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USCIS' Medical Admissibility Screening Process Needs Improvement, Office of Inspector General, 2018

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USCIS’ Medical Admissibility
Screening Process
Needs Improvement

September 21, 2018
OIG-18-78

DHS OIG HIGHLIGHTS


USCIS’ Medical Admissibility Screening 

Process Needs Improvement 

 
September 21, 2018

Why We Did
This Audit
USCIS is responsible for
verifying that foreign
nationals applying for
lawful permanent
resident status meet
health-related standards
for admissibility. We
performed this audit to
determine whether
USCIS has controls in
place to ensure it
complies with these
standards.

What We
Recommend
We made eight
recommendations that,
when implemented, will
improve USCIS’
selection and oversight
of physicians and its
review of foreign
nationals’ medical
forms.

What We Found
U.S. Citizenship and Immigration Services (USCIS) has
inadequate controls for verifying that foreign nationals
seeking lawful permanent residence status meet
health-related standards for admissibility. First, USCIS is not
properly vetting the physicians it designates to conduct
required medical examinations of these foreign nationals, and
it has designated physicians with a history of patient abuse or
a criminal record. This is occurring because USCIS does not
have policies to ensure only suitable physicians are
designated. Second, when reviewing these foreign nationals’
required medical forms, USCIS Immigration Services Officers,
are accepting incomplete and inaccurate forms because they
are not adequately trained and because USCIS does not
enforce its existing policies.
As a result of these deficiencies, USCIS may be placing foreign
nationals at risk of abuse by physicians performing medical
examinations. USCIS could also be exposing the U.S.
population to contagious or dangerous health conditions from
foreign nationals erroneously granted lawful permanent
resident status.

USCIS Response
USCIS concurred with the eight recommendations and
described corrective action to implement them. We consider
seven of the recommendations resolved, and one
recommendation is unresolved pending USCIS reconsidering
options for corrective action that were discussed after the
draft report was issued. All recommendations remain open.

For Further Information:
Contact our Office of Public Affairs
at (202) 981-6000, or email us at
DHS-OIG.OfficePublicAffairs@oig.dhs.gov

 

www.oig.dhs.gov

OIG-18-78

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Washington, DC 20528 / www.oig.dhs.gov

September 21, 2018
MEMORANDUM FOR: 	 The Honorable L. Francis Cissna
Director
U.S. Citizenship and Immigration Services
FROM: 	

John V. Kelly
Senior Official Performing the
Duties of the Inspector General

SUBJECT:	

USCIS’ Medical Admissibility Screening Process Needs
Improvement

Attached for your action is our final report, USCIS’ Medical Admissibility
Screening Process Needs Improvement. We incorporated the formal comments
from the U.S. Citizenship and Immigration Services in the final report.
The report contains eight recommendations aimed at improving USCIS’
selection and oversight of physicians and its review of foreign nationals’
medical forms. Your office concurred with the eight recommendations and
described corrective actions to implement them. Based on information provided
in your response to the draft report, we consider recommendation 4 open and
unresolved. As prescribed by the Department of Homeland Security Directive
077-01, Follow-Up and Resolutions for the Office of Inspector General Report
Recommendations, within 90 days of the date of this memorandum, please
provide our office with a written response that includes your (1) agreement or
disagreement, (2) corrective action plan, and (3) target completion date for each
recommendation. Also, please include responsible parties and any other
supporting documentation necessary to inform us about the current status of
the recommendation. Until your response is received and evaluated, the
recommendation will be considered open and unresolved.
Based on information provided in your response to the draft report, we
consider recommendations 1 through 3 and 5 through 8 open and resolved.
Once your office has fully implemented the recommendations, please submit a
formal closeout letter to us within 30 days so that we may close the
recommendations. The memorandum should be accompanied by evidence of
completion of agreed-upon corrective actions and of the disposition of any
monetary amounts.

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Please send your response or closure request to
OIGAuditsFollowup@oig.dhs.gov.
Consistent with our responsibility under the Inspector General Act, we will
provide copies of our report to congressional committees with oversight and
appropriation responsibility over the Department of Homeland Security. We will
post the report on our website for public dissemination.
Please call me with any questions, or your staff may contact
Sondra McCauley, Acting Assistant Inspector General for Audits, at
(202) 981-6000.
Attachment

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
 

Table of Contents
 
Background .................................................................................................... 1 

Results of Audit .............................................................................................. 4 

USCIS Does Not Properly Vet Physicians It Designates as 

Civil Surgeons ................................................................................ 4 

USCIS’ Review of Medical Forms Is Inadequate .................................... 11 

Recommendations ....................................................................................... 14 

Management Comments and OIG Analysis................................................... 16


Appendixes
Appendix A: Objective, Scope, and Methodology .................................. 20 

Appendix B: USCIS Comments to the Draft Report .............................. 23 

Appendix C: Office of Audits Major Contributors to This Report ........... 28 

Appendix D: Report Distribution .......................................................... 29 


Abbreviations
A-files
CDC
CFR
HHS
INA
ISO
LEIE
MQRR
NPDB
NPWR
OIG
U.S.C.
USCIS

www.oig.dhs.gov

Alien files


Centers for Disease Control and Prevention 

Code of Federal Regulations 

Health and Human Services 

Immigration and Nationality Act 

Immigration Services Officer 

List of Excluded Individuals and Entities 

Medical Quality and Risk Reduction 

National Practitioner Data Bank 

National Processing Workflow Repository 

Office of Inspector General 

United States Code 

U.S. Citizenship and Immigration Services 


OIG-18-78

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security

Background
U.S. Citizenship and Immigration Services (USCIS) administers the Nation’s
lawful immigration system, safeguarding its integrity and promise by efficiently
and fairly adjudicating requests for immigration benefits while protecting
Americans, securing the homeland, and honoring our values.
As part of its mission, USCIS reviews and adjudicates the applications of
foreign nationals who legally enter the United States and want to adjust from a
temporary status to a lawful permanent resident status. USCIS has the
authority to determine a foreign national’s admissibility to the United States;
according to the Immigration and Nationality Act (INA), immigrants who seek to
adjust their status may be inadmissible based on health-related grounds,
which are designed to protect the health of the U.S. population.1
When applying for adjustment of status, foreign nationals are required to
undergo a medical examination by a physician whom USCIS has designated as
a civil surgeon. Physicians apply to USCIS for designation as civil surgeons by
submitting an Application for Civil Surgeon Designation (Form I-910). Civil
surgeons do not determine a foreign national’s admissibility or eligibility for
immigration status adjustment; they perform the required medical examination
and report the findings on a Report of Medical Examination and Vaccination
Record (Form I-693) (medical form). The civil surgeon provides the sealed,
completed medical form to the applicant, who then provides it to USCIS.
Prior to March 11, 2014, individual USCIS field offices were responsible for
determining whether a physician met the requirements to be designated as a
civil surgeon. When the program was centralized in March 2014, USCIS
“grandfathered” more than 4,200 civil surgeons, thereby allowing them to
maintain their designation without completing a Form I-910 for further
verification. Since March 11, 2014, Immigration Services Officers (ISO) at
USCIS’ National Benefits Center review and adjudicate Forms I-910.

                                                       
1

8 United States Code (U.S.C.) § 1182(a)(1)

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Figure 1 shows USCIS’ process for designating physicians as civil surgeons.
Figure 1. USCIS’ Process for Designating Civil Surgeons, as of March 11, 2014

Source: Department of Homeland Security Office of Inspector General (OIG) representation of
USCIS data

Foreign nationals who legally enter the United States may apply to adjust to
lawful permanent resident status by submitting an Application to Register
Permanent Residence or Adjust Status (Form I-485) to USCIS.
ISOs at USCIS field offices and service centers review and adjudicate
applications for status adjustment. ISOs make the status adjustment
determination after reviewing the application (Form I-485) and supporting
documents, including the civil surgeon’s report on the medical form. ISOs
review the medical form to determine whether the foreign national meets the
health-related standards for admissibility. The medical form should contain the
results of the civil surgeon’s medical examination and documentation of any
health concerns that may make the foreign national inadmissible.
According to the INA, the following four medical conditions may make a foreign
national inadmissible on health related grounds:

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
•	 communicable diseases of public health significance (e.g., gonorrhea,
leprosy, and tuberculosis);
•	 failure to show proof of required vaccinations (e.g., polio, varicella, and
hepatitis A and B);
•	 physical or mental disorders with associated harmful behavior as defined
in the Diagnostic and Statistical Manual of Mental Disorders; and
•	 drug abuse or addiction.
Figure 2 shows USCIS’ medical form review process, which is used to verify the
medical admissibility of foreign nationals seeking to adjust to lawful permanent
resident status.
Figure 2. USCIS’ Medical Form Review Process

Source: DHS OIG representation of USCIS data

www.oig.dhs.gov

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OIG-18-78

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
In this report, we examine USCIS’ process for designating physicians as civil
surgeons and USCIS’ review of the medical forms of foreign nationals applying
to adjust to lawful permanent resident status.

Results of Audit
USCIS has inadequate controls for verifying that foreign nationals seeking
lawful permanent residence status meet health-related standards for
admissibility. First, USCIS is not properly vetting the physicians it designates
as civil surgeons. We determined that USCIS designated physicians with a
history of patient abuse or a criminal record as civil surgeons. This is occurring
because USCIS does not have adequate policies to ensure only suitable
physicians are designated as civil surgeons. Second, when reviewing these
foreign nationals’ required medical forms, ISOs are accepting incomplete and
inaccurate forms because they are not adequately trained and because USCIS
is not enforcing its existing policies.
As a result of these deficiencies, USCIS may be placing foreign nationals at risk
of abuse by some civil surgeons. USCIS could also be exposing the U.S.
population to contagious or dangerous health conditions from foreign nationals
erroneously granted lawful permanent resident status.

USCIS Does Not Properly Vet Physicians It Designates as Civil
Surgeons
In vetting physicians who apply to become civil surgeons, USCIS neither
ensures the physicians meet eligibility requirements for designation as civil
surgeons, nor has it prevented physicians with a history of patient abuse or
criminal records from being designated as civil surgeons. In addition, USCIS
allowed physicians to remain civil surgeons without verifying that they met
eligibility requirements, and it does not always promptly revoke the designation
of noncompliant civil surgeons. These deficiencies occurred because USCIS
lacks policies and procedures to ensure civil surgeons meet and maintain
professional requirements. As a result, USCIS could be risking the health and
safety of foreign nationals applying for lawful permanent residence.
USCIS Does Not Ensure Physicians Meet Civil Surgeon Eligibility Requirements
The INA gives USCIS the authority to designate civil surgeons to conduct
medical examinations of foreign nationals seeking immigration benefits, and
the Code of Federal Regulations (CFR)2 provides general requirements for
determining civil surgeon eligibility. According to the INA and the CFR, only
licensed physicians with at least 4 years of professional experience may be
                                                       
2

8 C.F.R. § 232.2 (2017).

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
designated as civil surgeons. The USCIS Policy Manual (policy manual) provides
more specific requirements for determining civil surgeon eligibility.3 According
to the policy manual, an application for civil surgeon designation must contain:



a completed Form I-910;
proof of U.S. citizenship, legal status, or authorization to work in the
United States;
 a copy of the physician’s medical degree verifying he or she is a Doctor of
Medicine or Doctor of Osteopathy;
	 a copy of the physician’s current full and unrestricted medical license in
the state in which he or she seeks to perform immigration medical
examinations; and
	 evidence to verify the requisite professional experience, such as letters of
employment verification.
USCIS ISOs do not ensure that the physicians’ applications they review comply
with requirements in the INA, CFR, and the policy manual. Specifically, we
statistically sampled and reviewed 135 I-910 files of civil surgeons approved by
USCIS between March 11, 2014, and June 30, 2017. For 19 of these 135 files
(14 percent), USCIS did not have the evidence to prove a physician met the
qualifications for a civil surgeon, with several of the 19 files missing more than
1 piece of evidence. Table 1 shows the evidence missing from the approved civil
surgeons’ files.
Table 1. Evidence Missing from 19 I-910 Files of Approved Civil Surgeons
Number of Files
with Evidence
Missing*

