Authorizing legislation - 42 CFR

Code of Federal Regulations
Title 42 - Public Health
Volume: 1Date: 2013-10-01Original Date: 2013-10-01Title: PART 34 - MEDICAL EXAMINATION OF
ALIENSContext: Title 42 - Public Health. CHAPTER I - PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH
AND HUMAN SERVICES. SUBCHAPTER C - MEDICAL CARE AND EXAMINATIONS.
Pt. 34PART 34—MEDICAL EXAMINATION OF ALIENSSec.34.1Applicability.34.2Definitions.34.3Scope of
examinations.34.4Medical notifications.34.5Postponement of medical examination.34.6Applicability of Foreign
Quarantine Regulations.34.7Medical and other care; death.34.8Reexamination; convening of review boards;
expert witnesses; reports.Authority:42 U.S.C. 252; 8 U.S.C. 1182 and 1222.§ 34.1 Applicability. The provisions of
this part shall apply to the medical examination of:(a) Aliens applying for a visa at an embassy or consulate of the
United States;(b) Aliens arriving in the United States;(c) Aliens required by the INS to have a medical examination
in connection with determination of their admissibility into the United States; and(d) Aliens applying for adjustment
status. [56 FR 25001, May 31, 1991]
§ 34.2 Definitions. As used in this part, terms shall have the following meanings:(a) CDC. Centers for Disease
Control, Public Health Service, U.S. Department of Health and Human Services.(b) Communicable disease of
public health significance. Any of the following diseases:(1) Chancroid.(2) Communicable diseases as listed in a
Presidential Executive Order, as provided under Section 361(b) of the Public Health Service Act. The current
revised list of quarantinable communicable diseases is available at http://www.cdc.gov and
http://www.archives.gov/federal-register.(3) Communicable diseases that may pose a public health emergency of
international concern if it meets one or more of the factors listed in § 34.3(d) and for which the CDC Director has
determined (A) a threat exists for importation into the United States, and (B) such disease may potentially affect
the health of the American public. The determination will be made consistent with criteria established in Annex 2
of the revised International Health Regulations (http://www.who.int/csr/ihr/en/), as adopted by the Fifty-Eighth
World Health Assembly in 2005, and as entered into effect in the United States in July, 2007, subject to the U.S.
Government's reservation and understandings:(i) Any of the communicable diseases for which a single case
requires notification to the World Health Organization (WHO) as an event that may constitute a public health
emergency of international concern, or(ii) Any other communicable disease the occurrence of which requires
notification to the WHO as an event that may constitute a public health emergency of international
concern.HHS/CDC's determinations will be announced by notice in the Federal Register.(4) Gonorrhea.(5)
Granuloma inguinale.(6) Leprosy, infectious.(7) Lymphogranuloma venereum.(8) Syphilis, infectious stage.(9)
Tuberculosis, active.(c) Civil surgeon. A physician, with not less than 4 years' professional experience, selected
by the District Director of INS to conduct medical examinations of aliens in the United States who are applying for
adjustment of status to permanent residence or who are required by the INS to have a medical examination.(d)
Class A medical notification. Medical notification of:(1) A communicable disease of public health significance;(2)(i)
A 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; or(3) Drug abuse or addiction.(e)
Class B medical notification. Medical notification of a physical or mental abnormality, disease, or disability serious
in degree or permanent in nature amounting to a substantial departure from normal well-being.(f) Director. The
Director of the Centers for Disease Control.(g) Drug abuse. The non-medical use of a substance listed in section
202 of the Controlled Substances Act, as amended (21 U.S.C. 802) which has not necessarily resulted in physical
or psychological dependence.(h) Drug addiction. The non-medical use of a substance listed in section 202 of the
Controlled Substances Act, as amended (21 U.S.C. 802) which has resulted in physical or psychological
dependence.(i) INS. Immigration and Naturalization Service, U.S. Department of Justice.(j) Medical examiner. A
panel physician, civil surgeon, or other physician designated by the Director to perform medical examinations of
aliens.(k) Medical hold document. A document issued to the INS by a quarantine inspector of the Public Health
Service at a port of entry which defers the inspection for admission until the cause of the medical hold is
resolved.(l) Medical notification. A document issued to a consular authority or the INS by a medical examiner,
certifying the presence or absence of:
(1) A communicable disease of public health significance;(2)(i) A 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;(3) Drug abuse or addiction; or(4) Any other physical abnormality, disease, or

disability serious in degree or permanent in nature amounting to a substantial departure from normal wellbeing.(m) Medical officer. A physician of the Public Health Service Commissioned Corps assigned by the Director
to conduct physical and mental examinations of aliens.(n) Mental disorder. A currently accepted psychiatric
diagnosis, as defined by the Diagnostic and Statistical Manual of Mental Disorders published by the American
Psychiatric Association, or by other authoritative sources.(o) Panel physician. A physician selected by a United
States embassy or consulate to conduct medical examinations of aliens applying for visas.(p) Physical disorder. A
currently accepted medical diagnosis, as defined by the Manual of the International Classification of Diseases,
Injuries, and Causes of Death published by the World Health Organization, or by other authoritative sources. [21
FR 9829, Dec. 12, 1956, as amended at 52 FR 32543, Aug. 28, 1987; 56 FR 25001, May 31, 1991; 73 FR 58056,
Oct. 6, 2008; 74 FR 56562, Nov. 2, 2009]
§ 34.3 Scope of examinations. (a) General. In performing examinations, medical examiners shall consider those
