Chapter 3 - Medical Disability Exception (Form N-648) (2024)

A. Medical Disability Exception Background

In 1994, Congress enacted legislation providing an exception to the English and civics requirements for naturalization applicants who cannot meet the requirements^[1] because of a physical or developmental disability or mental impairment.^[2]

The English and civicsrequirements do not apply to naturalization applicants who are unable to comply due to a “medically determinable” physical or developmental disability or mental impairment that has lasted, or is expected to last, at least 12 months. The regulations define medically determinable as an impairment that results from abnormalities which can be shown by medically acceptable clinical or laboratory diagnostic techniques.^[3]

The applicant must demonstrate that the applicant has a disability or impairment that affects functioning such that the applicant is unable to meet theEnglish and civicsrequirements for naturalization, even with reasonable accommodations.^[4]

A licensed medical professional^[5]mustcomplete a Medical Certification for Disability Exceptions (Form N-648) andcertify, under penalty of perjury, that the applicant’s physical or developmental disability or mental impairment prevents the applicant from meeting the English requirement, the civics requirement, or both requirements.

B. Filing

1. Form N-648 Submission

An applicant seeking an exception to the English or civics requirements or both should submit a Form N-648 as an attachment to the Application for Naturalization (Form N-400).^[6] However, USCIS should accept a Form N-648 submitted after the applicant files the naturalization application. Applicants should use the form edition of the Form N-648 listed on the form webpage.

2. Multiple Submissions

If the applicant submits more than one Form N-648 during the initial interview, during the re-examination, or anytime during the pendency of the same naturalization application, an officer may examine any significant discrepancies between the documents. However, the officer must provide the applicant with an opportunity to explain discrepancies.

C. Distinction Between Medical Disability Exception andAccommodation

Requesting an exception to the English or civics requirements or both is different from requesting an accommodation for the naturalization test or interview.^[7] An accommodation simply modifies the manner in which an applicant meets the educational requirements; it does not exempt the applicant from the English or civics requirements. Form N-648 is not used to request an accommodation.

Reasonable accommodations may include, but are not limited to, sign language interpreters, extended time for completing the English and civics requirements, and completing the English and civics requirements and naturalization interview at an off-site location. A disability exception, which can only be requested by submitting Form N-648, requires an applicant to show that the applicant’s physical or developmental disability or mental impairment prevents the applicant from complying with the English or civics requirements or both, even with reasonable accommodations. The impact of a particular physical or developmental disability or mental impairment may vary between applicants.

It may be possible for USCIS to accommodate one applicant who is affected by a particular physical or developmental disability or mental impairment, while another applicant affected by the same disability or impairment may be eligible for a disability exception.^[8] For example, an applicant who has a traumatic brain injury may require the accommodation of more time to complete the writing portion of the English test, while an applicant with the same diagnosis may not be able to write a simple sentence in English even with an accommodation, and needs to submit a Form N-648.

An applicant may request both a medical disability exception and a reasonable accommodation where both are needed. For example, if an applicant is deaf and uses a sign language interpreter and is also unable to meet the English and civics requirements due to a physical or developmental disability or mental impairment, the applicant may submit a Form N-648 and also request that USCIS provide a sign language interpreter for the naturalization interview.^[9]

D. Authorized Medical Professionals

USCIS only authorizes the following licensed medical professionals to certify the disability exception form:

• Medical doctors;

• Doctors of osteopathy; and

• Clinical psychologists.^[10]

These medical professionals must be licensed to practice in any state of the United States,theDistrict ofColumbia, Puerto Rico,Guam,the Virgin Islandsof the United States, or the Commonwealth of the Northern Mariana Islands.

E. Scope of Medical Examination

In order for USCIS to consider deeming a Form N-648 sufficient, the medical professional must, at a minimum:

• Conduct an examination of the applicant;

• Identify and describe each physical or developmental disability or mental impairment onForm N-648;

• Explain how each physical or developmental disability or mental impairment prevents the applicant from learning or demonstrating knowledge of English, civics or both;

• Attest that the physical or developmental disability or mental impairment has lasted or is expected to last at least 12 months; and

• Attestthat the cause of the physical or developmental disability or mental impairment is not related to the illegal use of drugs.