Type of Evidence Missing from File
Required sections on the I-910 Form completed
Proof of authorization to work in the United States
Copy of the physician’s medical degree
Copy of the physician’s medical license
Evidence of requisite (4 years) professional experience

5
2
6
1
9

Source: DHS OIG analysis of reviewed I-910 files

*The number of files adds up to more than 19 because some files were missing more than

1 type of evidence.

Based on the results of our statistical sample, approximately 14 percent of the
1,337 civil surgeon designations, or an estimated 188 designations of the civil
surgeon designation population, made between March 11, 2014, and June 30,
2017, may lack evidence to support USCIS’ decision to designate the physician
as a civil surgeon.
                                                       
3

USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B

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OIG-18-78

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
These I-910 review process deficiencies occurred because USCIS does not
provide formal training to ISOs responsible for adjudicating civil surgeon
applications and does not require second-level reviews. According to USCIS
officials, one reason they do not provide formal training is that only 1 or 2 ISOs
are assigned to review about 50 civil surgeon applications a month.
USCIS Designates Civil Surgeons Who May Put Foreign Nationals’ Health and
Safety at Risk
In addition to designating physicians who may not meet eligibility
requirements, USCIS failed to prevent physicians with a history of patient
abuse or a criminal record from being designated as civil surgeons. We
attribute this failure to inadequate reviews of physicians’ histories. Specifically,
USCIS does not require ISOs to consider medical board disciplinary history
before designating physicians as civil surgeons.
Of USCIS’ 5,569 active civil surgeons, 132 could pose a health or safety risk to
foreign nationals seeking to adjust their status.4 We identified 11 civil
surgeons, active as of June 30, 2017, who had been excluded by the
Department of Health and Human Services (HHS) OIG from participating in
federally funded health care programs for various offenses. These
11 physicians were on HHS OIG’s List of Excluded Individuals and Entities
(LEIE), a public list of individuals and entities excluded from participation in
Medicare, Medicaid, and all other Federal health care programs. Although
USCIS’ civil surgeons are not part of a federally funded health care program,
they are the only physicians USCIS authorizes to conduct immigration-related
medical examinations and to complete medical forms. As shown in table 2,
these 11 physicians’ offenses ranged from convictions related to fraud, patient
abuse, and neglect to exclusion or suspension from health care programs.
Table 2. Offenses of Physicians Excluded from Federally Funded Health Care
Programs
Number of Civil
Surgeons

Categories of Excludable Offenses
Conviction relating to program or health care fraud
Default on health education loan or scholarship
Federal or state health care program exclusion or suspension
Patient abuse or neglect conviction
Program-related conviction
Total number of civil surgeons excluded from federally
funded health care programs

1
2
4
1
3
11

Source: DHS OIG analysis of LEIE as of July 2017 and active civil surgeons as of June 30,
2017

                                                       
4

There were 5,569 total active civil surgeons as of June 30, 2017. 

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
Additionally, state medical boards have disciplined 121 active civil surgeons for
offenses that may meet HHS OIG’s criteria for exclusion. Twenty-nine of the
121 civil surgeons had disciplinary actions for egregious infractions. These
offenses include felony conviction for solicitation of capital murder and
engaging in dishonest, gross, and repeated negligent conduct in patient care
and treatment. Although some disciplinary conduct may have occurred years
ago, the nature of the offense may continue to render these physicians a risk to
those applying for immigration benefits. For example, USCIS designated the
following physicians as civil surgeons:
	 A physician in Georgia with a felony conviction for solicitation of capital
murder because he attempted to hire a hit man to kill a dissatisfied patient
in Houston, Texas. The California, Pennsylvania, and Texas Medical Boards
subsequently revoked his license for the criminal conviction. However, the
Georgia Medical Board allowed the physician to resume his practice several
years later.
	 A physician with a history of professional sexual misconduct and
exploitation of female patients from a position of power, authority, and
trust. The Texas Medical Board restricted his license for 5 years and the
physician was not allowed to be alone with female patients while conducting
physical examinations.
	 A physician disciplined by the California Medical Board for numerous
offenses, including allowing her medical assistants to dilute mumps,
measles, rubella, and varicella vaccines; pre-draw vaccines; administer
injections with less than effective needles; give free vaccines to ineligible
patients; falsify medical records; and other unprofessional behaviors.
Although Federal laws and regulations give USCIS discretion in designating
physicians as civil surgeons, the component has established only minimal
eligibility requirements for physicians. When they are determining whether to
designate a physician as a civil surgeon, USCIS does not require ISOs to
consider a physician’s medical board disciplinary history. Rather, USCIS
officials said ISOs only check the status of the medical license the physician
provided in the application. To guard against risking the health and safety of
these foreign nationals, USCIS should more thoroughly scrutinize physicians
before allowing them to become civil surgeons.
DHS has a resource USCIS could use to better monitor physicians who apply
for designation as civil surgeons. The Medical Quality and Risk Reduction
Branch (MQRR) in DHS’ Workforce Health and Safety Division is responsible
for protecting national security and mitigating liability by ensuring employees,
detailees, and contractors have the qualifications and other credentials (e.g.,
licenses) necessary to perform medical services for, or on behalf of, DHS.
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OIG-18-78

OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
MQRR uses the National Practitioner Data Bank (NPDB) to verify and
continuously monitor medical provider credentials, including qualifications,
licensure information, and other relevant health care provider data.5 Figure 3
shows the type of information captured in the NPDB.
Figure 3. Types of Information in the National Practitioner Data Bank

Source: https://www.npdb.hrsa.gov/resources/whatIsTheNPDB.jsp (last visited May 30,
2018)

USCIS could use MQRR’s access to the NPDB to assess the suitability of
physicians who apply to become civil surgeons. MQRR could notify USCIS of
                                                       
5 Congress created the NPDB as an information clearinghouse, with the primary goals of
improving health care quality, protecting the public, and reducing health care fraud and abuse
in the United States.

