Application for Civil Surgeon Designation

Instructions forApplication for Civil Surgeon Designation
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-910

OMB No. 1615-0114
Expires 05/31/2018

What Is the Purpose of Form I-910?
Form I-910, Application for Civil Surgeon Designation, is used by physicians seeking designation as a civil surgeon.

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What Is a Civil Surgeon?

By law, a civil surgeon is a physician designated by U.S. Citizenship and Immigration Services (USCIS) to conduct
immigration medical examinations for individuals applying for an immigration benefit in the United States.
Unless you are a medical officer of U.S. Public Health Service (PHS), you must have civil surgeon designation if you wish
to conduct immigration medical examinations in the United States. If you are not a designated USCIS civil surgeon (or a
PHS medical officer), you are not authorized to conduct medical examinations for immigration benefit applications in the
United States or complete Form I-693, Report of Medical Examination and Vaccination Record.
Civil surgeon designation does not authorize you to conduct immigration medical examinations for individuals seeking
immigration benefits abroad through the visa issuance process of U.S. Department of State (DOS). Those immigration
medical examinations are conducted by DOS-designated panel physicians overseas. For more information, visit the DOS
website at travel.state.gov/content/travel/en/us-visas/immigrate/the-immigrant-visa-process/interview/interviewprepare/medical-examination.html.
NOTE: Physicians performing medical examinations not related to immigration benefits, including medical examinations
for immigration detainees or U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection
(CBP), and other government entities (for example, PHS physicians), are not required to have civil surgeon designation.

Who Should Use Form I-910?

Use Form I-910 if you are a physician seeking civil surgeon designation to perform immigration medical examinations in
the United States and complete Form I-693, but you are not currently designated as a civil surgeon.
NOTE: Military and public health department physicians who qualify for blanket civil surgeon designation by USCIS are
not required to apply for civil surgeon designation on Form I-910. For information on blanket civil surgeon designation,
visit www.uscis.gov/civilsurgeons.

What Professional Qualifications Are Required for Civil Surgeon Designation?
In order for USCIS to designate you as a civil surgeon, you must:
1. Have an unrestricted license as a doctor of medicine (M.D.) or doctor of osteopathy (D.O.) in the U.S. state or U.S.
territory in which you seek to perform immigration medical examinations;
2. Have at least four years of professional experience as a physician; and
3. Have authorization to work in the United States.

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Are There Other Requirements for Civil Surgeon Designation?
In addition to meeting the professional qualifications, you must:
1. Apply for civil surgeon designation using Form I-910;
2. Submit the completed Form I-910 with the correct filing fee; and
3. Have active medical practices at the locations where you are requesting to perform immigration medical
examinations. USCIS will not grant your civil surgeon designation for locations where you intend to practice only in
the future or where you no longer practice.

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NOTE: Civil surgeon designation is at the discretion of USCIS. Although you may meet the specified, professional
qualifications and other requirements listed on Form I-910, USCIS cannot guarantee you will receive designation as a civil
surgeon.

What Are the Responsibilities of a Civil Surgeon?

If USCIS designates you as a civil surgeon, you must comply with the following requirements:

1. You are responsible for truthfully and accurately reporting the results of an applicant’s immigration medical
examination and all laboratory reports on Form I-693, where indicated, and for signing the civil surgeon’s certification
on Form I-693.
You must take reasonable steps to ensure the person appearing for the immigration medical examination is the same
person applying for the requested immigration benefit. Generally, applicants must present a valid, government-issued
photo identification (for example, a valid, unexpired passport or driver’s license) at the time of their immigration
medical examinations, and you must annotate the type of identification presented and identification number in Part 1.
of Form I-693, if applicable. The law imposes severe penalties for knowingly and willfully falsifying or concealing a
material fact or using any false documents in connection with immigration medical examinations.
You should also ensure the applicant’s name and Alien Registration Number (A-Number) (if any) are at the top of
each page of Form I-693 and match the information provided in Part 1. of Form I-693.
2. Follow Department of Health and Human Services (HHS) regulations and Centers for Disease Control and Prevention
(CDC) guidelines. USCIS designates civil surgeons with the understanding you will perform the immigration
medical examination according to HHS regulations found at 42 CFR part 34. These regulations include the specific
guidelines found in the Technical Instructions for the Medical Examination of Aliens in the United States (Technical
Instructions), published by CDC in Atlanta, Georgia. Civil surgeons should address any questions about the Technical
Instructions directly to CDC. USCIS cannot answer medical questions involving the Technical Instructions. The
Technical Instructions, including periodic updates posted by CDC, are available on the CDC website at www.cdc.gov/
immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil-surgeons.html.
3. Make referrals and file case reports, as required. The CDC’s Technical Instructions require you to:
A. Refer the applicant to the local health department if the chest x-ray suggests tuberculosis (TB) or if other healthrelated circumstances are present, as specified in the CDC’s Technical Instructions;
B. Ensure testing and therapy are given for diagnoses of communicable diseases of public health significance, as
outlined in the CDC’s Technical Instructions; and
C. File a case report with the appropriate public health authorities if required by local laws or regulations. You must
also advise the applicant you are filing a case report.

