The child is classified as an orphan (IR3 or IR4) or a Hague Convention adoptee (IH3 or IH4);^[20] and

• The child is seeking an immigrant visa as an immediate relative.^[21]

For the child to benefit from this exception, the adopting parent(s) must sign an affidavit prior to the immigrant visa issuance, affirming that the child will receive the required vaccination within 30 days of admission to the United States or at the earliest time that is medically appropriate. However, noncompliance with the vaccination requirements following the child's admission to the United States is not a ground for removal.

The Department of State has developed a standard affidavit form, Affidavit Concerning Exemption from Immigrant Vaccination Requirements for a Foreign Adopted Child (Form DS-1981), to ensure that adopting parents are aware of the possibility of an exception from the vaccination requirements and of their obligation to ensure that the child is vaccinated following admission.^[22] The completed form must be submitted to the consulate as part of the immigrant visa application.

Only orphans or Convention adoptees whose adoptive or prospective adoptive parents have signed an affidavit will be exempt from the vaccination requirement. If the adopting parent(s) prefers that the child meet the vaccination requirement as part of the visa application process, the child may benefit from the waiver(s) for those vaccinations which the panel physician determines are medically inappropriate.^[23]

When the adoptive or prospective adoptive parent cannot sign the affidavit in good faith because of religious or moral objections to vaccinations, the child will require a waiver.^[24]

Footnotes

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[^ 1] Effective December 14, 2009, CDC changed its methods on how to assess which vaccines should be required for immigration purposes. This led to changes in the list of required vaccines; some that were required prior to 2009 are no longer required since December 14, 2009. 

[^ 2] See INA 212(a)(1)(A)(ii).

[^ 3] Applicants who have completed the initial DTP/DTaP/DT or Td/Tdap series should receive a Td/Tdap booster shot every 10 years. If the last dose was received more than 10 years ago, the applicant is required to have the booster shot, otherwise the applicant is inadmissible under INA 212(a)(1)(A)(ii).

[^ 4] For more information, including current dosage requirements for the immigration medical examination, see the CDC Requirements for Immigrant Medical Examinations: COVID-19 Technical Instructions for Civil Surgeons webpage.

[^ 5] For more information, see the “Blanket Waivers Applicable to COVID-19 vaccinations” section of the CDC Requirements for Immigrant Medical Examinations: COVID-19 Technical Instructions for Civil Surgeons.

[^ 6] See Section D, Vaccination Chart [8 USCIS-PM B.9(D)] for more information. 

[^ 7] In these cases, the civil surgeon will administer the dose due at the time of the medical examination and mark on the form that there is not sufficient time to complete the entire vaccination series (insufficient time interval).

[^ 8] See INA 212(g)(2)(B).

[^ 9] See Section D, Vaccination Chart. [8 USCIS-PM B.9(D)]. 

[^ 10] Immuno-compromised condition refers to a medical state that does not allow the body to fight off infection.

[^ 11] See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate during pregnancy, available at cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html. 

[^ 12] See CDC’s Vaccination Technical Instructions for a list of the specific vaccines not medically appropriate for immuno-compromised persons, available at cdc.gov/immigrantrefugeehealth/exams/ti/civil/vaccination-civil-technical-instructions.html.

[^ 13] For more information, see the CDC Requirements for Immigrant Medical Examinations: COVID-19 Technical Instructions for Civil Surgeons.

[^ 14] See Chapter 3, Applicability of Medical Examination and Vaccination Requirement [8 USCIS-PM B.3] for more information on applicants who may use the vaccination assessment completed overseas for adjustment purposes.

[^ 15] See Section D, Vaccination Chart [8 USCIS-PM B.9(D)] for a chart of vaccine requirements by age. 

[^ 16] Since the applicant was not required to receive non-age appropriate vaccines at the time of the medical exam, the officer does not need to review these vaccine rows at the time of adjudication.

[^ 17] Please see information immediately above for the zoster and the HPV vaccine, since these vaccines have not been required since December 2009.

[^ 18] The applicant needs to demonstrate opposition to vaccinations in all forms, not just certain vaccinations. See Volume 9, Waivers and Other Forms of Relief, Part D, Health-Related Grounds of Inadmissibility, Chapter 3, Waiver of Immigrant Vaccination Requirement, Section E, Waiver due to Religious Belief or Moral Conviction [9 USCIS-PM D.3(E)].

[^ 19] Under INA 212(a)(1)(C), as amended by Section 2 of the International Adoption Simplification Act, Pub. L. 111-287 (PDF), 124 Stat. 3058, 3058 (November 30, 2010).

[^ 20] See INA 101(b)(1)(F) and INA 101(b)(1)(G), respectively.

[^ 21] Under INA 201(b): a child can either obtain an IR-3 or IR-4 immigrant visa as an immediate relative if the child is an “orphan” or an IH-3 or IH-4 immigrant visa if the child is a Hague Convention adoptee.

[^ 22] The affidavit is made under oath or affirmation in the presence of either the consular officer or a notary public.

[^ 23] See INA 212(g)(2)(B). This waiver authority has been delegated to the Department of State and a consular officer can grant the waiver. Neither a form nor a fee is required.

[^ 24] When the waiver application is for a child, the child’s parent must satisfy the waiver requirements under INA 212(g)(2)(C). The waiver is filed by submitting an Application for Waiver of Grounds of Inadmissibility (Form I-601) along with the required fee. See Volume 9, Waivers and Other Forms of Relief, Part D, Health-Related Grounds of Inadmissibility, Chapter 3, Waiver of Immigrant Vaccination Requirement [9 USCIS-PM D.3] for more information on the requirements for vaccination waivers based on religious beliefs or moral objections.