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
physicians who may not meet DHS suitability standards and may pose a risk
to foreign nationals or national security.
USCIS Allowed Civil Surgeons to Maintain Their Designation without Verifying
Their Eligibility
Prior to March 11, 2014, USCIS field offices designated physicians as civil
surgeons. In March 2014, USCIS centralized the civil surgeon program and
introduced the I-910 process, at which time the component “grandfathered”
more than 4,200 civil surgeons, thereby allowing them to maintain their
designation without verifying they met eligibility requirements.6 According to
USCIS officials, these civil surgeons were not required to complete a Form
I-910.
Our review of 25 active grandfathered civil surgeon files showed that USCIS did
not have the evidence necessary to support their designations. Specifically,
USCIS did not have a file to support the designation of 4 of the grandfathered
civil surgeons, and all 21 of the remaining civil surgeon files were missing 1 or
more types of evidence required by the policy manual.7 Table 3 shows the
evidence missing to support the grandfathered civil surgeon designations.
Table 3. Evidence Missing from 25 Grandfathered Civil Surgeon Designations
Number of Files with
evidence missing*

Type of Evidence Missing
Proof of authorization to work in the United States
Copy of the physician’s medical degree
Copy of the physician’s medical license
Evidence of requisite professional experience
Entire file missing

10
17
3
21
4

Source: DHS OIG analysis of reviewed grandfathered civil surgeon files
*The number of files adds up to more than 25 because some files were missing more than
1 type of evidence.

This deficiency occurred because, prior to March 11, 2014, when field offices
were designating physicians as civil surgeons, USCIS did not have formal
policies requiring evidence to support their designation. Also, when the
designation process was centralized, USCIS officials stated they did not ask the
more than 4,200 grandfathered civil surgeons to provide evidence verifying they
met the eligibility requirements.

                                                       
6 We did not include USCIS’ decision to grandfather civil surgeons designated prior to the
initiation of the I-910 process in the scope of this audit and take no position on the legality or
propriety of USCIS’ decision.  
7 USCIS Policy Manual, Volume 8, Part C, Chapter 2, Section B

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
USCIS Did Not Take Prompt Action against Civil Surgeons Who Failed to
Maintain a Current and Unrestricted Medical License
Revoking a physician’s designation as a civil surgeon makes him or her
ineligible to conduct immigration-related medical examinations. According to
the policy manual and Form I-910 instructions, USCIS may revoke a civil
surgeon’s designation for several reasons, including failure to:




maintain a currently valid and unrestricted license to practice as a
physician in any state in which the physician conducts immigration-related
medical examinations;
comply with Centers for Disease Control and Prevention (CDC) Technical
Instructions for Panel Physicians and Civil Surgeons (technical instructions);8
and
continue to meet the professional qualifications required for civil surgeon
designation, engaging in immigration fraud, or otherwise engaging in
activity that poses a risk to public health or safety. According to USCIS
regulations, a form's instructions are incorporated into the regulations
requiring its submission [8 CFR §103.2(a)(1)].

In reviewing a report that USCIS received in May 2017 on active civil surgeons,
we identified 48 civil surgeons, who were not in our statistical sample and
whose medical license was either expired or restricted. Although USCIS
received the report in May 2017, several months elapsed before the component
revoked the designations of 37 of the 48 civil surgeons. For the 37 civil
surgeons, USCIS revoked 1 designation in July 2017, 34 designations in
August 2017, and 1 designation in November 2017.9 As of December 2017, the
other remaining 11 civil surgeons were active and able to conduct medical
examinations while USCIS reviewed their medical license status.
USCIS did not promptly revoke these designations because its process for
identifying civil surgeons with inactive or restricted medical licenses is
inefficient. According to USCIS officials, to determine whether civil surgeons
should maintain their designation, USCIS checks the status of their medical
license using a contractor, Evercheck, which is only required to verify medical
license information on active civil surgeons biannually (every 6 months).
Further, one ISO is responsible for manually reviewing Evercheck’s biannual
report and determining whether a civil surgeon’s medical license is compliant.
According to USCIS officials, the review requires considerable effort and time
                                                       
CDC’s Technical Instructions for Panel Physicians and Civil Surgeons are on the CDC website 

and include instructions on recording findings from the medical examination and on 

vaccinations, medical history, and communicable diseases. (See

https://www.cdc.gov/immigrantrefugeehealth/exams/ti/civil/technical-instructions-civil­
surgeons.html, (last visited June 15, 2018).
 
9 One civil surgeon voluntarily relinquished the designation in August 2017. 

8

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OFFICE OF INSPECTOR GENERAL
Department of Homeland Security
because the biannual report contains medical license information for more
than 5,500 civil surgeons.
In addition to using the NPDB to monitor physicians applying to become civil
surgeons (as noted previously), the NPDB may be another resource to monitor
civil surgeons’ medical licenses. MQRR could notify USCIS of negative actions
against civil surgeons’ medical licenses reported in NPDB, and this information
could facilitate USCIS’ revocations.