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4. Notify USCIS of any changes relevant to your designation as a civil surgeon. You are responsible for notifying
USCIS in the event that:
A. You cease to practice medicine;
B. You cease to perform immigration medical examinations in the U.S. state or U.S. territory or at the locations
associated with your civil surgeon designation; or
C. Your contact information changes (for example, name of office, address, telephone number, fax number, or email
address).
NOTE: You should notify USCIS within 15 days of the change. See the When and How Do I Update My Civil
Surgeon Information section of these Instructions for more information.

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Can USCIS Revoke Civil Surgeon Designation?

USCIS may revoke a civil surgeon designation. Reasons for revocation include, but are not limited to:
1. Failure to continue meeting the professional qualifications required for civil surgeon designation;

2. Failure to meet the responsibilities of a civil surgeon, including failure to follow the CDC’s Technical Instructions;
3. Engaging in immigration fraud; or

4. Engaging in any activity that poses a risk to public health or safety.

General Instructions

USCIS provides forms free of charge through the USCIS website. In order to view, print, or fill out our forms, you should
use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not
have internet access, you may call the USCIS National Customer Service Center at 1-800-375-5283 and ask that we mail a
form to you. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Signature. Each application must be properly signed and filed. For all signatures on this application, USCIS will not
accept a stamped or typewritten name in place of a signature.
Validity of Signatures. USCIS will consider a photocopied, faxed, or scanned copy of the original, handwritten signature
valid for filing purposes. The photocopy, fax, or scan must be of the original document containing the handwritten, ink
signature.
Filing Fee. Each application must be accompanied by the appropriate filing fee. (See the What Is the Filing Fee section
of these Instructions.)
Evidence. At the time of filing, you must submit all evidence and supporting documents listed in the Specific Instructions
section of these Instructions.
Copies. You should submit legible photocopies of documents requested, unless the Instructions specifically state that you
must submit an original document. USCIS may request an original document at the time of filing or at any time during
processing of your application. If USCIS requests an original document from you, it will be returned to you after USCIS
determines it no longer needs your original.
NOTE: If you submit original documents when not required or requested by USCIS, your original documents may be
immediately destroyed after we receive them.

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Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and that
he or she is competent to translate from the foreign language into English. The certification must include the translator’s
signature. Department of Homeland Security (DHS) recommends the certification contain the translator’s printed name,
the signature date, and the translator’s contact information.
How To Fill Out Form I-910
1. Type or print legibly in black ink.
2. If you need extra space to complete any item within this application, use the space provided in Part 9. Additional
Information or attach a separate sheet of paper. Type or print your name and Civil Surgeon Identification (CSID)
Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your
answer refers; and sign and date each sheet.

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3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been
married and the question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many
children do you have” or “How many times have you departed the United States”), type or print “None” unless
otherwise directed.

Specific Instructions

NOTE: You must submit all evidence requested in these Instructions with your application. If you fail to submit required
evidence, USCIS may reject or deny your application for failure to submit requested evidence or supporting documents in
accordance with 8 CFR 103.2(b)(1) and these Instructions.
Part 1. Information About You (The Applicant)

NOTE: Complete Item Numbers 1.a. - 3.b. only if you were previously designated as a civil surgeon.