The medical professional should complete theForm N-648using common terminology that a person without medical training can understand. While staff associated with the medical professional may assist in completing the form, the medical professional alone is responsible forproviding the necessary information, answering the questions, andverifying and attesting to the accuracy of the form’s content.If information is missing from the Form N-648, the officer should review any extra documents provided by the medical professional to determine if the information completes the Form N-648.

Telehealth Examination

USCIS may accept a Form N-648 certified by an authorized medical professional who completed the applicant’s medical examination through a telehealth examination.^[11] The medical professional must be licensed. In conducting telehealth examinations, medical professionals must adhere to the respective state telehealth laws and requirements, otherwise USCIS may request a new Form N-648. After a telehealth examination, the applicant should ensure all signatures are present and then submit the Form N-648 to USCIS.

F. ReviewofMedical Certification

1. General Guidelines for Review

The officermust review the form for sufficiency^[12] to determine whether the applicant is eligible for the exception. The tables below provide general guidelines on whatstepsthe officer should and should not take whenreviewing theForm N-648.

2. Connection Between Medical Disability and Educational Requirements

When reviewing the request for the medical disability exception, the officer must determine whether the medical professional explained that the applicant has a physical or developmental disability or mental impairment that prevents the applicant from being able to demonstrate that they meet the English requirement, civics requirement, or both. Illiteracy alone is not a valid reason to seek an exception to theEnglish and civicsrequirements. In addition, advanced age, in and of itself, is not a medically determinable physical or developmental disability or mental impairment.

After review of the record, the officer may only grant an exception from the English or civics requirements if the applicant has demonstrated by a preponderance of the evidence that the physical or developmental disability or mental impairment results in functioning so impaired as to render the applicant unable to:

• Demonstrate an understanding of the English language, including reading, writing, and speaking words in ordinary usage in the English language;

• Demonstrate a knowledge and understanding of the fundamentals of history and of the principles and form of government of the United States; or

  See Also

  New Form N-648 and Policy Guidance on Disability WaiversInfographic Guide for the USCIS N-648 FormWhat Is Form N-648: Medical Certification for Disability Exceptions?

• Both.

3. Use ofInterpreters

Certification on Form N-648 and Presence of Interpreter at Medical Examination

If it is unclear whether an interpreter was used during the medical examination, the officer will ask the applicant if the medical examination that formed the basis of the Form N-648 was performed with the assistance of an interpreter. For example, the officer may question the applicant during the interview about the manner of communication used to conduct the medical examination. Interpreters providing interpretation services for telehealth medical examinations do not have to complete the interpreter certification on Form N-648. Instead, the medical professional must complete the interpreter certification on the form.

If necessary, the officer may also choose to question the interpreter who was present at the medical examination about the interpretation provided during a medical examination in connection with the applicant’s Form N-648.^[14] If the officer wishes to question an interpreter, the officer must place the interpreter under oath. If the person who interpreted at the medical examination is to be questioned as a witness, and is also present during the naturalization interview to provide interpretation services, the interpreter must be disqualified from interpreting for that applicant at the naturalization interview unless a good cause exception exists.^[15] Officers may not ask interpreters about the medical condition of the applicant.

If a good cause exception is not found, the officer should reschedule the interview, as needed, to permit the applicant an opportunity to find a new interpreter.

Interpreter at Interview

If the officer needs to ask the applicant questions about Form N-648 or explain why it is insufficient, the officer must do so in the applicant’s preferred language, with the use of an interpreter,^[16] and while the applicant is under oath. If the office has a language service available and the applicant agrees, the officer may use the language service when the interpreter provided by the applicant is disqualified.In the agency’s discretion, as in all cases, the officer may disqualify an interpreter provided by the applicant or a telephonic language service interpreter for cause and reschedule theinterview.^[17]

4. Credible Reasons to Doubt the Validity of Form N-648

There are different reasons that USCIS may find a Form N-648 insufficient, including if USCIS determines there are credible reasons to doubt the validity of the Form N-648 due to significant discrepancies, misrepresentation, or fraud.However, in general, USCIS acceptsthe medical professional’s diagnosis.