USCIS’ Review of Medical Forms Is Inadequate
As part of adjudicating applications to adjust to lawful permanent resident
status, ISOs review medical forms to verify foreign nationals meet healthrelated standards for admissibility. We reviewed 151 statistically sampled Alien
files (A-files)10 of foreign nationals whom USCIS had approved for lawful
permanent resident status. We identified errors in 44 of the medical forms in
these A-files. Some errors were caused by ISOs accepting incomplete and
inaccurate medical forms. In other cases, the forms were completed and
signed, but ISOs did not verify that the civil surgeon who signed the form was
active. Finally, in some instances, civil surgeons did not follow CDC’s technical
instructions.11
These deficiencies occurred because USCIS did not adequately train ISOs on
proper review of medical forms and USCIS did not enforce its existing policy,
which requires ISOs to return inaccurate medical forms to the foreign national
for corrective action. Also, USCIS does not review and track errors on medical
forms to monitor how well civil surgeons comply with CDC’s technical
instructions. As a result, USCIS cannot be certain the civil surgeons actually
administered all required tests and vaccinations and may have granted lawful
permanent residence status to medically inadmissible foreign nationals who
could pose a health risk to the U.S. population.
ISOs Accepted Incomplete and Inaccurate Medical Forms
When adjudicating foreign nationals’ status adjustment applications, ISOs are
required to determine a foreign national’s medical admissibility based on the
information in the medical form. According to USCIS policy, when determining
medical admissibility, ISOs must ensure medical forms are legible, complete,
valid, signed and dated, and placed in a sealed envelope. If these requirements
are not met, ISOs must return the medical form to the foreign national for
                                                       
A-files are the official files for immigration and naturalization records created or consolidated
for non-U.S. citizens.
11 We attributed some of the same errors on medical forms to two or even three causes. For
example, an ISO may have accepted an incomplete or inaccurate form, in which the civil
surgeon also failed to follow CDC’s technical instructions. For this reason, the number of errors
we identified exceeds the number of medical forms.
10

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Department of Homeland Security
corrective action.12 ISOs may suspend their decision on the adjustment of
status until a complete and accurate medical form is resubmitted. Also
according to the policy manual, ISOs may grant a waiver for certain
vaccinations, for example, if the foreign national has had a severe allergic
reaction to a vaccination.
In 32 of 151 A-files reviewed, ISOs did not comply with USCIS policy when
reviewing medical forms and accepted incomplete or inaccurate medical forms.
We identified the following errors:
	 19 medical forms missing vaccination information or in which the civil
surgeon marked the wrong box on the vaccination portion of the form.
	 5 medical forms missing required medical tests, such as tests for 

gonorrhea or syphilis. 

	 7 medical forms with various errors, such as the form was not signed by
an active civil surgeon, the form had expired (requiring a new form), the
civil surgeon signed the form before receiving test results, the civil
surgeon did not verify the foreign national’s identity, or the form did not
contain the required stamp from a health department.
	 1 medical form in which the civil surgeon’s information was not legible.
Based on our statistical sample results, from October 2013 through May 2017,
USCIS may have approved about 330,000 of 1,558,031 adjustment of status
applications population with inaccurate or incomplete medical forms. These
errors may have rendered the foreign nationals medically inadmissible.
This acceptance of invalid medical forms occurred because USCIS does not
adequately train ISOs on reviewing medical forms to determine whether the
foreign national meets health-related standards for admissibility. When hired,
USCIS provides new ISOs with fewer than 2 hours of training focused on
health-related admissibility standards or on reviewing medical forms — out of
200 total training hours. For ISOs reviewing applications that do not require an
in-person interview, USCIS provides up to 5 hours of total training focused on
health-related admissibility standards. USCIS also did not maintain a record to
demonstrate how often such training occurs and does not have a system in
place to ensure ISOs receive annual training.
ISOs Did Not Verify That Active Civil Surgeons Completed Medical Forms
USCIS policy requires foreign nationals’ medical forms be signed and dated by
an active civil surgeon who conducted the medical examination, but does not
                                                       
12

USCIS Policy Manual, Volume 8, Part B, Chapter 4

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Department of Homeland Security
require ISOs to verify the civil surgeon’s signature or whether the civil surgeon
was active at the time of the examination. The policy manual13 only states that
an ISO “should consult” the Find a Doctor tool on USCIS’ website14 to
determine whether the physician is a designated civil surgeon.
For 11 of the 151 A-files we reviewed USCIS could not demonstrate that an
active civil surgeon completed the form. In these 11 A-files, either the civil
surgeon’s signature on the medical form did not match USCIS’ records or the
civil surgeon was not in USCIS’ internal system of civil surgeon information,
the National Processing Workflow Repository (NPWR). Based on our statistical
sample results, nearly 110,000 of 1,558,031 population of A-files approved
from October 2013 through May 2017 may have similar errors.
Rather than consulting Find a Doctor, ISOs could use NPWR to validate a civil
surgeon’s status and signature when reviewing medical forms. Find a Doctor
contains the civil surgeon’s office information, but it does not contain images of
signatures or the dates a physician has been an active civil surgeon. NPWR
contains more information on civil surgeons, such as status and designation
date, signature,15 and, if applicable, periods of inactivity. However, USCIS does
not require ISOs to use NPWR. As of October 2017, only 658 of 6,226 ISOs had
access to the system.
USCIS officials said ISOs who do not have access to NPWR rely on their
familiarity with civil surgeons in their geographic location and on Find a Doctor.
However, neither method allows ISOs to fully substantiate a civil surgeon’s
information or verify that active civil surgeons are signing and dating medical
forms. USCIS has advertised NPWR’s usefulness to several USCIS field offices
and suggested ISOs request access.
Civil Surgeons Did Not Follow CDC’s Technical Instructions
Civil surgeons must follow CDC’s technical instructions for conducting medical
examinations and filling out medical forms; failure to comply with the
instructions is grounds for revoking civil surgeon designation. USCIS is not
reviewing and tracking errors on medical forms to monitor civil surgeons’
compliance with the technical instructions. This occurred because Federal
regulations do not specify that USCIS monitor and oversee civil surgeons.
Consequently, civil surgeons may not receive proper instruction. USCIS also
cannot effectively seek revocation of civil surgeons who fail to accurately
complete medical forms or determine whether civil surgeons are administering
required vaccinations and tests.
                                                       
USCIS Policy Manual, Volume 8, Part B, Chapter 4.
 
