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Thank you for your time and cooperation in assisting your patient with a naturalization application. Generally, applicants for citizenship must be able to speak, read, and write English and pass a test of U.S. history and civics. However, certain applicants with disabilities may qualify for a "disability waiver," which exempts them from one or both of these requirements. Your patient is seeking your assistance in applying for this waiver.

Who is Eligible for a Disability Waiver

1. The applicant must have a medically determinable physical or developmental disability or mental impairment that causes the applicant to be unable to learn English and/or U.S. history and civics.

2. The disability must be expected to last at least 12 months.

3. The disability must not be the result of illegal drug use.

The Doctor's Role in the Application Process
The Immigration and Naturalization Service (INS) relies on the medical opinion of the applicant's doctor in deciding whether to grant a disability waiver. The doctor provides this opinion by completing INS Form N-648 (Medical Certification for Disability Exceptions.) The INS requires that the N-648 be completed by either a medical doctor, a doctor of osteopathy, or a licensed clinical psychologist. Attached are specific instructions for completing each section of the N-648.
The INS generally makes a decision as to whether to grant or deny a request for a disability waiver at the time of the applicant's naturalization interview. In some cases the INS examiner may contact the certifying doctor or advise the applicant if additional information is needed before a decision can be made regarding the applicant's eligibility for a waiver.

HOW TO COMPLETE THE N-648 MEDICAL CERTIFICATION FORM

A. GENERAL INSTRUCTIONS

· Print or type your answers legibly on the form. INS examiners are not medical professionals; it is important to use terms that can be understood by a layperson (i.e. "stroke" rather than "CVA.") If you prefer, you may attach a separate answer sheet, but you must still sign the certification form and write "See attached statement" after each question.

· Please do not seal the envelope containing the completed medical certification. The applicant has a right to review the completed medical certification form.

B. Part II, Question 3

1. Part II, Question 3 asks you to describe your patient's symptoms and is the most important part of the form. Your answer must include three parts (the three "C"s):

· CAUSE: the nature and origin of the disability or illness;
· CONNECTION: the specific symptoms associated with the disability or illness that make it impossible for the applicant to learn English and/or U.S. Civics;
· CONSEQUENCE: your conclusion that the applicant cannot learn English and/or U.S. Civics.

2. Please provide specific examples of the way in which your patient's symptoms affect cognitive functioning and his or her ability to meet the English and civics requirements. Clearly state whether the disability affects your patient's ability to learn English or civics or both.

3. Use clear and unequivocal language (e.g. "As a result of his disabilities, Mr. X will NOT be able to learn English (and/or civics) sufficiently to pass the citizenship exam.")

4. Appendix A provides a list of symptoms that among those most relevant to the CONNECTION between the disability and the applicant's ability to learn or demonstrate knowledge of English and civics.

5. Assisting elderly applicants. Old age in and of itself is not a qualifying disability for purposes of the disability waiver. However, elderly applicants who suffer from age-related impairments that do impair learning (such as depression, dementia, or strokes) may be eligible for a waiver. In such cases it is important to stress that the inability to learn is as a result of the medically determinable disability or mental impairment, and not simply old age.
6. Illiteracy. The INS also will not approve a waiver for applicants unable to learn solely on the basis of illiteracy in their native language. In many cases, however, the applicant's illiteracy is causally connected to his or her disability. For example, the illiteracy may be the result of previously undiagnosed developmental delay, particularly if the applicant is from a country with few or no special education programs. Your answer should stress that the underlying disability is the primary cause of the applicant's inability to learn English and/or the civics materials.
7. Physical Disabilities. An applicant with physical disabilities will only be approved for a waiver if the disability or accompanying symptoms affect his or her ability to learn or demonstrate knowledge. For example, illness may be accompanied by pain, fatigue, or nausea, which impair concentration and may prevent the patient from attending classes.

8. Effects of Medication. The medication or treatment for a condition may affect vision, cause drowsiness or nausea or have other side effects that prevent the patient from the physical act of attending classes and studying. If this is the case, please note this in your answer to Question 3.

9. Deaf and/or blind applicants. .If a deaf applicant cannot learn through the use of written materials or tutoring, the answer to Question 3 must explicitly explain why. For example, if a deaf patient is illiterate in her own language or if there are no learning materials available in her language, it may not be possible for her to learn (written) English or civics. Clients with congenital deafness may face particular difficulties with learning and language acquisition. Similarly, the doctor must explain why a patient who is blind cannot learn English and/or civics through audio tapes or by attending classes where information is presented verbally.

