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.
