That the certifying medical professional use the electronic Form N-648 located in the FORMS section www. See instructions for Form N-648 for additional information which is also located in the FORMS section at www. Medical practice type Form N-648 03/11/15 Y Page 1 Applicant s Name A- Part III. INFORMATION ABOUT DISABILITY and/or IMPAIRMENT S 1. 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. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties including under Title 18 U.S.C. OMB No. 1615-0060 Expires 03/31/2017 Form N-648 Medical Certification for Disability Exceptions Department of Homeland Security U.S. Citizenship and Immigration Services 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. Section 1746 that the information I provided to the medical professional is true and correct. I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to civil penalties under Title 8 U.S.C. INTERPRETER S CERTIFICATION An interpreter must complete and certify the section below if an interpreter translated communications between the applicant and medical professional on the day of the examination that formed the basis of this Form N-648 certification. Interpreter Information Was a phone interpreter used No If no the interpreter is required to complete the information below. Before certifying this form the medical professional must conduct an in-person examination of the applicant. uscis. gov* Reminder About Eligibility Requirements Completing and Certifying This Form 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. 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. uscis. gov* If the medical professional completes the form by hand then responses must be legible and appear in black ink. MEDICAL PROFESSIONAL INFORMATION 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 may but are not required to attach to this completed form supportive medical diagnostic reports or records regarding the applicant.
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