10. Mental impairments. As with any other disability, the INS requires that the certifying doctor state a clear connection between the patient's mental disorder and inability to learn or demonstrate English or civics. It is very important to list specific symptoms and the ways in which these symptoms are manifested. Please note if the mental impairment is exacerbated by other disabilities in a way that makes learning difficult (e.g.. severe depression and deafness.)

11. DSM IV diagnostic codes for mental impairments. INS requires a DSMIV code number for mental impairments. The appendix includes a list of DSMIV codes for some common diagnoses, which might be relevant for elderly immigrant patients not previously diagnosed with a mental disorder:

C. Part II, Question 4
12. Developmental Disabilities. Question 4 states that developmental disabilities must be manifested before age 22. If you did not treat the patient prior to age 22, explain how you know that this requirement is met. For example, you can explain that (a) this is a condition that only occurs at birth (such as cerebral palsy), (b) you have reviewed medical records from when the patient was under age 22, or (c) family members reported the existence of clinical symptoms indicating developmental delays prior to age 22, such as learning difficulties and placement in special education.
13. Illegal Use of Drugs: If you believe that the patient's disability may be the result of the illegal use of drugs (or you are not sure whether drugs are involved), DO NOT COMPLETE THE FORM. Refer your client to an immigration attorney or legal services office. If any information regarding illegal drug use is disclosed to INS, your patient may face deportation.

13. Meaningful Oath Requirement. The INS requires that all applicants for naturalization have the ability to take a meaningful oath of allegiance to the U.S. An applicant's understanding of the oath is generally tested in the naturalization interview, in which the examiner asks a series of questions from the N-400, including: "Are you willing to bear arms for the United States?" and "Do you understand and believe in the Constitution of the United States?" Please note if your patient requires simpler phrasing of these questions; it is also helpful to state that the patient is able to form an attachment to the U.S. and to affirmatively choose to become a citizen.

QUESTION 6

14. Your Qualifications. Provide a detailed statement establishing your qualifications to diagnose your patient's disability. You do not have to be a specialist, as long as you are familiar with the causes and symptoms associated with your patient's disability. This experience may come from treating other patients or from medical training.

15. Truthfulness of Certification. A doctor or psychologist signs the N-648 under penalty of perjury. Note that as long as you do not knowingly provide false information to the INS, you cannot be subjected to any civil penalties or liabilities. This is no different from the truthfulness standard required for signing other government forms and insurance claim statements.

APPENDIX

A. Common Symptoms
Some of the symptoms relevant to showing a connection between the applicant's ability to learn or demonstrate knowledge of English and/or civics are:

· Memory impairment: inability to learn new information or to recall previously learned information;
· Disturbance in executive functioning, which involves planning, organizing, sequencing and abstracting;
· Difficulties with concentration and focus;
· Delirium, disorientation, confusion, agitation;
· Difficulty in expressing herself or in understanding what is said to her (expressive/ receptive communication disorders);
· Painful or medically fragile condition which impairs concentration and prevents the patient from leaving home to attend English or civics classes;
· Fatigue, loss of energy or a sense of hopelessness (often associated with depression) which impairs concentration and prevents the patient from leaving home to attend English or civics classes;
· Paranoia, hostility, anxiety and/or delusions which prevent the patient from expressing what he knows or has learned;
· Unpredictable behavior in response to stress and anxiety (which may be a result of post-traumatic stress disorder or other anxiety disorders) so that the patient cannot perform in a testing, classroom or interview/interrogation setting;
· Low intellectual functioning and/or learning disabilities that affect reading and writing ability.

B. Common DSM Codes
Some DSM Codes that may be relevant for applicants with mental impairments:

290.40 Vascular Dementia, uncomplicated
293.0 Delirium due to (general medical condition)
294.0 Amnestic Disorder due to (general medical condition)
294.10 Dementia due to (general medical condition; can include MS, etc.), Without Behavioral Disturbance
294.10 Dementia of the Alzheimer's Type, With Early Onset, Without Behavioral Disturbance
294.10 Dementia of the Alzheimer's Type, With Late Onset, Without Behavioral Disturbance
294.11 Dementia Due to...[indicate general medical condition], With Behavioral Disturbance
294.11 Dementia of Alzheimer Type, With Early Onset, With Behavioral Disturbance
294.11 Dementia of Alzheimer Type, With Late Onset, With Behavioral Disburbance
294.8 Dementia NOS
294.8 Amnestic Disorder NOS
294.9 Cognitive Disorder
296.30 Major depressive disorder, recurrent, unspecified severity
300.4 Dysthymic disorder
309.81 Post-traumatic stress disorder
300.02 Generalized anxiety disorder
300.0 Anxiety disorder NOS
300.9 Unspecified mental disorder, non-psychotic