Item Numbers 1.a. - 1.d. General Information About Previous Civil Surgeon Designation. If you were previously
designated as a civil surgeon, select “Yes” and provide the period of prior designation, the USCIS office that granted the
designation, and the CSID Number issued, if known.
Item Numbers 2.a. - 2.b. Revocation. If USCIS revoked your previous civil surgeon designation, select “Yes” and
provide the date of revocation. Attach the revocation letter you received from USCIS. Also explain the circumstances
surrounding the revocation in a separate sheet of paper attached to your Form I-910 or in Part 9. Additional Information.
Please note that USCIS may deny your Form I-910 if the grounds upon which your previous designation was revoked still
exist.
Item Numbers 3.a. - 3.b. Voluntary Termination. If you voluntarily terminated your previous civil surgeon
designation, select “Yes” and provide the date of voluntary termination. Also explain the circumstances surrounding the
voluntary termination in a separate sheet of paper attached to your Form I-910 or in Part 9. Additional Information.
Item Numbers 4.a. - 4.c. Your Full Name. Provide your full legal name as shown on your birth certificate or legal name
change document in the spaces provided.
Item Numbers 5.a. - 5.c. Other Names Used. Provide all other names you have used since birth, including your maiden
name, any nicknames, and any names that appear in your documents. If you need extra space, use Part 9. Additional
Information to provide other names used.
Item Number 6. Date of Birth. Provide your date of birth in mm/dd/yyyy format in the space provided. For example,
type or print October 5, 1967 as 10/05/1967.

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Item Number 7. Gender. Select the box that indicates whether you are male or female.
Item Number 8. USCIS Online Account Number (if any). If you have previously filed an application or petition using
the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)), provide the
USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account Number by
logging in to your account and going to the profile page. If you previously filed certain applications or petitions on a
paper form through a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice issuing
you a USCIS Online Account Number. You may find your USCIS Online Account Number at the top of the notice. The
USCIS Online Account Number is not the same as an A-Number. If you were issued a USCIS Online Account Number,
enter it in the space provided.

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Item Number 9. Alien Registration Number (A-Number) (if any). An Alien Registration Number, otherwise
known as an “A-Number,” is typically issued to people who apply for, or are granted, certain immigration benefits. In
addition to USCIS, ICE, CBP, and DOS may also issue an A-Number to certain foreign nationals. If you were issued an
A-Number, type or print it in the spaces provided. If you have more than one A-Number, use the space provided in Part
9. Additional Information to provide the information. If you do not have an A-Number or if you cannot remember it,
leave this space blank.
Part 2. Clinical Office Locations

Item Numbers 1. - 5. Name and Physical Address of the Clinic/Practice. Provide the name, physical address,
telephone number, fax number, and email address of the clinic or practice where you intend to perform immigration
medical examinations if granted civil surgeon designation. Failure to provide this information may result in the denial
of your Form I-910.
If you intend to perform immigration medical examinations in more than one location, provide the details for each
additional location in Part 9. Additional Information.
NOTE: You must currently have active practices at the locations where you are requesting to perform immigration
medical examinations. USCIS will not grant civil surgeon designation for locations where you intend to practice only in
the future.
NOTE REGARDING PHYSICAL ADDRESS: The physical address is the address where you are practicing medicine
and where applicants will come to have the medical examination performed. The physical address must match the
location of your medical clinic or practice.
Item Numbers 6. - 14. Additional Office Information. You may submit additional information to USCIS for inclusion
in the public list of civil surgeons. USCIS displays this information on our website for applicants who want to find a civil
surgeon. USCIS will update the public list with this information.
Part 3. Information About Your Status in the United States
Item Numbers 1. - 4. Provide information about the immigration status you were granted in the United States that allows
you to work and practice medicine in the United States. A physician meeting the professional qualifications for civil
surgeon designation can receive designation as a civil surgeon only if authorized to work in the United States. Specify
whether you are a U.S. citizen or national, a lawful permanent resident, a nonimmigrant authorized to work as a physician
in the United States, or an immigrant in another status that would allow you to practice medicine in the United States.
Attach evidence establishing your legal status in the United States.
1. If you select Item Number 1., submit proof that you are a U.S. citizen or national, such as a copy of a U.S. passport,
birth certificate, or Certificate of Naturalization.
2. If you select Item Number 2., submit a copy of your valid Form I-551, Permanent Resident Card. If you are
currently seeking to renew or replace your Form I-551, submit evidence your Form I-90, Application to Replace
Permanent Resident Card, is pending or approved. For more information, visit
www.uscis.gov/green-card/after-green-card-granted.

