20 Massachusetts Avenue, NW

Washington, DC 20529

HQRPM 70/33-P

AD07-01

To: FIELD LEADERSHIP

From: Donald Neufeld /s/

Acting Deputy Associate Director

Domestic Operations Directorate

Date: September 18, 2007

Re: Guidance Clarifying the Adjudication of Form N-648, Medical Certification for Disability

Exceptions

Revisions to Adjudicator’s Field Manual (AFM) Chapters 72.2(d) (AFM Update AD07-01)

This memorandum explains and clarifies review standards in the adjudication of Form N-648

(Medical Certification for Disability Exceptions) under 8 CFR 312 and also revises subchapter

next edition of Form N-648 to detail and clarify eligibility requirements and to facilitate the

adjudication of the form.

On May 10, 2006, USCIS issued a memorandum entitled “Adjudication of Form N-648,

Medical Certification for Disability Exceptions to the Immigration and Nationality Act (INA)

Section 312 Naturalization Requirements.” The May 2006 memorandum updated Chapter

adjudication of Form N-648. Naturalization applicants, who have a medically determinable physical

or mental impairment that renders them unable to demonstrate a proficiency of the English language

or knowledge of U.S. history and government, may submit Form N-648 in order to establish

eligibility for an exception to the English and/or U.S. history and government requirements.

Guidance Clarifying on the Adjudication of Form N-648 (AD07-01)

inquiries pertaining to the adjudication of Form N-648. To address these inquiries, USCIS is

issuing the following field guidance.

The adjudicator is directed to comply with the following guidance and instructions when

evaluating Form N-648. Major points of emphasis are highlighted in this section and further

instructions are described in detail in section 4 of this memorandum.

A. Submission of Form N-648 8 CFR 312.2(b)(2) indicates that Form N-648 must be submitted as an attachment to the

applicant’s Form N-400, Application for Naturalization. Nevertheless, USCIS has routinely

encountered applicants submitting multiple N-648s at different stages of the N-400 review process

when USCIS has not requested or required the submission of additional N-648s. This practice

generally places an undue administrative burden on the adjudicator and casts doubt on the

applicant’s claim to the disability exception under section 312 of the Act. Accordingly, the applicant

should submit Form N-648 for consideration at the time the N-400 application is filed. Neither the

submission of Form N-648 after the filing of the N-400 nor the submission of multiple Form N-648s

is, by itself, sufficient grounds to reject a request for an exception to the English and/or U.S. history

and government requirements. However, the submission of late or multiple Form N-648s may raise

credible doubts about the veracity of the medical certifications or justify additional scrutiny to ensure

the applicant is entitled to the exception unless there is evidence of changed facts or circumstances

that would explain the basis for filing multiple forms.

In addition, USCIS reserves the right to require the submission of additional N-648s, if there

are credible doubts as to the veracity of the medical certification.

B. Appropriate Role of the Adjudicator in Reviewing Form N-648

In reviewing the Form N-648, the adjudicator’s role is to determine whether the Form N-648

contains sufficient information to establish that the applicant is eligible for a disability exception

under section 312 of the Act. The adjudicator accordingly should focus on determining whether the

medical professional has established and documented the nature and extent of the diagnosed medical

condition and how the applicant’s diagnosed condition has impaired functioning so severely that it

has rendered the applicant unable to learn or demonstrate knowledge of English and/or United States

history and government. To this end, the adjudicator must ensure that the Form N-648 contains:

• An explanation of the origin, nature, and extent of the medical condition which is established

and documented by medically acceptable clinical or laboratory diagnostic techniques,

including a list of the medically acceptable clinical or laboratory diagnostic tests employed in

reaching the diagnosis.

severely affects the applicant that it renders him/her unable to learn or demonstrate English

proficiency and/or knowledge of United States history and government;

• An attestation that the disability has lasted, or is expected to last, 12 months or longer; and

• An attestation that the disability is not the direct effect of the illegal use of drugs.

C. Making Medical Determinations

The adjudicator is not a physician and should not be placed in the position of making a

medical determination. Hence, the adjudicator should not engage in medical determination practices

reserved for and performed by a licensed medical professional.

D. Questioning the Veracity of the Medical Determination

As mentioned in previous guidance, the adjudicator should assume that the medical

professional’s diagnosis is valid in the absence of credible doubt. As a general rule, USCIS does not

want an applicant with a disability to submit extensive medical reports or medical background

information regarding the applicant’s condition.

E. Procedures for Cases of Suspected Fraud

The adjudicator should not presume the existence of fraud merely based on the number of

applicants who seek a medical examination from a particular medical professional. Because

applicants of an immigrant community commonly seek the care and services of medical

professionals who share the same language, culture, ethnicity, and/or nationality, this practice is not,

in and of itself, an indication of fraud.

If the adjudicator has reason to suspect fraud, the adjudicator should consult with the Office

of Fraud Detection and National Security (FDNS) according to the current fraud referral policy. All

referrals to FDNS should be based on fraud indicators that can be articulated.

In the event that FDNS is unable to provide a final response within a period of 120 days from

the date of the initial interview, the adjudicator should proceed with the adjudication of the

application.

F. Explain the Reasons for N-400 Denial Decisions Based on the Deficiency of an N-648

Every denial that is based in whole or in part on credible doubts about or the deficiencies of

an N-648 must explain the reasons why the credible doubts and deficiencies are preponderant over

favorable medical evidence submitted on behalf of the applicant. Merely stating that the applicant

has failed to meet the requirements for the waiver is insufficient.

G. Maintain a Local Field Office Point-of-Contact (POC)

Finally, to facilitate communication with USCIS external customers and stakeholders, each

district or field office should maintain a point-of-contact (POC) for the N-648 program. Such POC

should be an adjudicator with expert knowledge of N-648 adjudications or a supervisory

adjudications officer who is responsible for administration of the N-648 program within the district

or field office. The POC will be responsible for overseeing N-648 training and quality assurance

within the district or field office and conducting liaison with community-based organizations,

medical associations, and medical professionals interested in the N-648 process.

If the adjudicator has credible doubts about the veracity of the medical certification, the

adjudicator should seek supervisory guidance and approval as a general practice before requesting

the applicant’s medical records. Furthermore, the adjudicator is encouraged to consult with the N-

648 supervisory adjudications officer or POC, as needed, before requiring the applicant to complete

a supplemental disability determination.

the AFM is revised as follows:

8 CFR 312.2(b)(2) indicates that Form N-648 must be submitted as an attachment to the

applicant’s Form N-400, Application for Naturalization. Notwithstanding, USCIS routinely

encounters instances where USCIS has not required the submission of more than one

Form N-648 and yet the N-400 applicant submits multiple Form N-648s upon and after

initially filing his or her N-400. This practice can cast doubt on the credibility of the

applicant’s claim to the disability exception, especially if the adjudicator discovers

discrepancies between and among the N-648s. The submission of Form N-648 after the

filing of the Form N-400 or the submission of multiple Form N-648s is not, by itself,

sufficient grounds to reject a request for an exception to the English and/or U.S. history and

government requirements. However, the submission of late or multiple Form N-648s may

be considered in determining whether there are credible doubts about the veracity of the

medical certification or justify additional scrutiny to ensure the applicant is entitled to the

exception unless there is evidence of changed facts or circumstances that would explain

submission of additional N-648s, if there are credible doubts about the veracity of the

medical certification.

A properly submitted Form N-648 will remain valid indefinitely unless the adjudicator

determines that the N-400 applicant doesn’t qualify for the exemption.

If an applicant submits to or the adjudicator administers the English proficiency and/or U.S.

history and government test(s) at any time during the N-648 review process and the

applicant passes such test(s), then the applicant will have satisfied the requirements of

section 312 of the Act. In this instance, the adjudicator should indicate in the record of

proceeding that the applicant has passed the required test(s) and that the N-648 is no

longer required.

practice in the United States (including Guam, Puerto Rico, and the Virgin Islands) are

medical doctors, 2) doctors of osteopathy, and 3) clinical psychologists. The medical

professional must certify under penalty of perjury that his or her statements are true and

correct and agree to the release of all pertinent medical records upon consent of the

applicant and as requested by USCIS.

(2) Role of the Medical Professional. The medical professional completing the N-648 must

have general experience in the area of the applicant's disability and must be qualified to

diagnose the applicant's disability and/or impairment(s). A doctor who is a general

practitioner and not a specialist may complete the form if his or her experience or other

qualifications permit him or her to make the disability and/or impairment(s) assessment.

The medical professional must also be able to attest to the origin, nature, and extent of the

medical condition and explain how the medical condition affects the applicant’s ability to

demonstrate English proficiency and/or knowledge of U.S. history and government. In

particular, the medical professional should establish and certify the applicant’s diagnosis,

explaining in plain English and layman’s terms how the medical professional diagnosed the

anatomical, physiological, or psychological impairment and explaining how the diagnosed

condition affects the applicant’s ability to learn or demonstrate English proficiency and/or

knowledge of U.S. history and government. The medical professional should also cite the

medically acceptable clinical or laboratory diagnostic tests or other diagnostic methods

used and the results and conclusions drawn from these diagnostic tests which assisted the

medical professional in reaching the definitive diagnosis.

(1) Primary Focus of the Adjudicator. The adjudicator is responsible for determining

whether the applicant meets the requirements of Section 312 of the Immigration and

Nationality Act. In reviewing the Form N-648, the adjudicator’s role is to determine whether

the Form N-648 contains sufficient information to establish that the applicant is eligible for a

disability exception. Therefore, the adjudicator should focus on determining whether the

medical professional has established and documented the nature and extent of the

diagnosed medical condition and how the applicant’s diagnosed condition has impaired

knowledge of English and/or United States history and government.

To this end, the adjudicator must ensure that the Form N-648 contains:

established and documented by medically acceptable clinical or laboratory

laboratory diagnostic tests used in diagnosing the condition.

severely affects the applicant that it renders him/her unable to learn or demonstrate

knowledge of English and/or United States history and government.

longer; and

(2) Making Medical Determinations. The adjudicator is not a physician and should not be

placed in the position of making a medical determination. Accordingly, the adjudicator

should not:

laboratory diagnostic techniques, tests, or methods;

in lieu of the medical professional’s diagnosis;

condition as a routine practice; and

was a proper basis for the medical professional’s diagnosis.

(3) Questioning the Veracity of the Medical Certification. The adjudicator should assume

that the medical professional’s diagnosis is unless there is credible doubt about the veracity

of the medical certification. As a general rule, USCIS does not want an applicant with a

disability to submit extensive medical reports or medical background information regarding

the applicant’s condition.

Notwithstanding, credible doubts may arise when the adjudicator establishes or has reason

to believe that:

FDNS, Immigration and Customs Enforcement, or other law enforcement agency, or

a state medical board;

“boiler plate” language that does not appear to reflect a case-specific analysis;

medical professional;

professional;

indicates fraud or willful misrepresentation;•

the course of diagnosing the applicant’s medical condition; or

• The medical professional neglected to conduct specific medical, clinical, or

laboratory diagnostic techniques that are considered standard methods in

diagnosing the applicant’s medical condition.

If the adjudicator finds or has reason to believe the medical determination is suspect at the

time of the naturalization interview, the adjudicator may question the applicant about the

facts pertaining to the applicant’s medical care, job duties, community and civic affairs,

and/or other daily living activities. In particular, the adjudicator’s line of inquiry should focus

on eliciting facts about the applicant’s activities and conduct, which may reveal the

applicant’s functional capacity or inability to demonstrate English proficiency and/or

knowledge of U.S. history and government. If the applicant’s conduct and responses are

inconsistent with the description of the applicant’s diagnosed condition as described on the

Form N-648 and other supporting documentation, the adjudicator may have a justifiable

basis for doubting the authenticity of the medical determination.

If the adjudicator has credible doubts about the veracity of the medical certification, the

adjudicator should refer to (E)(5)(c) below for guidance on requesting medical records and

requiring a supplemental disability determination.

(4) Maintaining a Point-of-Contact (POC) for N-648 Process. To facilitate communication

with USCIS external customers and stakeholders, each district or field office should

maintain a point-of-contact (POC) for the N-648 program. Such POC may be an

adjudicator with expert knowledge of N-648 adjudications or a supervisory adjudications

officer who is responsible for administration of the N-648 program within the district or field

office. The POC will be responsible for overseeing N-648 training and quality assurance

within the district or field office and conducting liaison with community-based organizations,

medical associations, and medical professionals interested in the N-648 process.

Guidance Clarifying on the Adjudication of Form N-648 (AD07-01)

(E) Review of Form N-648

that it is properly completed.

(2) Nexus between Medical Impairment and Applicant’s Ability to Learn or Demonstrate

English Proficiency and/or Knowledge of United States history and government. The

information, whether the applicant has proven by preponderance of evidence that the

anatomical, physiological, or psychological abnormality described has so severely

impaired the applicant’s functioning that the applicant is unable to demonstrate English

proficiency and/or knowledge of U.S. history and government. Consequently, the

adjudicator should focus on determining whether the medical professional has established

the connection between the nature and extent of the diagnosed medical condition and the

applicant’s inability to demonstrate English proficiency and/or knowledge of U.S. history

explanation in plain English and layman’s terms of (a) how the medical professional

diagnosed the disability or impairment, and (b) how the diagnosed disability or impairment

renders the applicant unable to demonstrate English proficiency and/or knowledge of U.S.

history and government.

The adjudicative standards used to evaluate disability exceptions under section 312 of the

itself, is not a medically determinable physical or developmental disability or mental

impairment. The diagnosed mental disability must result in an impairment of functioning so

severe that the applicant is unable to learn or demonstrate English proficiency and/or

knowledge of U.S. history and government.

(3) Medical, Clinical, or Laboratory Diagnostic Techniques. There are no key words,

phrases, or a specific test that will, by itself, demonstrate a sufficient nexus between the

applicant’s medical impairment and the applicant’s ability to learn or demonstrate English

proficiency or knowledge or U.S. history and government. Likewise, there are no lists of

conditions, symptoms, or complications that will always be caused by or linked to certain

disabilities or impairments. The medical professional, however, should include a list of all

medically acceptable clinical or laboratory diagnostic techniques or other diagnostic

methods and the results and conclusions of these diagnostic tests which assisted the

medical professional in determining and concluding that the applicant has a disability that

so severely renders him/her unable to learn or unable to demonstrate English proficiency

and/or knowledge of U.S. history and government.

(4) Consideration of Federal Agency Reports and Determinations. The adjudicator should

consider any authoritative federal agency report or determination in the applicant’s record

file that addresses the applicant’s diagnosed medical condition. To illustrate, if the Social

Security Administration has granted the applicant a disability benefit based on the

applicant’s diagnosed medical condition, then such determination may validate the medical

medical condition is consistent with the medical professional’s diagnosis, then such report

may authenticate the applicant’s diagnosed condition.

(5) Issuance of Form N-14 to Address the Deficiencies of the N-648.

(a) Discontinued Use of N-648B, Notice of Incomplete N-648 Medical Certification

For Disability Exception. The adjudicator should use Form N-14 in lieu of the N-

648B to address deficiencies in the N-648. Use of the N-648B is hereby

discontinued.

(b) Clarification of the Medical Professional’s Assessment. If the medical

professional’s assessment is unclear and/or if an applicant’s request for a disability

exception is otherwise deemed to be insufficient, the adjudicator must request

additional information to clarify the assessment and address any deficiencies. Such

request may include asking the medical professional to explain the medical, clinical,

or laboratory diagnostic techniques used to diagnose the applicant’s medical

condition, to explain the applicant’s medical condition in plain English and layman’s

terms, and/or to explain how the applicant’s diagnosed condition renders the

applicant unable to demonstrate English proficiency or knowledge of U.S. history

and government.

In the case of minor deficiencies to the N-648, the adjudicator may request

additional information without requiring the applicant to submit a new N-648. In the

case of major deficiencies, the adjudicator may require the applicant to submit a new

N-648. The burden is on the applicant to obtain the information from the medical

professional who completed the N-648.

(c) Request for Medical Records and Requirement of Supplemental Disability

Determination. USCIS has the authority to request the release of the applicant’s

medical records if there is credible doubt as to the veracity of the medical

certification. The adjudicator may only request and review medical records to

include verifying the completion and results of any medically acceptable clinical or

laboratory diagnostic techniques used to diagnose the impairment. As noted above,

the adjudicator may not request medical records solely to question whether there

was a proper medical basis for the noted impairment.

USCIS also reserves the right to refer the applicant to another authorized medical

professional, at the applicant’s expense, when USCIS has credible doubts about the

veracity of the medical certification. See 8 CFR 312.2(b)(2).

If the adjudicator has credible doubts about the veracity of the medical certification,

the adjudicator should seek supervisory guidance and approval as a general

practice before requesting the applicant’s medical records. Furthermore, the

Guidance Clarifying on the Adjudication of Form N-648 (AD07-01)

or POC, as needed, before requiring the applicant to complete a supplemental

disability determination.

If an applicant is required to complete a supplementary disability determination, each

district or field office must provide the applicant with the contact information of the

appropriate state medical board, which maintains a list of licensed and boardcertified

medical professionals in the appropriate specialty area, such as psychiatrist,

(6) Examination. Under 8 CFR 312.5, an applicant should receive two opportunities to

meet the requirements of section 312 of the Act. If the adjudicator finds that the Form

N-648 is insufficient to establish eligibility for an exception from the English and/or U.S.

history and government requirements for naturalization, the adjudicator must give the

applicant a choice to either proceed with testing or to be rescheduled for re-examination.

The adjudicator must explain to the applicant that rescheduling the examination will

constitute a refusal to submit to testing, which is considered the equivalent of failing the test

for purposes of the two opportunities under 8 CFR 312.5. If the applicant refuses to submit

to testing, the adjudicator must note on the application, “Applicant refused testing.” This

notation will help to ensure that the applicant is only scheduled for one additional chance to

meet the requirements of section 312.

If an applicant fails the test or chooses to reschedule, the adjudicator must issue a Form N-

14, which must include a detailed explanation of the deficiencies and inconsistencies in the

Form N-648 and, if appropriate, request the applicant to obtain another evaluation from an

authorized medical specialist for a supplemental determination. The adjudicator must

schedule the applicant for re-examination within 45 days of responding to the N-14 or filing

the new N-648.

If the applicant fails to submit the new N-648, then the adjudicator should proceed with the

adjudication based on the N-648 form contained in the applicant’s record file.

(7) Denial of N-400. If upon re-examination, the adjudicator determines that an applicant is

not eligible for a disability exception and the applicant fails to pass the English and/or U.S.

history and government tests, the Form N-400 must be denied. The merits and deficiencies

of the Form N-648 may be reviewed in the context of a hearing on the denial of the Form N-

400 under section 336 of the Act. An applicant may submit additional documentation for

review at the 336 hearing.

Every denial that is based in whole or in part on credible doubts about or deficiencies of an

N-648 or its supporting certification must explain the reasons why the credible doubts and

deficiencies outweigh any favorable medical evidence submitted on the applicant’s behalf.

Merely stating that the applicant has failed to meet the requirements for the waiver is

insufficient. See 8 CFR 316.14(b)(1) and 8 CFR 336.1(b).

Guidance Clarifying on the Adjudication of Form N-648 (AD07-01)

(F) Procedures for Cases of Suspected Fraud

Because applicants of an immigrant community commonly seek the care and services of

medical professionals who share the same language, culture, ethnicity, and/or nationality,

this practice is not, in and of itself, an indication of fraud.

If the adjudicator has reason to suspect fraud, the adjudicator should consult with the Office

of Fraud Detection and National Security (FDNS) according to the current fraud referral

policy. All referrals to FDNS should be based on fraud indicators that can be articulated.

After conferring with FDNS and consulting with the appropriate N-648 supervisory

adjudications officer or POC, if appropriate, the adjudicator may issue a Form N-14 to the

applicant, requiring the applicant to obtain another medical evaluation from an authorized

medical professional for a supplemental disability determination. A new Form N-648 must

then be completed and filed, and the applicant must be scheduled for re-examination within

45 days of filing the new Form N-648.

If Form N-14 is issued for the purpose of obtaining another medical evaluation for

supplemental disability determination, the adjudicator must include the contact information

for the specific state medical association and category of specialized medical professional

that the applicant should contact in order to complete the new Form N-648. The information

for the state medical associations and the categories of specialized medical professionals

are attached in Appendix 72-13 Attachment A and Appendix 72-13 Attachment B. An

applicant’s failure to appear at the re-examination or failure to submit a new Form N-648

may result in denial of the Form N-400.

In the event that FDNS is unable to provide a final response within a period of 120 days

from the date of the initial interview, the adjudicator should proceed with the adjudication of

the application.

***

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In addition, current subchapter 72.2(d)(6), “N-648B: Notice of Incomplete Medical Certification for

Disability Exception,” is deleted and subchapters 72.2(d)(7) through (d)(10) are renumbered

accordingly as follows:

***

Guidance Clarifying on the Adjudication of Form N-648 (AD07-01)

HQRPM 70/33-P

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This memorandum revises sections of

This memorandum is intended solely for the instruction and guidance of USCIS personnel in

performing their duties relative to adjudications. It is not intended to, does not, and may not be

relied upon to create any right or benefit, substantive or procedural, enforceable at law or by any

individual or other party in removal proceedings, in litigation with the United States, or in any other

form or manner. In addition, the instruction and guidance in this memorandum is in no way

intended to and does not prohibit enforcement of the immigration laws of the United States.

Questions regarding this memorandum may be directed to Mark Phillips, USCIS Office of

Regulations and Product Management (RPM), through appropriate supervisory channels.

Distribution: Regional Directors

District Office Directors

Service Center Directors

Field Office Directors

Asylum Office Directors

cc: USCIS Headquarters Directors

Bureau of Immigration and Customs Enforcement

Bureau of Customs and Border Protection