matters that relate to the following:(1) A communicable disease of public health significance;(2)(i) A 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;(3) Drug abuse or addiction; and(4) Any other physical
abnormality, disease, or disability serious in degree or permanent in nature amounting to a substantial departure
from normal well-being.(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) 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, for the examining physician to reach a conclusion about the presence or absence of a physical or
mental abnormality, disease, or disability.(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 (b)(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 X-ray examination and serologic testing. (1) As
provided in paragraph (e)(2) of this section, a chest x-ray 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.(2) Chest X-ray
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 x-ray examination;(ii) For applicants under 15 years of age, a chest x-ray 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 HIV.(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 x-ray 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 M. tuberculosis antigens, or chest x-ray 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 the U.S. Department of Homeland Security 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 tuberculin reaction, a chest X-ray 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 less than 2 years old 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 tuberculin
reaction, a chest X-ray 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 they have 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.(4) Additional testing requirements. All applicants subject to the chest radiograph requirement,
and for whom the radiograph shows an abnormality suggestive of tuberculosis disease, shall be required to
undergo additional testing for tuberculosis.(5) How and where performed. All chest x-ray images used in medical
examinations performed under the regulations to this part shall be large enough to encompass the entire chest
(approximately 14×17 inches; 35.6×32.2 cm).(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 X-ray images, if any,
shall be placed in a separate envelope which shall be sealed. When more than one chest X-ray image is used as
a basis for the examiner's conclusions, all images shall be included.(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 excludable
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.
[73 FR 58056, Oct. 6, 2008, as amended at 73 FR 62211, Oct. 20, 2008; 74 FR 56562, Nov. 2, 2009]
§ 34.4 Medical notifications. (a) Medical examiners shall issue medical notifications of their findings of the
presence or absence of Class A or Class B medical conditions. The presence of such condition must have been
clearly established.(b) Class A medical notifications. (1) The medical examiner shall report his/her findings to the
consular officer or the INS by Class A medical notification which lists the specific condition for which the alien may
be excluded, if an alien is found to have:(i) A communicable disease of public health significance;(ii)(A) A 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; or(B) 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;(iii) Drug abuse or addition.Provided,
however, That a Class A medical notification of a physical or mental disorder, and behavior associated with that
disorder that may pose, or has posed, a threat to the property, safety, or welfare of the alien or others, shall in no
case be issued with respect to an alien having only mental shortcomings due to ignorance, or suffering only from
a condition attributable to remediable physical causes or of a temporary nature, caused by a toxin, medically
prescribed drug, or disease.(2) The medical notification shall state the nature and extent of the abnormality; the
degree to which the alien is incapable of normal physical activity; and the extent to which the condition is
remediable. The medical examiner shall indicate the likelihood, that because of the condition, the applicant will
require extensive medical care or institutionalization.(c) Class B medical notifications. (1) If an alien is found to
have a physical or mental abnormality, disease, or disability serious in degree or permanent in nature amounting
to a substantial departure from normal well-being, the medical examiner shall report his/her findings to the
consular or INS officer by Class B medical notification which lists the specific conditions found by the medical
examiner. Provided, however, that a Class B medical notification shall in no case be issued with respect to an
alien having only mental shortcomings due to ignorance, or suffering only from a condition attributable to
remediable physical causes or of a temporary nature, caused by a toxin, medically prescribed drug, or disease.(2)
The medical notification shall state the nature and extent of the abnormality, the degree to which the alien is
incapable of normal physical activity, and the extent to which the condition is remediable. The medical examiner
shall indicate the likelihood, that because of the condition, the applicant will require extensive medical care or
institutionalization.(d) Other medical notifications. If as a result of the medical examination, the medical examiner
does not find a Class A or Class B condition in an alien, the medical examiner shall so indicate on the medical
notification form and shall report his findings to the consular or INS officer. [56 FR 25003, May 31, 1991]
§ 34.5 Postponement of medical examination. Whenever, upon an examination, the medical examiner is unable
to determine the physical or mental condition of an alien, completion of the medical examination shall be
postponed for such observation and further examination of the alien as may be reasonably necessary to
determine his/her physical or mental condition. The examination shall be postponed for aliens who have an acute
infectious disease until the condition is resolved. The alien shall be referred for medical care as necessary.