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3. If you select Item Number 3.a., you must also provide the information requested in Item Numbers 3.b. - 3.h.
A. Item Number 3.b. Date of Last Arrival in the U.S. (mm/dd/yyyy). Provide the date of your last arrival to the
United States.
B. Item Number 3.c. Form I-94, Arrival-Departure Record. If CBP or USCIS issued you a Form I-94, ArrivalDeparture Record, provide your Form I-94 number and date that your authorized period of stay expires or expired
(as shown on your Form I-94). The Form I-94 number also is known as the Departure Number on some versions
of Form I-94.
NOTE: If you were admitted to the United States by CBP at an airport or seaport after April 30, 2013, CBP
may have issued you an electronic Form I-94 instead of a paper Form I-94. You may visit the CBP website
at www.cbp.gov/i94 to obtain a paper version of an electronic Form I-94. CBP does not charge a fee for this
service. Some travelers admitted to the United States at a land border, airport, or seaport after April 30, 2013,
with a passport or travel document, who were issued a paper Form I-94 by CBP, may also be able to obtain a
replacement Form I-94 from the CBP website without charge. If you cannot obtain your Form I-94 from the
CBP website, you may obtain it by filing Form I-102, Application for Replacement/Initial Nonimmigrant ArrivalDeparture Record, with USCIS. USCIS does charge a fee for this service. See the USCIS website at
www.uscis.gov/I-102 for more information.

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C. Item Numbers 3.d. - 3.h. Passport and Travel Document Numbers. If you used a passport or travel document
to travel to the United States, enter either the passport or travel document information in the appropriate space on
the application, even if the passport or travel document is currently expired.
4. Select Item Number 4. if USCIS issued you an Employment Authorization Document (EAD) that authorizes you to
work in the United States. Attach a copy of your valid, unexpired EAD as proof you are authorized to work in the
United States.
Part 4. Medical Licenses

Item Numbers 1.a. - 2.d. You must have a license to practice medicine in each U.S. state or U.S. territory in which you
seek to perform immigration medical examinations. For each U.S. state or U.S. territory in which you seek to perform
immigration medical examinations, provide the following:
1. The name of the U.S. state or U.S. territory that issued your medical license;
2. The medical license number;

3. The date the medical license was issued; and
4. The date the medical license expires.

Attach a copy of each of your medical licenses to your Form I-910.
Part 5. Medical Degrees
Item Numbers 1.a. - 2.c. Only doctors of medicine (M.D.) and doctors of osteopathy (D.O.) may receive designation as
civil surgeons. Provide the following:
1. The names of the schools you attended;
2. The dates of your attendance; and
3. The type of medical degrees you earned.
Attach a copy of each of your medical degrees to your Form I-910.

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Part 6. Professional Experience
Item Numbers 1.a. - 2.h. To receive designation as a civil surgeon, you must establish you have practiced medicine as a
physician (M.D. or D.O.) for at least four years. Provide the following information to cover a period of at least four years:
1. The names of each employer;
2. The dates of your employment with each employer; and
3. The contact information for each employer.
NOTE: In calculating whether you meet the four-year practice requirement as a physician, do not count your postgraduate medical training in an internship or residency program. You can, however, count the time you practiced
medicine on the basis of a post-residency fellowship. Submit evidence establishing your professional experience, such as
evaluations, certificates of completion, business tax returns and business licenses (for self-employed physicians), or letters
of employment verification.

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Part 7. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature

Item Numbers 1. - 5.b. If someone assisted you in completing the application, select the box indicating that you used a
preparer. Further, you must sign and date your application and provide your daytime telephone number, mobile telephone
number (if any), and email address (if any). Every application MUST contain the signature of the applicant. A stamped
or typewritten name in place of a signature is not acceptable.
Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than
the Applicant
Item Numbers 1.a. - 9.b. This section must contain the signature of the person who completed your application, if
other than you, the applicant. If the person who completed this application is associated with a business or organization,
that person should complete the business or organization name and address information. Anyone who helped you
complete this application MUST sign and date the application. A stamped or typewritten name in place of a signature
is not acceptable. If the person who helped you prepare your application is an attorney or accredited representative,
he or she may also need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, along with your application.
NOTE: Select Item Number 7. if the preparer may act as a secondary point of contact for you, if USCIS is unable to
contact you using the information provided in Part 2. Clinical Office Locations.
Part 9. Additional Information

Item Numbers 1.a. - 7.d. If you need extra space to provide any additional information within this application, use the
space provided in Part 9. Additional Information. If you need more space than what is provided in Part 9., you may
make copies of Part 9. to complete and file with your application, or attach a separate sheet of paper. Type or print your
name and CSID Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to
which your answer refers; and sign and date each sheet.
You may also submit a statement with additional information on a separate sheet of paper, but you must annotate in Part 9.
that you are attaching a separate sheet. You must submit the separate sheet at the same time you submit your Form I-910.
Type or print your name and CSID Number (if any) at the top of each separate sheet; indicate the Page Number, Part
Number, and Item Number of Form I-910 to which the additional information relates; and sign and date each sheet.
We recommend that you print or save a copy of your completed application to review in the future
and for your records.

