Health related forms, documents and templates
This section contains policy, procedures and guidance used by IRCC staff. It is posted on the department’s website as a courtesy to stakeholders.
Immigration medical examinations
- IMM 5743E - Client Consent and Declaration - To give consent to undergo an immigration medical examination (PDF, 556.53 KB)
- IMM 5419E - Medical Report - To medically process immigrant and certain visitor applicants by ports abroad and Canada Immigration Centres (PDF, 1.56 MB)
- IMM 5725E - Assessment of Activities of Daily Living (ADL) - Part of the immigration medical examination for some clients (PDF, 629.45 KB)
- IMM 5727E - Global Assessment of Functioning Scale (GAF) - Part of the immigration medical examination for some clients (PDF, 539.19 KB)
- IMM 5728E - Acknowledgement of HIV Post-test Counselling - Mandatory for all clients that test positive for HIV (PDF, 528.39 KB)
- IMM 5733E - Instruction for Pregnant Client - X-ray Deferred - Used to defer chest x-rays for pregnant clients (PDF, 578.95 KB)
- IMM 5734E - Specialist’s Referral Form - Used to refer client to a specialist (PDF, 588.64 KB)
- IMM 5738E - Chart of Early Childhood Development (CECD) - Part of the immigration medical examination for some clients (PDF, 0.97 MB)
- Letter - Results of the immigration medical examination – Syphilis screening - To inform an applicant of the results of the syphilis screening test and to ask them to keep record of the proof of treatment.
Medical surveillance (forms and documents)
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
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