Health related forms, documents and templates

• IMM 5743E - Client Consent and Declaration - To give consent to undergo an immigration medical examination (PDF, 556.53KB)
• IMM 5419E - Medical Report - To medically process immigrant and certain visitor applicants by ports abroad and Canada Immigration Centres (PDF, 1.56MB)
• IMM 5725E - Assessment of Activities of Daily Living (ADL) - Part of the immigration medical examination for some clients (PDF, 629.45KB)
• IMM 5727E - Global Assessment of Functioning Scale (GAF) - Part of the immigration medical examination for some clients (PDF, 539.19KB)
• IMM 5728E - Acknowledgement of HIV Post-test Counselling - Mandatory for all clients that test positive for HIV (PDF, 528.39KB)
• IMM 5733E - Instruction for Pregnant Client - X-ray Deferred - Used to defer chest x-rays for pregnant clients (PDF, 578.95KB)
• IMM 5734E - Specialist’s Referral Form - Used to refer client to a specialist (PDF, 588.64KB)
• IMM 5738E - Chart of Early Childhood Development (CECD) - Part of the immigration medical examination for some clients (PDF, 0.97MB)
• 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.

• Document - Medical surveillance Handouts: Tuberculosis - Given to new arrivals in Canada with inactive tuberculosis or other complex non-infectious tuberculosis

• 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 - Refusal Letter for Sponsorship Withdrawal in the Family Class
• Sample - Interpreter Declaration Form

Sample - Letter to Medical Officer (from Visa/Immigration Officer) about New Medical Information in Procedural Fairness Cases

Procedural fairness regarding a danger to public health and public safety

Sample - Procedural Fairness Letter (non excessive demand)

Procedural fairness regarding excessive demand on health (i.e., out-patient medication) and/or social services

• Sample - Procedural Fairness Letter (excessive demand)
• Sample - Declaration of Ability and Willingness
• Document - Immigration and Refugee Protection Regulations (re: Excessive Demand) - To provide the client with an excerpt of the regulations pertaining to inadmissibility on health grounds