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What Is the Filing Fee?
The filing fee for Form I-910 is $785.
Exception: There is no filing fee for an application submitted by a medical officer in the U.S. Armed Forces or from
a civilian physician employed by the U.S. Government who examines members and veterans of the of the U.S. Armed
Forces and their dependents at a military, Department of Veterans Affairs, or U.S. Government facility in the United
States.
NOTE: The filing fee is not refundable, regardless of any action USCIS takes on this application. DO NOT MAIL
CASH. You must submit all fees in the exact amounts.

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Payments by Check or Money Order

Use the following guidelines when you prepare your check or money order for the Form I-910 filing fee:

1. The check or money order must be drawn on a bank or other financial institution located in the United States and must
be payable in U.S. currency; and
2. Make the check or money order payable to U.S. Department of Homeland Security.

NOTE: Spell out U.S. Department of Homeland Security; do not use the initials “USDHS” or “DHS.”
Notice to Those Paying by Check. If you send USCIS a check, we will convert it into an electronic funds transfer (EFT).
This means we will copy your check and use the account information on it to electronically debit your account for the
amount of the check. The debit from your account will usually take 24 hours and your bank will show it on your regular
account statement.
You will not receive your original check back. We will destroy your original check, but will keep a copy of it. If USCIS
cannot process the EFT for technical reasons, you authorize us to process the copy in place of your original check. If
your check is returned as unpayable, we will re-submit the payment to the financial institution one time. If the check is
returned as unpayable a second time, we will reject your application and charge you a returned check fee.
Payments by Credit Card

If you are filing your form at a USCIS Lockbox facility, you can pay your filing fee using a credit card. Please see Form
G-1450, Authorization for Credit Card Transactions, at www.uscis.gov/G-1450 for more information.
How To Check If the Fees Are Correct

Form I-910’s filing fee is current as of the edition date in the lower left corner of this page. However, because USCIS fees
change periodically, you can verify that the fee is correct by following one of the steps below.
1. Visit the USCIS website at www.uscis.gov, select “FORMS,” and check the appropriate fee; or
2. Call the USCIS National Customer Service Center at 1-800-375-5283 and ask for fee information. For TTY (deaf or
hard of hearing) call: 1-800-767-1833.

Where To File?
Please see our website at www.uscis.gov/I-910 or call our National Customer Service Center at 1-800-375-5283 for the
most current information about where to file this application. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

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Where Is Civil Surgeon Information Listed?
USCIS provides a list of civil surgeons for public use. You can access the list in two ways:
1. Visit the USCIS website at my.uscis.gov/findadoctor and enter a zip code or address; or
2. Call the USCIS National Customer Service Center at 1-800-375-5283 and follow the instructions in the automated
menu. For TTY (deaf or hard of hearing) call: 1-800-767-1833.

When and How Do I Update My Civil Surgeon Information?

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You should notify USCIS within 15 days of any changes relevant to your designation, including address and other contact
information, practice location, and medical license restrictions, suspensions, or revocations.
Visit the USCIS website at www.uscis.gov/I-910 for the most current information about how and where to submit an
update to your civil surgeon information.
NOTE: If the change is an update to your contact information that involves practicing in a new U.S. state or U.S. territory,
then you may not perform immigration medical examinations in the new U.S. state or U.S. territory until USCIS approves
the change. In this case, you must submit your new contact information to USCIS with evidence you are licensed to
practice medicine in the new U.S. state or U.S. territory in which you seek to perform immigration medical examinations.
USCIS will also conduct compliance reviews or audits to ensure the accuracy of civil surgeon information. As part of
these compliance reviews or audits, USCIS may contact you to verify some or all of the information provided on Form
I-910. If USCIS is unable to verify your continued eligibility for designation or confirm your contact information, or if
USCIS determines you are no longer practicing medicine or performing immigration medical examinations, USCIS may
revoke or terminate your designation and remove you from the public list.

Processing Information

Initial Processing. Once USCIS accepts your application, we will check it for completeness. If you do not completely
fill out this application, you will not establish a basis for your eligibility and USCIS may reject or deny your application.
Requests for More Information. USCIS may request that you provide more information or evidence to support your
application. We may also request that you provide the originals of any copies you submit. If we request an original
document from you, it will be returned to you after USCIS determines it no longer needs your original.
Decision. The decision on Form I-910 involves a determination of whether you have established eligibility for the
designation you are seeking. USCIS will notify you of the decision in writing.