The officer mustprovide the applicant an opportunity to addressany specific discrepancies or inconsistenciesduring the interview. When issuing a Request for Evidence (RFE), the officershould only request the information necessary to make a determination on the sufficiency of theForm N-648.In some cases, USCIS may require the submission of an additionalFormN-648 orrequestthe applicant'smedical reports orothersupplementary medical background informationifthere is a question as to whether the medical professional actually examined the applicant or there arecredible reasons to doubt the validity of the Form N-648 because it is clearly contradicted by other evidence.

Below are some examples of credible reasons to doubt the validity of the form certification to assist officers in determining the sufficiency ofForm N-648:^[18]

• During the interview, the officer determines that the applicant was not examined by the certifying medical professional, someone other than the authorized medical professional certified the form, or the applicant paid for the Form N-648 without having an examination and diagnosis by an authorized medical professional;

• The medical professional who completed the Form N-648 is under investigation for immigration fraud, Medicaid fraud, or other fraud schemes identified by USCIS Fraud Detection and National Security (FDNS) Directorate, Immigration and Customs Enforcement, or another federal, state, or local agency, or a state medical board;

• The interpreter used during the medical examination, the naturalization interview, or both, is known or suspected, by FDNS or another state or federal agency, to be involved in any immigration fraud, including and especially Form N-648 related fraud;

• The evidence in the record or other credible information available to the officer indicates fraud or misrepresentation;

• The applicant provides multiple Forms N-648 with different diagnoses and information; or

• Any other articulable grounds that are supported by the record.

If any one or more of these indicators are present, the officer should consult witha supervisor for next steps, which may include requesting additional documentation or finding theForm N-648insufficient.

In addition, there may be cases where USCIS suspects or determines that an applicant, interpreter, or medical professional has committed fraud in the process of seeking a medical disability exception. The officer should consult with a supervisor to determine whether to refer such a case to FDNS.If an officer or the local FDNS office determines that an applicant, interpreter, or medical professional hasmade material misrepresentations orcommitted fraud, the officer must explain those findings in a Notice of Intent to Deny or denial notice, as appropriate.Additionally, if an officer determines that an in-person or a telehealth examination did not appear to comply with state law or licensing regulations, the officer may refer the case to FDNS.

Requestinga SupplementalFormN-648 from a Different Medical Professional

In general, USCIS does not request a supplemental Form N-648 from a different medical professional after evaluating the originally submittedForm N-648.However,if there is a question as to whether the medical professional actually examined the applicant or there are credible reasons to doubt the validity of the medical certificationbecause it is clearly contradicted by other evidence, the officer may request a new Form N-648 from a different medical professional.^[19]The officer should exercise caution when requesting an applicantobtain a supplemental Form N-648 from another authorized medical professional.The officer should:

• Consult with a supervisor and receive supervisory approval before requesting that the applicant submit a supplemental Form N-648;

• Explain to the applicant, through an RFE, the reasons for doubting the veracity of the information on the original Form N-648, including any sworn statements, observations or applicant responses to questions during the interview that raised issues of credible doubt; and

• Provide the applicant with the relevant state medical board contact information to facilitate the applicant’s ability to find another medical professional.

G. Sufficiency of Form N-648

As previously stated, in general, USCIS should accept the medical professional’s diagnosis. The Form N-648 should be completed by the certifying medical professional no more than 180 days before the applicant files the naturalization application. Once this requirement is satisfied, the Form N-648 remains valid for the entire naturalization process connected to that particular Form N-400.

An officer reviews the Form N-648 in its totality and may determine that the Form N-648 is sufficient, even if some of the questions have incomplete responses. The officer should determine that a request for a medical disability exception is sufficient if the file and testimony establish that the applicant is eligible for the medical disability exception. The file may include medical documentation and information in addition to the Form N-648.

