§ 34.3 Scope of examinations. ( a ) *General.* In performing examinations, medical examiners shall consider those matters that relate to the following: ( 1 ) Communicable disease of public health significance;
( 2 ) Documentation of having received vaccination against “vaccine-preventable diseases” for an alien who seeks admission as an immigrant, or who seeks adjustment of status to one lawfully admitted for permanent residence, which shall include at least the following diseases: Mumps, measles, rubella, polio, tetanus and diphtheria toxoids, pertussis, *Haemophilus influenza* type B and hepatitis B, and any other vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) for which HHS/CDC determines there is a public health need at the time of immigration or adjustment of status. Provided, however, that in no case shall a Class A medical notification be issued for an adopted child who is 10 years of age or younger if, prior to the admission of the child, an adoptive parent or prospective adoptive parent of the child, who has sponsored the child for admission as an immediate relative, has executed an affidavit stating that the parent is aware of the vaccination requirement and will ensure that, within 30 days of the child's admission, or at the earliest time that is medically appropriate, the child will receive the vaccinations identified in the requirement;
( 3 ) ( i ) A current physical or mental disorder and behavior associated with the disorder that may pose, or has posed, a threat to the property, safety, or welfare of the alien or others;
( ii ) A history of a physical or mental disorder and behavior associated with the disorder, which behavior has posed a threat to the property, safety, or welfare of the alien or others and which behavior is likely to recur or lead to other harmful behavior;
( 4 ) Drug abuse or drug addiction; and
( 5 ) Any other physical or mental health condition, disease, or disability serious in degree or permanent in nature.
( b ) *Scope of all medical examinations.* ( 1 ) All medical examinations will include the following: ( i ) A general physical examination and medical history, evaluation for tuberculosis, and serologic testing for syphilis.
( ii ) A physical examination and medical history for diseases specified in §§ 34.2(b)(1), and 34.2(b)(4) through 34.2(b)(10).
( 2 ) For the examining physician to reach a determination and conclusion about the presence or absence of a physical or mental abnormality, disease, or disability, the scope of the examination shall include any laboratory or additional studies that are deemed necessary, either as a result of the physical examination or pertinent information elicited from the alien's medical history or other relevant records.
( c ) Additional medical screening and testing for examinations performed outside the United States. ( 1 ) HHS/CDC may require additional medical screening and testing for medical examinations performed outside the United States for diseases specified in §§ 34.2(b)(2) and 34.2(b)(3) by applying the risk-based medical and epidemiologic factors in paragraph (d)(2) of this section.
( 2 ) Such examinations shall be conducted in a defined population in a geographic region or area outside the United States as determined by HHS/CDC.
( 3 ) Additional medical screening and testing shall include a medical interview, physical examination, laboratory testing, radiologic exam, or other diagnostic procedure, as determined by HHS/CDC.
( 4 ) Additional medical screening and testing will continue until HHS/CDC determines such screening and testing is no longer warranted based on factors such as the following: Results of disease outbreak investigations and response efforts; effectiveness of containment and control measures; and the status of an applicable determination of public health emergency of international concern declared by the Director General of the WHO.
( 5 ) HHS/CDC will directly provide medical examiners information pertaining to all applicable additional requirements for medical screening and testing, and will post these at the following Internet addresses: *http://www.cdc.gov/ncidod/dq/technica.htm* and *http://www.globalhealth.gov*.
( d ) *Risk-based approach.* ( 1 ) HHS/CDC will use the medical and epidemiological factors listed in paragraph (d)(2) of this section to determine the following: ( i ) Whether a disease as specified in § 34.2(b)(3)(ii) is a communicable disease of public health significance;
( ii ) Which diseases in § 34.2(b)(2) and (3) merit additional screening and testing, and the geographic area in which HHS/CDC will require this screening.
( 2 ) Medical and epidemiological factors include the following: ( i ) The seriousness of the disease's public health impact;
( ii ) Whether the emergence of the disease was unusual or unexpected;
( iii ) The risk of the spread of the disease in the United States;
( iv ) The transmissibility and virulence of the disease;
( v ) The impact of the disease at the geographic location of medical screening; and
( vi ) Other specific pathogenic factors that would bear on a disease's ability to threaten the health security of the United States.
( e ) *Persons subject to requirement for chest radiograph examination and serologic testing.* ( 1 ) As provided in paragraph (e)(2) of this section, a chest radiograph examination and serologic testing for syphilis shall be required as part of the examination of the following: ( i ) Applicants for immigrant visas;
( ii ) Students, exchange visitors, and other applicants for non-immigrant visas required by a U.S. consular authority to have a medical examination;
( iii ) Applicants outside the United States who apply for refugee status;
( iv ) Applicants in the United States who apply for adjustment of their status under the immigration statute and regulations.
( v ) Applicants required by DHS to have a medical examination in connection with determination of their admissibility into the United States.
( 2 ) *Chest radiograph examination and serologic testing.* Except as provided in paragraph (e)(2)(iv) of this section, applicants described in paragraph (e)(1) of this section shall be required to have the following: ( i ) For applicants 15 years of age and older, a chest radiograph examination;
( ii ) For applicants under 15 years of age, a chest radiograph examination if the applicant has symptoms of tuberculosis, a history of tuberculosis, or evidence of possible exposure to a transmissible tuberculosis case in a household or other enclosed environment for a prolonged period;
( iii ) For applicants 15 years of age and older, serologic testing for syphilis and other *communicable diseases of public health significance* as determined by the Director through technical instructions.
( iv ) *Exceptions.* Serologic testing for syphilis shall not be required if the alien is under the age of 15, unless there is reason to suspect infection with syphilis. An alien, regardless of age, in the United States, who applies for adjustment of status to lawful permanent resident, shall not be required to have a chest radiograph examination unless their tuberculin skin test, or an equivalent test for showing an immune response to *Mycobacterium tuberculosis* antigens, is positive. HHS/CDC may authorize exceptions to the requirement for a tuberculin skin test, an equivalent test for showing an immune response to *Mycobacterium tuberculosis* antigens, or chest radiograph examination for good cause, upon application approved by the Director.
( 3 ) *Immune response to Mycobacterium tuberculosis antigens.* ( i ) All aliens 2 years of age or older in the United States who apply for adjustment of status to permanent residents, under the immigration laws and regulations, or other aliens in the United States who are required by DHS to have a medical examination in connection with a determination of their admissibility, shall be required to have a tuberculin skin test or an equivalent test for showing an immune response to *Mycobacterium tuberculosis* antigens. Exceptions to this requirement may be authorized for good cause upon application approved by the Director. In the event of a positive test of immune response, a chest radiograph examination shall be required. If the chest radiograph is consistent with tuberculosis, the alien shall be referred to the local health authority for evaluation. Evidence of this evaluation shall be provided to the civil surgeon before a medical notification may be issued.
( ii ) Aliens in the United States less than 2 years of age shall be required to have a tuberculin skin test, or an equivalent, appropriate test to show an immune response to *Mycobacterium tuberculosis* antigens, if there is evidence of contact with a person known to have tuberculosis or other reason to suspect tuberculosis. In the event of a positive test of immune response, a chest radiograph examination shall be required. If the chest radiograph is consistent with tuberculosis, the alien shall be referred to the local health authority for evaluation. Evidence of this evaluation shall be provided to the civil surgeon before a medical notification may be issued.
( iii ) Aliens outside the United States required to have a medical examination shall be required to have a tuberculin skin test, or an equivalent, appropriate test to show an immune response to Mycobacterium tuberculosis antigens, and, if indicated, a chest radiograph.
( iv ) Aliens outside the United States required to have a medical examination shall be required to have a tuberculin skin test, or an equivalent, appropriate test to show an immune response to *Mycobacterium tuberculosis* antigens, and a chest radiograph, regardless of age, if he/she has symptoms of tuberculosis, a history of tuberculosis, or evidence of possible exposure to a transmissible tuberculosis case in a household or other enclosed environment for a prolonged period, as determined by the Director.
( 4 ) *Additional testing requirements.* All applicants may be required to undergo additional testing for tuberculosis based on the medical evaluation.
( 5 ) *How and where performed.* All chest radiograph images used in medical examinations performed under the regulations to this part shall be large enough to encompass the entire chest.
( 6 ) *Chest x-ray, laboratory, and treatment reports.* The chest radiograph reading and serologic test results for syphilis shall be included in the medical notification. When the medical examiner's conclusions are based on a study of more than one chest x-ray image, the medical notification shall include at least a summary statement of findings of the earlier images, followed by a complete reading of the last image, and dates and details of any laboratory tests and treatment for tuberculosis.
( f ) *Procedure for transmitting records.* For aliens issued immigrant visas, the medical notification and chest radiograph images, if any, shall be placed in a separate envelope, which shall be sealed. When more than one chest radiograph image is used as a basis for the examiner's conclusions, all images shall be included. Records may be transmitted by other means, as approved by the Director.
( g ) *Failure to present records.* When a determination of admissibility is to be made at the U.S. port of entry, a medical hold document shall be issued pending completion of any necessary examination procedures. A medical hold document may be issued for aliens who: ( 1 ) Are not in possession of a valid medical notification, if required;
( 2 ) Have a medical notification which is incomplete;
( 3 ) Have a medical notification which is not written in English;
( 4 ) Are suspected to have an inadmissible medical condition.
( h ) The Secretary of Homeland Security, after consultation with the Secretary of State and the Secretary of Health and Human Services, may in emergency circumstances permit the medical examination of refugees to be completed in the United States.
( i ) All medical examinations shall be carried out in accordance with such technical instructions for physicians conducting the medical examination of aliens as may be issued by the Director. Copies of such technical instructions are available upon request to the Director, Division of Global Migration and Quarantine, Mailstop E03, HHS/CDC, Atlanta GA 30333.