The Find a Doctor tool is on the USCIS website at https://my.uscis.gov/findadoctor (last 

visited June 15, 2018). Foreign nationals may use this tool to locate a civil surgeon. 
 
15 NPWR does not contain images of every civil surgeon’s signature.

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Of the 151 A-files reviewed, 28 contained medical forms in which the civil
surgeon did not follow CDC’s technical instructions for completing the form.
These errors included no evidence of testing the foreign national for gonorrhea
and missing or incorrectly marked vaccinations. As stated previously, ISOs
accepted medical forms with this missing or inaccurate information.
Some of the missing information could indicate civil surgeons did not
administer required tests and vaccinations, which may mean some foreign
nationals did not meet health-related standards for admissibility. For example,
according to the CDC, having gonorrhea is grounds for inadmissibility. In
addition, the CDC’s Vaccination Technical Instructions for Civil Surgeons require
civil surgeons, among other things, to administer required vaccines, such as
those for polio, hepatitis B, varicella, and influenza, to those applying for status
adjustment. Based on our statistical sample results, nearly 289,000 of the
population of 1,558,031 A-files approved from October 2013 through May 2017
may have similar errors.
According to the Government Accountability Office, management should
establish and operate activities to monitor its internal control system and
evaluate the results,16 but USCIS has done neither. According to USCIS, it is
not responsible for monitoring civil surgeons. USCIS officials also informed us
that the component does not have a process to monitor civil surgeons’
compliance with CDC technical instructions for completing immigration-related
medical forms, even though failure to comply with these instructions is
grounds for revoking USCIS designation as a civil surgeon.

Recommendations
Recommendation 1: We recommend the USCIS Chief of the Regulatory
Coordination Division for the Office of Policy and Strategy develop stricter
ineligibility requirements for civil surgeon designations, which could include
standards used by the Department of Health and Human Services Office of
Inspector General, and implement processes to strengthen the vetting process
of physicians and active civil surgeons.
Recommendation 2: We recommend the Associate Director for the Field
Operations Directorate:
 
a.	 establish a training regimen for personnel responsible for adjudicating
civil surgeon applications; and
b. establish quality control reviews of civil surgeon application decisions.
                                                       
16 Principle

16 of Government Accountability Office Standards for Internal Control in the Federal
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Recommendation 3: We recommend the Associate Director for the Field
Operations Directorate review grandfathered civil surgeons to confirm that they
meet current eligibility requirements, and that USCIS maintain all required
documents. At a minimum, the eligibility requirements should include:
a.	 prompt review and identification of noncompliant civil surgeons;
b. issuance of Intent to Revoke notices within 30 days of identification; and
c.	 re-evaluation of active civil surgeons to determine whether they meet the
newly developed requirements.
Recommendation 4: We recommend the Associate Director for the Field
Operations Directorate evaluate the Medical Quality and Risk Reduction
Branch services and implement applicable services to assist USCIS in making
its civil surgeon determinations.
Recommendation 5: We recommend the Director for USCIS strengthen its
training program on health admissibility by:
a.	 providing focused training on what the USCIS Policy Manual considers a
complete and accurate medical form; and
b. developing a schedule for recurrent training for Immigration Services
Officers, at least annually.
Recommendation 6: We recommend the Associate Director for Field
Operations Directorate establish a quality control process to ensure that
Immigration Services Officers only accept complete and accurate medical
forms, as required by written policy.
Recommendation 7: We recommend the Office of Policy and Strategy update
the USCIS Policy Manual so Immigration Services Officers are required to verify
the authenticity of the civil surgeon’s information, such as signature and
designation status, on the medical form.
Recommendation 8: We recommend the Associate Director for Field
Operations Directorate establish a process to track civil surgeon medical form
errors to identify areas that need improvement. The process should include:
a.	 tracking civil surgeons’ accuracy in complying with CDC’s Technical
Instructions for Panel Physicians and Civil Surgeons;
b. tracking the completeness of the forms; and
c.	 establishing a system to ensure civil surgeons understand and follow the
CDC’s Technical Instructions for Panel Physicians and Civil Surgeons and
to ensure civil surgeons who fail to fulfill their responsibilities face
prompt revocation.

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Management Comments and OIG Analysis
USCIS concurred with our eight recommendations. We included a copy of the
USCIS management comments in their entirety in appendix B. We also received
technical comments to the draft report and made revisions to the report as
appropriate. We consider seven recommendations to be resolved and open until
USCIS implements the proposed corrective actions. Recommendation 4 is
unresolved pending USCIS evaluating implementation options presented after
the draft was issued. A summary of USCIS’ response and our analysis follows.
USCIS Response to Recommendation #1: Concur. USCIS agreed that stricter
eligibility requirements for civil surgeon designation and a strengthened vetting
process will improve the quality and integrity of the program. USCIS’ Office of
Policy and Strategy will lead a working group to evaluate current requirements
and pursue regulatory amendments that would establish additional
requirements that would enhance the program’s integrity. The group will also
examine the feasibility of establishing an audit process to assess how well civil
surgeons are complying with USCIS requirements and Technical Instructions
for conducting the medical exam. USCIS anticipates completing actions to
implement this recommendation by December 31, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we
evaluate the results of the working group and verify USCIS has implemented
stricter eligibility requirements and strengthened the vetting process.
USCIS Response to Recommendation #2: Concur. The Director stated that
USCIS’ Field Operations Directorate personnel are in the process of finalizing
training materials for personnel responsible for adjudicating civil surgeon
applications. USCIS will also establish a quality assurance program that will
include a 100 percent review of newly trained officer’s work. USCIS anticipates
completing actions to implement this recommendation by March 31, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we review
the revised training materials and evaluate the effectiveness of the quality
assurance program.
USCIS Response to Recommendation #3: Concur. USCIS plans to implement
a 100 percent review of active grandfathered civil surgeon records to confirm
they meet eligibility requirements. If deficiencies are discovered, USCIS will
issue a Request of Evidence and/or Notice of Intent to Revoke to resolve the
deficiency. To the extent feasible, USCIS will issue the Notice of Intent to
Revoke within 30 days of identification of a noncompliant civil surgeon. USCIS

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anticipates completing actions to implement this recommendation by
March 31, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we review
USCIS’ documentation supporting the review of the grandfathered civil
surgeons.
USCIS Response to Recommendation #4: Concur. The Director stated that
USCIS completed an evaluation of the MQRR Branch services and determined
that MQRR is not equipped to provide the services USCIS requires in making
its civil surgeon determinations. Specifically, the Director stated that the NPDB
does not validate medical licenses; MQRR can input only 10 physicians per
day; and MQRR can only add or remove physicians on a quarterly basis. Based
on these actions, the Director requested that the OIG consider this
recommendation resolved and closed as implemented.
OIG Analysis: We consider these actions nonresponsive to the
recommendation, and they will remain unresolved and open. In follow-on
discussions between the OIG and MQRR officials, we learned that MQRR is
willing to work with USCIS to implement a batch submission process for
1,000 physicians at a time, which would drastically reduce the turnaround
time. Further, MQRR officials confirmed they add and remove medical
providers from the NPDB daily, and perform random credentialing records
review to assess the accuracy of the information on a quarterly basis. MQRR
did acknowledge that the NPDB does not validate medical licenses, but stated
the NPDB does collect negative actions on a provider’s license. MQRR has
committed to researching and reviewing medical credentialing software to
automate the state licensure verification and the NPDB monitoring process.
OIG shared this information with USCIS after reviewing management’s
technical comments to the draft report. USCIS has since agreed to reconsider
MQRR’s options. USCIS has committed to providing an updated response
within 90 days from the issuance of the final report.
USCIS Response to Recommendation #5: Concur. The Director committed to
USCIS strengthening its training program on health admissibility through a
series of actions. Multiple USCIS directorates and offices will work together to
determine if training on the medical form during the ISO Basic Training
Program can be enhanced. If it is determined that a more focused medical form
training (i.e., increased training time) is feasible, USCIS would develop, review,
and implement new training materials. USCIS will also work to develop an
electronic training course on the medical form that new officers would be
required to take after completing the Basic Training. This training would be
available in the Department’s Performance and Learning Management System
and could also be utilized as refresher training for officers, as needed. Once
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developed, the electronic medical form training course would be made available
to all officers and required annually for those officers working on benefit types
that require familiarity with health admissibility. USCIS anticipates completing
actions to implement this recommendation by March 30, 2020.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we review
USCIS’ documentation supporting the new training material and course.
USCIS Response to Recommendation #6: Concur. USCIS agrees that a
quality control process for the medical forms will assist them in accepting only
complete and accurate medical forms. USCIS will establish a quality control
review process for the medical forms to ensure compliance with written USCIS
policy. USCIS will regularly review its written policies on medical forms to
ensure that they comply with current CDC Technical Instructions. USCIS
anticipates completing actions to implement this recommendation by
September 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we review
USCIS’ quality control process.
USCIS Response to Recommendation #7: Concur. The Director stated that
USCIS’ Office of Policy and Strategy, together with other USCIS directorates,
will examine the feasibility of requiring officers to verify the authenticity of the
civil surgeon’s information in the record, including comparing signatures of
civil surgeons with their exemplar signatures contained in USCIS records, as
well as other information relating to a civil surgeon. If deemed feasible, the
Office of Policy and Strategy will revise the Policy Manual, as appropriate.
USCIS anticipates completing actions to implement this recommendation by
December 31, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. However, we recommend USCIS take all necessary
steps to implement a process requiring an officer to follow policy ensuring
foreign nationals’ medical forms be signed and dated by an active civil surgeon.
We will close this recommendation after we review USCIS’ documentation on
the feasibility study and subsequent changes to the policy manual.
USCIS Response to Recommendation #8:  Concur. USCIS states it is
committed to developing and implementing a process that tracks medical
errors as well as being able to identify areas of improvement. The creation of
this process may entail the development of new technology, which supports
such tracking. In the interim, officers may use the National Benefit Center’s
Civil Surgeons mailbox to report non-compliant civil surgeons. USCIS will
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consult with the Office of the Chief Counsel regarding revocation of a civil
surgeon who is failing to fulfill his or her responsibilities. In addition, USCIS
plans to aggregate the overall I-693 errors and consult with the CDC on the
best way to communicate with civil surgeons so that it can ensure physicians
understand and follow the Technical Instructions, as well as the consequences
of not doing so. USCIS anticipates completing actions to implement this
recommendation by September 30, 2019.
OIG Analysis: We consider these actions responsive to the recommendation,
which is resolved and open. We will close this recommendation after we review
USCIS’ proposed process and the results of any discussions with CDC.