An officer may find the Form N-648 insufficient if the form does not include the required information as detailed below.

1. Sufficient Form N-648

A request for a medical disability exception is sufficient if it contains the following information:​

• Clinical diagnosis of the applicant’s physical or developmental disability or mental impairment;^[20]

• Indication as to whether the physical or developmental disability or mental impairment has lasted, or is expected to last, at least 12 months;

• Statement that the physical or developmental disability or mental impairment is not the result of the illegal use of drugs;

• Description of the clinical methods used to diagnose the physical or developmental disability or mental impairment;

• Date that the medical professional last examined the applicant for the physical or developmental disability or mental impairment;^[21]and

• A sufficient explanation of how the applicant’s physical or developmental disability or mental impairment prevents the applicant from meeting the English requirement, the civics requirement, or both requirements.

In addition the Form N-648 is completed, certified, and signed by all appropriate parties^[22] and no significant discrepancies, or fraud indicators exist, based on the totality of evidence in the record, that call into question a finding of eligibility under a preponderance of the evidence standard.

The table below provides the general procedures for cases where an applicant qualifies for a medical disability exception. The procedures apply to any phase of the naturalization examination, includingthe initialexamination, re-examination, or hearing on a denial.

2. Insufficient Form N-648

Arequest for a medicaldisabilityexception is insufficient if theForm N-648does not contain all of the required information.^[24]

The table below provides the general procedures USCIS follows when theForm N-648is found to be insufficient.The procedures apply to any phase of the naturalization examination, includingthe initialexamination,re-examination,or hearing on a denial.^[25]

If USCIS identifies deficiencies in a Form N-648, which the applicant is unable to sufficiently explain at the interview, an applicant does not have to submit a new Form N-648. USCIS will accept a previously submitted Form N-648 which contains updated or additional information. However, the resubmitted form must be re-signed and dated by the same medical professional who signed the original Form N-648. USCIS will accept a resubmitted Form N-648 under these circ*mstances even if a new edition of Form N-648 has been published since the Form N-648 was initially submitted, and the resubmitted form now has an expired edition date. USCIS will also accept a letter or other medical documentation addressing the Form N-648 deficiencies, if it is signed and dated by the same medical professional who signed the Form N-648.

H. Interview, Re-Examination,and Hearing after an Insufficient Form N-648

1. Initial Interview

Passing the English and CivicsRequirements^[27]

If an applicant’sForm N-648is found to be insufficient, but the applicant subsequently meets the English and civics requirements in the sameexamination:

• The officer must provide the applicant the opportunity to proceed with the rest of the naturalization interview to determine if the applicant meets the other applicable eligibility requirements.

• The officer should not determine that the applicant engaged in fraud or lacks good moral character for the sole reason that the applicant met the educational requirements after submitting an insufficient Form N-648.

• The officer may question the applicant further, however, on the reasons for submitting the form, and any other relevant factors, if necessary.^[28]

Failing the English and CivicsRequirements

If an applicant’sForm N-648is found to be insufficient, and the applicant fails to meet the English or civics requirements:

• The officer must notify the applicant of the Form N-648 deficiencies in writing by issuing an RFE that specifically addresses the issues with the Form N-648.
• The officer should schedule the applicant to appear for are-examination for a second opportunity to meet the English or civics requirements or both, between 60 and 90 days after the initial examination. If the applicant requests that the re-examination be rescheduled to a date that is more than 90 days after the initial examination, the applicant must agree in writing to waive the requirement under INA 336 that USCIS must adjudicate the application within 120 days from the initial interview before the applicant may apply to U.S. district court for review of a pending application for naturalization, and instead permit USCIS to adjudicate the application within 120 days from the re-examination before seeking review.^[29]

2. Re-Examination

If new information is receivedin support of aForm N-648that USCIS found insufficient at the initial interview,the officermustreview the new evidenceatthe re-examination.In addition, theofficer conducting the re-examinationshouldreviewthe original Form N-648 and accompanying evidence for consistency with the new information.