[56 FR 25003, May 31, 1991]
§ 34.6 Applicability of Foreign Quarantine Regulations. Aliens arriving at a port of the United States shall be
subject to the applicable provisions of 42 CFR part 71, Foreign Quarantine, with respect to examination and
quarantine measures. [56 FR 25003, May 31, 1991]
§ 34.7 Medical and other care; death. (a) An alien detained by or in the custody of the INS may be provided
medical, surgical, psychiatric, or dental care by the Public Health Service through interagency agreements under
which the INS shall reimburse the Public Health Service. Aliens found to be in need of emergency care in the
course of medical examination shall be treated to the extent deemed practical by the attending physician and if
considered to be in need of further care, may be referred to the INS along with the physician's recommendations
concerning such further care.(b) In case of the death of an alien, the body shall be delivered to the consular or
immigration authority concerned. If such death occurs in the United States, or in a territory or possession thereof,
public burial shall be provided upon request of the INS and subject to its agreement to pay the burial expenses.
Autopsies shall not be performed unless approved by the INS. [56 FR 25003, May 31, 1991]
§ 34.8 Reexamination; convening of review boards; expert witnesses; reports. (a) The Director shall convene a
board of medical officers to reexamine an alien:(1) Upon the request of the INS for a reexamination by such a
board; or(2) Upon an appeal to the INS by an alien who, having received a medical examination in connection
with the determination of admissiblity to the United States (including examination on arrival and adjustment of
status as provided in the immigration laws and regulations) has been certified for a Class A condition.(b) For
boards convened to reexamine aliens certified as:(1) Having a communicable disease of public health
significance, the board shall consist of three medical officers, at least one of whom is experienced in the diagnosis
and treatment of the communicable disease for which medical notification has been made, and the decision of the
majority of the board shall prevail;(2)(i) Having a 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; or(ii)
Having 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; or(iii) Being a drug abuser or addict;(3) In circumstances covered by paragraph (b)(2)
of this section, the board shall consist of three medical officers, at least one of whom shall be a board certified
psychiatrist, and the decision of the majority of the board shall prevail.(c) Reexamination shall include:(1) Review
of all records submitted by the alien, other witnesses, or the board;(2) Use of any laboratory or additional studies
which are deemed clinically necessary as a result of the physical examination or pertinent information elicited

from the alien's medical history;(3) Consideration of statements regarding the alien's physical or mental condition
made by a physician after his/her examination of the alien; and(4) An independent physical or psychiatric
examination of the alien performed by the board, at the board's option.(d) An alien who is to be reexamined shall
be notified of the time and place of his/her reexamination not less than 5 days prior thereto.(e) The alien, at
his/her own cost and expense, may introduce as witnesses before the board such physicians or medical experts
as the board may in its discretion permit; provided that the alien shall be permitted to introduce at least one expert
medical witness. If any witnesses offered are not permitted by the board to testify, the record of the proceedings
shall show the reason for the denial of permission.
(f) Witnesses before the board shall be given a reasonable opportunity to examine the medical notification and
other records involved in the reexamination and to present all relevant and material evidence orally or in writing
until such time as the proceedings are declared by the board to be closed. During the course of the hearing the
alien's attorney or representative shall be permitted to examine the alien and he/she, or the alien, shall be
permitted to examine any witnesses offered in the alien's behalf and to cross-examine any witnesses called by the
board. If the alien does not have an attorney or representative, the board shall assist the alien in the presentation
of his/her case to the end that all of the material and relevant facts may be considered.(g) The findings and
conclusions of the board shall be based on its medical examination of the alien, if any, and on the evidence
presented and made a part of the record of its proceedings.(h) The board shall report its findings and conclusions
to the INS, and shall also give prompt notice thereof to the alien if his/her reexamination has been based on
his/her appeal. The board's report to the INS shall specifically affirm, modify, or reject the findings and
conclusions of prior examining medical officers.(i) The board shall issue its medical notification in accordance with
the applicable provisions of this part if it finds that an alien it has reexamined has a Class A or Class B
condition.(j) If the board finds that an alien it has reexamined does not have a Class A or Class B condition, it
shall issue its medical notification in accordance with the applicable provisions of this part.(k) After submission of
its report, the board shall not be reconvened, nor shall a new board be convened, in connection with the same
application for admission or for adjustment of status, except upon the express authorization of the Director. [56
FR 25004, May 31, 1991]