Health related forms, documents and templates
In support of transparency efforts, this section contains policy, procedures and guidance used by CIC staff as a courtesy to stakeholders.
Immigration Medical Examinations
- IMM 5743E - Client Consent and Declaration - To give consent to undergo an immigration medical examination (PDF, 557 KB)
- IMM 5419E - Medical Report - To medically process immigrant and certain visitor applicants by ports abroad and Canada Immigration Centres (PDF, 1.6 MB)
- IMM 5725E - Assessment of Activities of Daily Living (ADL) - Part of the immigration medical examination for some clients (PDF, 629 KB)
- IMM 5727E - Global Assessment of Functioning Scale (GAF) - Part of the immigration medical examination for some clients (PDF, 539 KB)
- IMM 5728E - Acknowledgement of HIV Post-test Counselling - Mandatory for all clients that test positive for HIV (PDF, 528 KB)
- IMM 5733E - Instruction for Pregnant Client - X-ray Deferred - Used to defer chest x-rays for pregnant clients (PDF, 579 KB)
- IMM 5734E - Specialist’s Referral Form - Used to refer client to a specialist (PDF, 589 KB)
- IMM 5738E - Chart of Early Childhood Development (CECD) - Part of the immigration medical examination for some clients (PDF, 991 KB)
Medical Surveillance (forms and documents)
- Document - Medical surveillance Handouts: Tuberculosis - Given to new arrivals in Canada with inactive tuberculosis or other complex non-infectious tuberculosis
- Document - Medical surveillance Handouts: Syphilis - Given to new arrivals in Canada with a previous syphilis infection that has been adequately treated
HIV: Automatic partner notifications (documents and template letters)
- Document - Health Follow-Up Handout: HIV Infection (for applicant) - Contact information for HIV specialists in Canada given to clients with HIV
- Document - HIV contact Information in Canada (for sponsor) - Contact information for HIV specialists in Canada given to a sponsor of a client that has HIV
- Document - Automatic Partner Notification Policy (for applicant) - Short summary of the Automatic Partner Notification Policy given to clients
- Sample - Acknowledgment of the Automatic Partner Notification Policy for HIV Positive Applicants in the Family and Dependant Refugee Classes
Medical Refusals and Procedural Fairness (forms, documents and template letters)
Procedural fairness regarding a danger to public health and public safety:
Procedural fairness regarding excessive demand on health (i.e. out-patient medication) and/or social services:
- Date Modified:
