8 CITIZENSHIP AND DISABILITIES
N-648 information
Instructions for doctor and psychologists on filling out the N-648
medical waiver
Your role as a doctor
Questions frequently asked by doctors
Asion Law Caucus information
Sample letter to a Physician
Sample letter to request accommodation for a
disability
Sample file completed
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N-648 MEDICAL CERTIFICATION
FOR DISABILITY
INFORMATION SHEET
M
ost refugees resettled in the U.S. are eligible
to apply for naturalization after five years of
residency. Some refugees have severe disabilities that
prevent them from learning how to read, write or
speak English, or make it difficult to learn U.S. history
and civics. These individuals are eligible to apply for a
“disability waiver” which provides an exemption from
having to take the test if they have documentation
of how their disability interferes with their ability to
learn. Some examples include a person with severe
Post Traumatic Stress Disorder, a stroke survivor,
or a person with Traumatic Brain Disorder. If a
person has a disability but could take the test with an
accommodation, such as a visually impaired individual
having the test available in Braille or a sign language
interpreter for a deaf person, they are not eligible to
apply for the waiver.
The definition of disability is similar to the one
used by other federal agencies: an impairment which
substantially limits one or more major life activities
such as walking, seeing, hearing, speaking, breathing,
learning, working, caring for oneself, or performing
manual tasks (ADA). In recent years, a waiver of oath
has been enacted for individuals who are not able to
understand it because of their disability.
New changes to the application process have resulted
in an increase in denial for cases. This section was
compiled to help you understand how to complete a
waiver application and provide you with resources to
assist your clients who may be eligible for the waiver or
take the citizenship test.
Included are:
√ Citizenship Resources
√
Instructions for doctors and psychologists
completing the forms
√ Sample doctor letter
√ Accommodations request form
√ Asian Law Caucus guidelines for Form N648
Hacklye & Seronne Immigration and Consular Law (2001). http://
www.hackleyserrone.com/USCitizenship.htm
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Citizenship Resources
1. Visit CLINIC’s website page on refugee
citizenship and civic participation at
www.cliniclegal.org/Refugee.html. You will find useful
information about the citizenship test and citizenship
for people with disabilities. To listen to an audio
recorded presentation while viewing PowerPoint
slides on helping people with disabilities become
citizens, go to the CLINIC website at
http://www.cliniclegal.org/Refugee/disabilities.html.
2. U.S. Citizenship and Immigration Service: http://
www.uscis.gov/portal/site/uscis. This site has all the forms
needed for applying for the disability waiver and fee
waivers as well as a number of resources to prepare
for the test:
◊ civics flash cards
◊ sample civics lessons
◊ sample test questions
TECHNICAL ASSISTANCE FOR
QUESTIONS PERTAINING TO
CITIZENSHIP:
Examples of questions:
How do we get services such as fingerprints and other services
for citizenship for a bedridden or nursing home patient?
We have a client who is deaf and do not know how we should
get citizenship services for him.
How can I tell if this N-648 is going to be acceptable to
USCIS?
My client was denied a disability waiver, and I need help with
the appeal.
The USCIS officer told me that he has a list of “acceptable”
disabilities for N-648s and my client’s disability is not on the
list. Is there such a list, and how should I respond?
Contact:
Laura Burdick
Senior Immigration Specialist
Catholic Legal Immigration Network, Inc. (CLINIC)
415 Michigan Ave., NE, Rm. 150
Washington, DC 20017
tel: 202-635-5820
fax: 202-635-2649
e-mail: lburdick@cliniclegal.org
INSTRUCTIONS FOR DOCTORS
AND PSYCHOLOGISTS ON
FILLING OUT THE N-648
MEDICAL WAIVER
Print or type
your answers.
The N-648
must be legible.
Go to www.
uscis.gov/
files/forms/N648.pdf for a
fillable form
that you can
save as a PDF
file and print. When you are finished with the form,
give it to your patient or to your patient’s attorney.