If an applicant submits a Form N-648 for the first time at the re-examination interview, the officer should review theformto determine if it is sufficient.^[30] If the applicant has established eligibility for the disability exception, the officer should continue the naturalization interview and examination, exempting the applicant from the English or civics requirements, or both, as indicated on the Form N-648. If the medical professional indicated on the form that the applicant is unable to comply with the English speaking requirement, the applicant may use an interpreter during the interview and examination.

Ifan RFE related to an insufficient Form N-648 was issued at the initial interview andthe interviewing officer determines that the evidence submitted in response to the RFE is insufficient:

• The officer must explain the reasons for the insufficiency in the applicant’s preferred language verbally during the interview, using an interpreter, if needed. The RFE also needs to have an explanation of the insufficiency;

• The officer must proceed with the re-examination as if the applicant had not submitted aForm N-648;

• The officer must administer any portion of the English and civics tests that the applicant previously failed;

• The officer must not issue another RFE related to any insufficient Form N-648 to provide the applicant another opportunity to submit a Form N-648 or to take the English and civics tests for a third time;

• If the applicant fails any portion of the test or declines to take the test, the officer must deny the naturalization application based on the applicant’s failure to meet the English or civics requirements or both; and

• In the notice to deny the application for naturalization, the officer must provide an explanation for finding the Form N-648 insufficient.

3. Hearing on Denial

An applicant whose naturalization application was denied may fileaRequest for a Hearing on a Decision in Naturalization Proceedings Under Section 336 (Form N-336)within 30 calendar days of receiving the adverse decision.^[31]

USCIS may conduct a fullde novohearing on a denied naturalization application, includinga fullreview of any previously submittedForm N-648as well as other information contained in therecord.^[32] Anapplicant may submit additional documentation at the hearing, includinga newor initialFormN-648andrelevant medical diagnostic reports, records, or statements. At the hearing, an applicant will only be allowed to submit one Form N-648 and only allowed to attempt to satisfy the educational requirements once.

In addition, the officer also should follow the same procedures in the hearing as provided in this chapter when making a determination that aForm N-648filed for the first time at the hearing is sufficient or insufficient.

Footnotes

[^ 1] The term “English and civics requirements” refers todemonstratingEnglish languageproficiency,which is determined by anability to read, write, speak, and understandEnglish, as well asknowledge of U.S.historyand government,which is determined by a civics test.See Chapter 2,English and Civics Testing,Section A, Educational Requirements [12 USCIS-PM E.2(A)].

[^ 2] SeeINA 312(b)(1).SeeSection 108 of theImmigration and Nationality Technical Corrections Act of 1994,Pub. L. 103-416 (PDF), 108 Stat. 4305, 4309(October 25, 1994)(addingINA 312(b)).

[^ 3] SeeINA 312(b). See8 CFR 312.1(b)(3) and8 CFR 312.2(b).

[^ 4] The applicant has the burden of proof by the preponderance oftheevidence standard.

[^ 5] See Section D, Authorized Medical Professionals [12 USCIS-PM E.3(D)].

[^ 6] See8 CFR 312.2(b)(2).Applicants filing a naturalization application online should upload a scanned copy of the Medical Certification for Disability Exceptions (Form N-648) using their USCIS online account.

[^ 7] See Part C, Accommodations [12USCIS-PM C].

[^ 8] See the Disability Accommodations for the Public webpage to request an accommodation.

[^ 9] See Part C, Accommodations, Chapter 3, Types of Accommodations [12 USCIS-PM C.3].

[^ 10] See8 CFR 312.2(b)(2).

[^ 11] See the What is telehealth? webpage from the U.S. Department of Health and Human Services.

[^ 12] See Section G, Sufficiency of Form N-648 [12 USCIS-PM E.3(G)].

