or if a consular memorandum with the visa states that the alien has a specified class A or B condition which existed when he was admitted earlier, under P. L. 271 (79th Cong.).

A medical hold should not be issued for an alien referred to in "a" to "c" above, unless necessary in order to diagnose a suspected serious condition not mentioned in the alien's documents, or unless the alien fails to present a complete medical examination report, and X-ray film, if required by paragraph 18 of this chapter. (In such cases the reason for the hold should be fully explained on the form.) However, if an alien has been given a visa or authorized to reenter (per "a"- "c" above) although afflicted with tuberculosis, a medical hold should not be issued in the absence of an X-ray film. The Medical Officer in Charge shall assist the Immigration Service in determining requirements necessary to protect the public health upon entry of aliens referred to in "a"- "c"; in respect to tuberculosis, see chapter 8.

7. When a quarantine inspector notes that the medical report presented by an alien gives a diagnosis of a class B condition of such a nature that the diagnosis is not likely to be contested, he transcribes the information to a medical certificate.

8. When a quarantine inspector observes an obvious class B condition (such as amputation) not mentioned in the alien's medical report, he issues a medical certificate for the responsible medical officer.

9. In preparing a medical certificate the quarantine inspector signs it as follows:

(Name of quarantine inspector), Quarantine Officer

for (Name and title of responsible medical officer), U.S.P.H.S. 10. The quarantine inspector should obtain the advice of a medical officer when:

a. The alien's medical report gives a diagnosis of a class B condition of such a nature that the inspector thinks the diagnosis is likely to be contested;

b. The inspector suspects the presence of any condition that is not obvious and not mentioned in the alien's medical report. When the medical officer cannot make a diagnosis at the place of inspection, a medical hold should be issued.

11. Medical officers should establish inspection, examination, and supervisory procedures so that a minimum number of medical holds will be necessary, and so that medical examinations will be made as soon as feasible when holds have been issued. It would be

well to avoid making a diagnosis and issuing a medical certificate for a condition such as "Hypertension" or "Obesity" where the condition is of such a degree that it would have been reasonable for the consular medical examiner not to have reported it.

Procedure

12. On shipboard the inspector checks the Quarantine Declaration for reports of illness, and questions the ship's master regarding the health of aliens on board. He inspects the clinical record of any aliens treated during the voyage. At airports the inspector checks the aircraft General Declaration for reports of illness, and questions the aircraft commander regarding the health of aliens on the aircraft. If feasible, the inspector should obtain signed statements from ships' masters or aircraft commanders when they give information regarding class A conditions.

13. While the alien approaches for medical inspection, the inspector looks for deformities, lameness, or other obvious defects. He is alert to detect irregularities in movement, due to ankylosed joints or shortened or deformed extremities, and to detect tabetic, steppage, hemiplegic, or spastic gaits caused by nervous system disorders.

14. The inspector tries to gain an idea of the alien's alertness, reasoning ability, and general mental reaction. To accomplish this, when there is no language barrier the inspector diplomatically asks the alien brief questions about such matters as his trip and other everyday affairs. When it appears advisable, the inspector may ask additional questions that a person with normal intelligence should be able to answer.

15. The inspector makes every effort to detect signs and symptoms of mental disease and defect. Any suggestion, no matter how trivial, that points to abnormal mentality is sufficient cause for detaining the alien for a thorough examination.

16. The alien's manner of appearing for inspection, his conversation, dress, and any peculiar or unusual conduct on his part are all to be observed. The inspector should take into consideration racial characteristics in physique, costume, and behavior.

17. During inspection, aliens with defective hearing, defective vision, or fever frequently assume peculiar attitudes and do strange things, which may be suggestive of mental abnormality. In such cases further examination may disclose the real condition.

18. The inspector reviews any medical reports and X-ray films carried by aliens except films carried by an alien with excludable

disease waiver, which may also be reviewed if there appears to be a special need for it.1 Section 34.4 of the regulations (chapter 1) states the basic requirements for medical examination reports, X-rays, and serologic tests. This section should be interpreted as follows:

a. Immigrants.2 --The immigrant visa should have attached to it an envelope containing a medical examination report that includes an X-ray reading and serologic test report. An X-ray film, if required (see subparagraphs 18 d (2) and 18 d (3) below), should be carried in this envelope or separately. If these requirements are not met, a medical hold shall be issued pending examination including X-ray, serologic test, and any other necessary procedures.

b. Nonimmigrants.-- When an alien has a nonimmigrant visa (stamped in the passport or other authorized document), the inspector should look for the classification symbol in the visa.

(1) Students and exchange visitors.

(a) If the visa bears classification symbol "F" or "J," the alien is a student or exchange visitor. (State Department directives guide the consul in determining which students and exchange visitors are to be medically examined upon application for a visa. The determination is based primarily on the proposed length of stay in the United States, and on whether medical requirements have already been met as part of the preliminary procedures in the exchange program. Certain exchange visitor "leaders" are exempt from examination at the consulate unless they are suspected of having excludable disease. When a student or exchange visitor is required to be examined upon application for a visa, the examination is required to include a chest X-ray and a serologic test. In the case of those who are examined, the symbol "MED" is placed by the consular officer in the visa. When the visa thus indicates that a medical examination has been required, the consular officer gives the student or exchange visitor a sealed envelope containing the medical examination report, and the X-ray film or films if required. (b) It is not the inspector's responsibility to determine which students and exchange visitors should have been medically examined at the consulate. However, the inspector should find out which ones carry a medical examination report. When a student or exchange visitor has a medical examination report, and it does not include a serologic test report and an X-ray reading and film, the

1 The Medical Officer in Charge should arrange for quarantine inspectors to receive necessary training in the elements of chest X-ray interpretation.

2 Quarantine personnel should consult immigration officers as necessary to ensure recognition of visas.

inspector shall issue a medical hold pending X-ray and serologic

test.

(c) When a student or exchange visitor does not submit a medical examination report, the inspector notes whether the visa bears the notation "MED." When "MED" appears, the inspector shall issue a medical hold pending examination including X-ray and serologic test. When "MED" is not on the visa, the inspector shall not issue a medical hold unless there is reason to suspect the presence of disease.

(2) Nonimmigrants other than students and exchange visitors--that is, with a nonimmigrant visa bearing a classification symbol other than "F" or "J." (The consul requires medical examination of any of these nonimmigrants whom he suspects of being medically inadmissible. The symbol "MED" is placed in the visa in the case of those examined.)

(a) The inspector should find out whether there is a medical examination report. When one of these nonimmigrants has a medical examination report, it is not required to include an X-ray reading or a serologic test report. However, the inspector should see whether the medical examination report indicates that further examination is advisable.

(b) When a medical examination report is not submitted, the inspector notes whether the visa bears the symbol "MED." When "MED" appears, the inspector shall issue a medical hold pending examination. A chest X-ray and a serologic test are included when the examiner considers them necessary. When "MED" does not appear, the inspector shall not issue a medical hold unless there is reason to suspect the presence of disease.

c. General. As provided in other paragraphs of this chapter, an alien is detained for medical examination when necessary to make a diagnosis of a suspected disease. The inspector should check with the immigration officer before detaining an alien who is in immediate transit to a foreign country; detention will probably be unnecessary if early departure of the alien is ensured (unless he appears to have a disease that requires isolation).

d. Exceptions to Requirements--X-ray Examination and Serologic Test.

(1) Section 34.4 (b) (1) of the regulations (chapter 1) states exceptions to X-ray examination and serologic test requirements for aliens below specified ages.

3 If any nonimmigrant presents the same visa that was carried on an earlier trip, the document in which the visa appears will bear an Immigration Service endorsement. "MED" does not have significance after the original trip.

(2) Pursuant to section 34.4 (b) (3), an alien who is required to present, at the United States port of entry, a medical examination report on form FS-398 is also required to present any X-ray film or films used in the examination, unless the FS398 has been signed by:

(a) A commissioned medical officer of the United

States Public Health Service, or

(b) Certain physician employees of the Division of Foreign Quarantine, United States Public Health Service, who are specifically designated by the Chief of the Division and named on the list in appendix D.

NOTE. (i) In addition to their signature on form FS398, all medical examiners are to have their name typed or printed on the form.

(ii) Commissioned medical officers referred to in 2 (a) above shall also have the following typed or printed on form FS-398: rank, followed by "United States Public Health Service: or "USPHS."

(3) Excludable Disease Waiver--All Films to Be Carried. Whenever an alien with known or suspected tuberculosis enters the United States under excludable disease waiver, he is to carry with him a sealed envelope containing all pertinent X-ray films. This applies even when the FS-398 has been signed by a commissioned medical officer or designated physician referred to in subparagraph 18d (2) above. (See chapter 8 for other instructions on excludable disease waiver cases.)

(See also paragraph 6 of this chapter regarding absence of X-ray film in certain cases. For validity period of visa medical examinations and related provisions on issuance of medical holds, see chapter 2, par. 5.)

19. When a quarantine inspector believes a film indicates a questionable pulmonary condition, but the medical examination report shows essentially negative findings, he should obtain the advice of a medical officer and, if the condition warrants, a medical hold should be issued. When an alien presents a medical examination report describing a class B pulmonary condition, the quarantine inspector may transcribe the information to a medical certificate. 20. The inspector carefully observes:

a. The eyes, to detect irregularities. Observance of one or more of the following signs may warrant further examination: opacities or inflammation of the cornea, opacities of the lens, nystagmus (an involuntary, rapid movement of the eyeball), squint, bulging eyes, an effort to see clearly on the part of the alien, clumsiness, and uncertainty of gait.