Part I
You or your patient must fill out this part
completely; the patient must sign.
Part II
Question 1: For the waiver to be approved by
USCIS, the answers must be as follows:
(a)Yes (b) Yes (c) No
* If you cannot mark the answers as above,
consult with your patient or your patient’s
attorney.
Question 2(a): Write each of your patient’s
diagnoses and give a description of the symptoms
associated with each diagnosis.
Question 2(b): Write the DSM-IV codes for
each diagnosis and give a list of diagnostic tests
administered to reach each diagnosis.
Although not requested, the N-648 must include
“a list of the medically acceptable clinical or
laboratory diagnostic tests employed in reaching the
diagnosis” and the results of each test. In the past,
immigration officers at the local immigration office
approved the N-648 forms that did not include such
a list. Now an N-648 will be rejected if it does not
include a list of the diagnostic tests employed.
Some doctors and psychologists have told us that
they reach the patient’s diagnosis on the basis of
a diagnostic interview rather than standardized
testing because no test is available or because named
tests are not appropriate. In some cases, the local
immigration office has approved language such as:
“This diagnosis can be made on the basis of a
diagnostic interview, as it was in Ms. Doe’s case
by asking her whether she has symptoms of major
depressive disorder listed in the DSM-IV. Because of
the language barrier and cultural differences,
commonly used written diagnostic tools would not
be valid or reliable. Using a diagnostic interview to
diagnose Major Depressive Disorder is an accepted
procedure among members of the psychology
profession.”
* Please note that if you would rather use the
“diagnostic interview” approach, you need to
provide as much detail as possible about your
method or technique.
Question 3: Describe the connection between
the applicant’s impairment and the applicant’s
inability to learn and demonstrate knowledge of
English and/or Civics. You must explicitly connect
the patient’s impairment and his or her inability to
learn English and/or Civics. Please make detailed
statements explaining the reasons that the conditions
you diagnose limit the patient’s ability to learn.
You should state each limitation that your patient
personally experiences as a result of the condition
you diagnose, state how each limitation prevents
your patient from learning, and explain how these
limitations are a direct result of your patient’s
condition.
Questions 4 and 5: For a complete waiver, the
boxes must be as such:
a. English Requirement - (a) Yes (b) all boxes
checked
b. US History and Civics Requirement – Yes
* If you cannot mark the boxes as above, consult
with your patient or your patient’s attorney.
Question 6, 7 and 8: Completely fill out questions
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6, 7, and 8. If you have only seen the patient once,
please write as much information as possible about
how the patient was referred to you. If you have seen
the patient more than once, describe your history with
your patient.
Final Section: Sign
the form in blue ink to
clearly show that your
signature is original.
YOUR ROLE AS THE DOCTOR:
Filling Out the N-648,
Medical Certification for Disability Exceptions
Why have I been asked to fill out this form?
• The person who asked you to fill out this form is in
the process of applying to become a citizen of the
United States.
• Part of the Naturalization process is to take an
English language test as well as a U.S. history and
civics test.
• This person believes that their disability prevents
them from learning English and history and therefore
is unable to take that part of the Naturalization test.
• This person is asking you to verify that they are
unable to learn the English language and United
States history and civics as a result of their disability.
Am I qualified to fill out the N-648?
• Any medical professional who is licensed to practice
in the United States and is either a medical doctor;
a doctor of osteopathy; or a clinical psychologist is
qualified.
What information must I cover in order for
my patient’s N-648 to be approved?
You must:
• Establish and certify the applicant’s diagnosis,
explaining the origin, nature and extent of the
medical condition.
• Explain how
the anatomical,
physiological,
or psychological
impairment
diagnosis was arrived
at (including
which medically
acceptable clinical or laboratory diagnostic
tests were used to reach the diagnosis).
• List the diagnostic tests. Diagnostic testing
is not requested on the N-648 but it is a necessary
component to a completed form.
• Explain how this condition limits the applicant’s
ability to learn or demonstrate knowledge of English
and/or U.S. history and government.
• The applicant must be unable to learn English
and/or U.S. civics and history. It is not sufficient that
the applicant finds learning English and/or U.S.
civics and history difficult.
• Sign the form, preferably in blue ink. The N-648
submitted to USCIS must include your original
signature.
How much time do I have to fill out the N648?
• The applicant must submit the N-648 to
immigration authorities within six months of when
the medical professional or psychologist completed
it.
• You must have the appropriate experience and
qualifications that enable you to diagnose and assess
the claimed disability and/or impairment.
Prepared by Legal Aid Society of Minneapolis, Immigration Law Project 2007
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QUESTIONS FREQUENTLY ASKED BY
DOCTORS ABOUT FILLING OUT
THE N-648
1. Why is naturalization so important?
Becoming a citizen allows an immigrant to do some
things more easily. For example, they can:
• petition for their family members to
come to the U.S.;
• travel more easily outside the U.S.;
• have initial access to public benefits; and
• not face cut-offs from public benefits.
2. Does the N-648 have to be typed?
No. The N-648 must be legible but it does not have to
be typed. One easy way to type the N-648 is to go to
http://www.uscis.gov/files/form/N-648.pdf. If you have Acrobat
Reader 7.0, fill in the form on the USCIS site and then
print to sign.
3. Can I fill out the form if I have only
seen the patient once?
Yes, if you are able to make a diagnosis of a physical
or mental disability using recognized diagnostic tools
after seeing the patient one time.
BUT - If you will be unable to fill out the N-648 after
the first visit, please make subsequent appointments
with your patient at the time of your first visit. Time
is of the essence with these applications. Most of the
people requesting the N-648 form are in jeopardy of
losing their SSI benefits unless they become citizens of
the United States.
4. What happens if my patient’s N-648
that I filled out for them is denied?
If the applicant’s N-648 is denied at the initial
interview, the applicant will be told to produce a
different or amended N-648 and sent home. If the
immigration officer questions the credibility of the
doctor, the officer may request medical records from
the applicant’s doctor.
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5. Where can I get more information
about the N-648 form and the
naturalization process?
• Review this N-648 informational binder
• Go to the USCIS website at www.uscis.gov
6. What if I did not administer a named
test to reach my diagnosis?
Although the Immigration Service requires that a
named test such as the Mini-Mental Status Exam, or
the Beck Depression Inventory be administered, the
local immigration office has occasionally accepted
language such as the following:
This diagnosis can be made on the basis of a diagnostic
interview, as it was in Ms. Doe’s case by asking her whether she
has symptoms of major depressive disorder listed in the DSMIV. Because of the language barrier and cultural differences,
commonly used written diagnostic tools, such as the Beck
Depression Inventory would not be valid or reliable. Using a
diagnostic interview to diagnose Major Depressive Disorder is an
accepted procedure among members of the medical profession.
7. What if a patient comes in with an
N-648 that has been denied by the
Immigration Service?
You should refer them to an attorney. Please refer to
the legal services list in the pocket at the end of this
binder to find out which legal service office serves the
county where the applicant lives.
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ASIAN LAW CAUCUS
Guidelines for Form N-648: The Disability Waiver for Naturalization
Unless a special exception applies, applicants for U.S. citizenship must be interviewed in English, and must
demonstrate that they can read, write, and speak English at a functional level. They must also pass a test on U.S.
history and government, currently chosen from a list of 100 questions.
1. A Disability Waiver of these requirements is available under 8 CFR § 312.1(b)(3)/312.2(b) IF:
a. A person is UNABLE to demonstrate an understanding of English or a knowledge of U.S.
history and government
b. Because of a medically determinable physical or mental impairment or combination
of impairments, and
c. The impairment has lasted or is expected to last at least 12 months.