[^ 13] An officer may allow an applicant or the interpreter (if the same interpreter was present at the time of the Form N-648 examination) to sign the form at the naturalization interview if their signatures are missing; however, if a missing signature from the certifying medical professional or interpreter present at the time of the Form N-648 examination cannot be provided at the interview, an officer issues an RFE to have the medical professional or the interpreter sign the Form N-648.

[^ 14] If necessary, the officer may issue a subpoena to the interpreter for this purpose. Officers should consult with Office of the Chief Counsel before issuing a subpoena that seeks health information.

[^ 15] In the officer’s discretion, a good cause exception may be granted that would allow the witness to interpret. SeeThe Role and Use of Interpreters in Domestic Field Office Interviews (PDF, 497.54 KB), PM-602-0125.1, issued January 17, 2017. See Part B, Naturalization Examination, Chapter 3, Naturalization Interview, Section A, Roles and Responsibilities, Subsection 3, Interpreters [12 USCIS B.3(A)(3)].

[^ 16] The interpreter must be under oath. See Part B, Naturalization Examination, Chapter 3, Naturalization Interview, Section A, Roles and Responsibilities, Subsection 3, Interpreters [12 USCIS B.3(A)(3)].

[^ 17] See The Role and Use of Interpreters in Domestic Field Office Interviews (PDF, 497.54 KB), PM-602-0125.1, issued January 17, 2017, and Part B, Naturalization Examination, Chapter 3, Naturalization Interview, Section A, Roles and Responsibilities, Subsection 3, Interpreters [12 USCIS B.3(A)(3)].

[^ 18] The list provided is not exhaustive and is meant only to provide some examples for officers when reviewing Form N-648 for sufficiency. Officers should consult with a supervisor if there are any questions.

[^ 19] The officer requests this evidence by issuing an RFE, Form N-14.

[^ 20] The officer may not find the Form N-648 insufficient solely because the Diagnostic Statistical Manual or International Classification of Diseases medical codes are missing in the form if the medical professional has provided a sufficient description of the clinical diagnosis for all the physical or developmental disabilities or mental impairments.

[^ 21] If the date of last examination is missing from the Form N-648, the officer may review the date of signature of the medical professional in Part 6 and confirm with the applicant if that was the date of last examination. The officer should not determine that the form is insufficient solely because the date of last examination is missing on the form if the date can be confirmed during the naturalization interview.

[^ 22] An officer may allow an applicant or the interpreter (if the same interpreter was present at the time of the Form N-648 examination) to sign the form at the naturalization interview if their signatures are missing; however, if a missing signature from the certifying medical professional or interpreter present at time of the Form N-648 examination cannot be provided at the interview, an officer issues an RFE to have the medical professional or the interpreter place the signature(s) on the same Form N-648.

[^ 23] See Part J, Oath of Allegiance, Chapter 3, Oath of Allegiance Modifications and Waivers, Section C, Waiver of the Oath [12 USCIS-PM J.3(C)].

[^ 24] Before determining that a Form N-648 is insufficient due to missing information, officers should review all sections to confirm that the information needed does not appear in a different section of the form.

[^ 25] See Part B, Naturalization Examination, Chapter 3, Naturalization Interview, Section D, Subsequent Re-examination [12 USCIS-PM B.3(D)]. See Part B, Naturalization Examination, Chapter 6, USCIS Hearing and Judicial Review [12 USCIS-PM B.6]. See Request for a Hearing on a Decision in Naturalization Proceedings Under Section 336 (Form N-336).

[^ 26] An officer should annotate that the applicant declined to take any part of the educational requirements in the record.

[^ 27] SeeINA 312.

[^ 28] The officer may question the applicant about a Form N-648 with the use of an interpreter.

[^ 29] See 8 CFR 312.5(b).

[^ 30] For more information see Section F, Review of Medical Certification, Subsection 4, Credible Reasons to Doubt the Validity of Form N-648 [12 USCIS-PM E.3(F)].

[^ 31] See Part B, Naturalization Examination, Chapter 6, USCIS Hearing and Judicial Review [12 USCIS-PM B.6].

[^ 32] See8 CFR 336.2.