USCIS Forms and Information
To ensure you are using the latest version of this application, visit the USCIS website at www.uscis.gov where you can
obtain the latest USCIS forms and immigration-related information. If you do not have internet access, you may order
USCIS forms by calling the Forms Request Line at 1-800-870-3676. You may also obtain forms and information by
calling the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call:
1-800-767-1833.
Instead of waiting in line for assistance at your local USCIS office, you can schedule an appointment online at
www.uscis.gov. Select “Make an Appointment” and follow the screen prompts to set up your appointment. Once you
finish scheduling an appointment, the system will generate an appointment notice for you.
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Penalties
If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-910, we will
deny your Form I-910 and may deny any other immigration benefit. In addition, you will face severe penalties provided
by law and may be subject to criminal prosecution.

USCIS Compliance Review and Monitoring
By signing this application, you have stated under penalty of perjury (28 U.S.C. section 1746) that all information and
documentation submitted with this application are complete, true, and correct. You also authorize the release of any
information from your records that USCIS may need to determine your eligibility for the designation you are seeking and
consent to USCIS verifying such information.

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DHS has the authority to verify any information you submit to establish eligibility for the designation you are seeking at
any time. USCIS’ legal authority to verify this information is in 8 U.S.C. sections 1103 and 1222(b) and 8 CFR 232.2(b).
To ensure compliance with applicable laws and authorities, USCIS may verify information before or after your case is
decided.
Agency verification methods may include, but are not limited to: review of public records and information; contact
through written correspondence, the internet, fax, other electronic transmission, or telephone; unannounced physical site
inspections of medical clinics or practices; and interviews. USCIS will use information obtained through verification to
assess your compliance with the laws and to determine your eligibility for designation.
Subject to the restrictions under 8 CFR 103.2(b)(16), USCIS will provide you with an opportunity to address any adverse
or derogatory information that may result from a USCIS compliance review, verification, or site visit after a formal
decision is made on your case or after the agency has initiated an adverse action which may result in revocation or
termination of an approval.

DHS Privacy Notice

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the
Immigration and Nationality Act section 232.
PURPOSE: The primary purpose for requesting the requested information is to determine whether you are eligible to be
designated as a USCIS Civil Surgeon. DHS will use the information you provide to grant or deny the immigration benefit
you are seeking.
DISCLOSURE: Providing this information is voluntary. However, failure to provide the requested information, and any
requested evidence, may delay a final decision in your case or result in denial of your request to be designated as a Civil
Surgeon.
ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign
government agencies and authorized organizations. DHS follows approved routine uses, as described in the associated
published system of records notices [DHS-USCIS-007 - Benefits Information System] and as described in the Privacy
Impact Assessment [DHS/USCIS/PIA-067 Civil Surgeon Designation] which you can find at www.dhs.gov/privacy.
DHS may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.

Form I-910 Instructions 12/23/16 N

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Paperwork Reduction Act
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection
of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public
reporting burden for this collection of information is estimated at 2 hours per response, including the time for reviewing
instructions, gathering the required documentation and information, completing the application, preparing statements,
attaching necessary documentation, and submitting the application. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship
and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW,
Washington, DC 20529-2140; OMB No. 1615-0114. Do not mail your completed Form I-910 to this address.

Draft
Not for
Reproduction
04/18/2018

Is Your Application Complete?

Ensure you have completed the following actions before you file Form I-910 with USCIS.

Did you fill out the application properly, leaving spaces blank on any questions that did not apply to you?
Did you sign and date your application where required?

If you had someone else prepare the application on your behalf, did that person complete Part 8. Contact
Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant
and sign and date the application?
If the person who prepared the application on your behalf was an attorney, did the attorney submit Form G-28 with
the application?
Did you include a check or money order according to the What Is the Filing Fee section of these Instructions?
Did you attach the required documentation or evidence, including proof of your immigration status in the United
States, copies of medical degrees and current U.S. state or U.S. territory medical licenses, and proof that you meet
the professional experience requirement because you have practiced medicine as a physician (M.D. or D.O.) for at
least four years?
If you intend to perform immigration medical examinations in more than one location, did you provide details for
each additional location in Part 9. Additional Information?

Form I-910 Instructions 12/23/16 N

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