2. “Medically determinable” means:
a. An impairment that results from anatomical, physiological, or psychological abnormalities;
b. Which can be diagnosed with medically acceptable clinical or laboratory diagnostic techniques; and
c. Which results in functioning so impaired as to render an individual UNABLE to demonstrate an
understanding of English and a knowledge of U.S. history and government.
3. What U.S. Citizenship & Immigration Services looks for in an N-648:
a. The doctor or clinical psychologist must state the diagnosis and how it was made, including
results of any testing that was conducted and a DSM-IV Code, if applicable;
b. If the patient is taking medication for a psychiatric condition, the doctor should
explain whether the medication has lessened the degree of impairment or produced an
improvement in memory or concentration, or whether the impairment is still severe;
c. Explain how the condition affects the patient’s memory, ability to learn new tasks, ability to
concentrate, ability to understand abstract ideas, or ability to communicate; and
d. Make a connection between the diagnosed condition and the applicant’s inability to learn or to
demonstrate knowledge of English and U.S. history and civics.
EXAMPLES OF N-648 DESCRIPTIONS OF COMMON IMPAIRMENTS:
Patient with senile dementia:
Rejected: The patient is an 85-year-old female who shows signs of senile dementia. She does not know
a word of English. It would be impossible for her to learn English and U.S. history. (Note: There is no
explanation of the degree of her dementia, or how having dementia would prevent her from learning English or
U.S. history and civics.)
Accepted: The patient is an 85-year-old female with Alzheimer’s type (senile) dementia (DSM-IV 290.0),
resulting in severe memory impairment as well as confusion and disorientation, as reflected in the most recent
mini mental status exam score (4/17/2006): 9 out of 30. Her memory has become so impaired that she is
unable to retain even the most basic information. For example, at this point she can no longer remember how
many children she has. In terms of daily functioning, she cannot recall information such as whether or not she
has eaten lunch today, and she must rely on others to tell her whether she has eaten yet. Given this degree of
severe cognitive impairment, she is not capable of learning and retaining new language skills or knowledge of
U.S. history and government.
Patient with major depression and post-traumatic stress disorder:
Rejected: The patient suffers from depression with post-traumatic stress disorder. Her condition makes
concentration and memory retention very difficult. She scored very low on the mini mental status exam with
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Reprinted with permission
a particularly low score on memory and concentration. It is my professional opinion that her condition makes
learning English and U.S. history and civics difficult. (Notes: The degree of the depression is not stated,
and no DSM-IV code is given. USCIS says that “difficulty” is not the same as “inability,” and
wants to know if the condition made the patient so impaired that she was unable to learn
English or U.S. history and civics).
Accepted: The patient has been treated in our clinic since May 2003 and suffers from major depression
(DSM-IV 296.33) with post-traumatic stress disorder (DSM-IV 309.81). Although she is currently taking
medication to control anxiety and depression, severe symptoms continue. Her symptoms include chronic
unwelcome and intrusive thoughts which create severe anxiety, fear, and worry. She cannot effectively
organize her thinking, focus her attention for any significant period of time, plan for the future, or think
abstractly. As a result of her condition, her memory is severely impaired, as measured by her mini mental
status exam results (8 of 30). After a ten-minute delay, she was able to recall only 1/3 of objects shown to
her. This level of memory impairment, coupled with her disorganized and unfocused thinking, renders her
unable to acquire a useful amount of English language skills or knowledge of U.S. history and government.
Patient in constant severe pain:
Accepted: The patient was injured in a serious auto accident in 2001, fracturing her spine and requiring
abdominal surgery. During the surgery, her bowel was perforated, leading later to abdominal hernias and
abscesses, bowel fistula, and the need for a series of further surgeries. As a result, she is in constant pain and
has severe anxiety and panic attacks, as well as depression. The DSM-IV Code for her condition is 293.83
(Mood disorder due to chronic pain condition). Because of the prolonged complications following her series
of abdominal surgeries, the patient is in constant pain, is frequently dizzy, and has severe anxiety and panic
attacks, as well as chronic depression. The pain and dizziness, in combination with her depressed mental
state and anxiety, have severely impaired both her short-term memory and her ability to concentrate to such
a degree that it is not possible for her to learn and retain new material, even in Cantonese.
Stroke:
Accepted: I have been treating the patient for the aftereffects of a stroke since October 2001. The
stroke resulted in significant permanent damage to the right hemisphere of his brain, as reflected in CT
scans performed on 11/3/01 and 5/9/02. This brain damage has affected his memory capacity and ability
to concentrate to such a degree that it is not possible for him to learn and retain any significant amount
of new information. The stroke also left him with very limited ability to use the left side of his body. Due
to his inability to control the muscles on the left side of his face, the patient’s communication ability is
severely impaired, and his speech is often unintelligible. As a result of these serious impairments, it is not
possible for him to learn new language skills or information on U.S. history and government structure, or to
communicate his understanding of these subject areas. However, he is capable of indicating “yes” or “no” in
response to questions in Cantonese.
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Re: (Client)
Dear Dr. _______________,
The patient mentioned above requested that I write to you on his/her behalf regarding his/her application for
naturalization. For individuals with certain disabilities, a waiver was created to exempt them from taking the
citizenship test provided their disability prevents them from learning the information (English and U.S. history
and civics) necessary to successfully pass the naturalization exam. There is no standard list of disabilities which
would qualify for the waiver; rather, requests are evaluated on a case-by-case basis. To obtain a waiver, a person
must provide medical documentation on how their disability interferes with their ability to learn English, history,
and civics. To this end the Medical Certification for Disability Exception (N-648) form must be completed and
accompany the person’s naturalization application. Information is provided below to help medical practitioners
complete the form.
In completing the form, the following are important factors to consider:
• The form must be completed and signed by a physician (M.D.), osteopath (D.O.),
or psychologist (Ph.D.).
• The U.S. Citizenship and Immigration Services (USCIS) prefers that you type the form.
The form can be filled out on the USCIS website and printed at
http://www.uscis.gov/files/form/N-648.pdf.
• The application will be reviewed by an immigration officer with no
medical training; therefore, it must be written in lay terms.
• A full explanation of the diagnosis must be given (see question 2(a).
• A DSM IV code must be given for any mental impairments (see question 2(b).
Most importantly,
•The link between the physical or mental disability and how it prevents the patient from
learning English and U.S. history and civics must be fully explained (see question 3). This includes an
explanation of the specific symptoms associated with the disability that affect the patient’s ability to learn
new information.
•Also in question 3, USCIS requires an explanation of how the disability was
diagnosed and a list of what medically accepted clinical or laboratory diagnostic
tests were used.
Attached are some examples of well-written forms created by the Asian Law Caucus for your review. (Patient
name) requests your assistance in completing the form on his/her behalf detailing his/her impairment.
He/she thanks you for your time regarding this important matter.
Sincerely,
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(SAMPLE LETTER - REQUEST FOR ACCOMMODATIONS AT CIS INTERVIEW)
To:
District Director, U.S. Citizenship and Immigration Services
Address:
__________________________________________________________________
From:
__________________________________________________________________
(Print Applicant’s Name)
Alien Registration Number:
Address:
________________________________________________
__________________________________________________________________
__________________________________________________________________
Telephone Number: ____________________________________________________________
RE:
ACCOMMODATIONS FOR MY DISABILITY AT MY CIS INTERVIEW
I have the following disability:_____________________________________________________
(Circle one:) I am / am not requesting a waiver of the testing requirements based on my disability.
Because of my disability, it is hard for me to:_________________________________________
______________________________________________________________________________
______________________________________________________________________________
In accordance with Section 504 of the Rehabilitation Act, please make the following
accommodations for me at my CIS interview:_______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature:____________________________________
Date:__________________
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