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Appendix A
Objective, Scope, and Methodology
DHS OIG was established by the Homeland Security Act of 2002 (Public Law
107−296) by amendment to the Inspector General Act of 1978.
We performed this audit to determine whether USCIS has controls in place to
ensure foreign nationals meet health-related standards for admissibility prior
to granting lawful permanent resident status. The scope of the audit includes a
review of USCIS’ roles, policies, and standard operating procedures. The scope
period for this audit was from October 2013 through June 2017.
To achieve our objective, we reviewed Federal and component guidance on
health-related standards for inadmissibility. We interviewed officials from DHS
offices — Citizenship and Immigration Ombudsman, Civil Rights and Civil
Liberties, and MQRR Branch; and USCIS offices — Customer Service and
Public Engagement, Field Operations Directorate, Fraud Detection National
Security, National Benefits Center, Office of Chief Counsel, Office of Policy and
Strategy, and Service Center Operations Directorate. The team also interviewed
officials from the U.S. Department of State and CDC to gain an understanding
of the similarities or differences between the medical examination process
within the United States and the medical examination process in foreign
countries.
We performed site visits to the Texas Service Center in Dallas, Texas; and the
National Benefits Center in Lee’s Summit, Missouri, to gain an understanding
of USCIS’ review process for medical examination forms related to adjustment
of status and the civil surgeon application review process.
We performed a limited review of the internal controls associated with USCIS’
medical screening process. Specifically, we evaluated USCIS compliance with
Form I-910 applications and Form I-693 medical forms and compared them to
USCIS policies and procedures. The findings identified in this report can be
adequately addressed by implementation of our recommendations. In making
these recommendations, OIG acknowledges that to the extent we recommend
new policies, USCIS may be required to conduct formal rulemakings pursuant
to the Administrative Procedures Act, 5 U.S.C. §551 et seq., applicable
regulations, and judicial precedents.

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Appendix A (cont.)
We performed a review to determine whether any civil surgeon active as of
June 30, 2017, appeared on HHS OIG’s LEIE. Furthermore, we compared
whether disciplinary actions for active civil surgeons notated on Evercheck’s
May 2017 report would meet the LEIE criteria for exclusion if that surgeon
participated in a federally funded health care program. We retrieved medical
board orders and administrative hearing documents from the appropriate state
medical board websites.
Sampling Methodology
The team selected three samples: I-910 civil surgeon applicants, grandfathered
civil surgeons, and A-files. The civil surgeon and the A-file data was retrieved
from the Standard Management Analysis Reporting Tool. Prior to selecting our
samples, we tested the reliability of component-generated data during fieldwork
on the Tool. We determined the information was sufficiently reliable to support
the audit’s conclusions. Each sample selection was performed as follows:
I-910 Civil Surgeons — As of June 30, 2017, there were 1,337 active civil
surgeons who had completed the I-910 application. Assuming a population
proportion of 50 percent, with the population size of 1,337 active civil
surgeons, the minimum sample size required for a 95 percent confidence level
and allowable error of ± 8 percent is 135. This sample of 135 I-910 application
files was randomly selected with the help of IDEA software. To test for
compliance with USCIS civil surgeon professional requirements, we used the
sample results of these 135 I-910 files of active civil surgeons to infer it to the
population of 1,337 active civil surgeons.
Grandfathered Civil Surgeons — Our audit population was the number of
grandfathered civil surgeons who had active designations as of June 30, 2017.
At that time, USCIS had 4,232 grandfathered civil surgeons. The team
performed a random sample to assess the level of documentation for
professional requirements contained in the file. We selected a judgmental
sample size of 25 grandfathered civil surgeons. We did not infer the results of
this sample and only reported on the 25 files reviewed.
Alien files — Our audit population was limited to A-files stored at the National
Records Center, retired or archived, that contained an approved application to
adjust status and a medical form adjudicated from October 1, 2013, through
May 31, 2017. We did not include active A-files, even if they had adjusted
status during our scope period, to minimize disruptions to USCIS business,
such as being used for another USCIS process or a court case. The audit
population consisted of 1,558,031 A-files containing an approved medical form

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Appendix A (cont.)
and adjudicated between October 1, 2013, and May 31, 2017. Assuming a
population proportion of 50 percent, with the population size of
1,558,031 A-files, the minimum sample size required for a 95 percent
confidence level and allowable error of ± 8 percent is 151. This sample of
151 A-files was randomly selected with the help of Excel software. To determine
whether ISOs reviewed and processed the medical forms according to USCIS
policy, we used the sample results of these 151 A-files to infer it to the
population of 1,558,031 A-files.
This performance audit was conducted between February 2017 and March
2018 pursuant to the Inspector General Act of 1978, as amended, and
according to generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based upon our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions based
upon our audit objectives.

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Appendix B
USCIS Comments to the Draft Report

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Appendix C
Office of Audits Major Contributors to This Report
Yesi Starinsky, Director
Loretta Atkinson, Audit Manager
Christine Alvarez, Auditor in Charge
Julian Brown, Auditor
Victoria Buono, Program Analyst
Jennifer Eads, Program Analyst
Mary Nowak, Auditor
Juan Santana, Auditor
M. Faizul Islam, Ph.D. Statistician
Kevin Dolloson, Communications Analyst
Kelly Herberger, Supervisory Communications and Policy Analyst
Gary Alvino, Independent Reference Reviewer
Brad Mosher, Independent Reference Reviewer

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Appendix D
Report Distribution
Department of Homeland Security
Secretary
Deputy Secretary
Chief of Staff
General Counsel
Executive Secretary
Director, GAO/OIG Liaison Office
Assistant Secretary for Office of Policy
Assistant Secretary for Office of Public Affairs
Assistant Secretary for Office of Legislative Affairs
USCIS Component Liaison
Office of Management and Budget
Chief, Homeland Security Branch
DHS OIG Budget Examiner
Congress
Congressional Oversight and Appropriations Committees

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Additional Information and Copies
To view this and any of our other reports, please visit our website at:
www.oig.dhs.gov.
For further information or questions, please contact Office of Inspector General 

Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. 

Follow us on Twitter at: @dhsoig. 


OIG Hotline

To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click
on the red "Hotline" tab. If you cannot access our website, call our hotline at
(800) 323-8603, fax our hotline at (202) 254-4297, or write to us at:
Department of Homeland Security
Office of Inspector General, Mail Stop 0305
Attention: Hotline
245 Murray Drive, SW
Washington, DC 20528-0305

 

 

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