Panel Members’ Handbook 2013

Table of Contents

Foreword

Citizenship and Immigration Canada’s (CIC) Health Branch is responsible for the administration and delivery of the Department’s health programs. These responsibilities include management of the panel members (including panel physicians, panel radiologists and laboratories) who perform immigration medical examinations (IMEs) in Canada and abroad.

CIC provides immigration medical services through six regional medical offices (RMOs). In providing these services, the RMOs rely on the IMEs that panel members conduct on clients for permanent residency and some categories of temporary residency in Canada. Health findings on the IMEs allow CIC medical officers to make recommendations on the medical admissibility of persons requesting entry to Canada.

In order to modernize how it conducts its business, CIC is committed to simpler, more accessible services; to continuous, innovative and adaptable operational improvement; and to robust program integrity and delivery of quality service. As part of its modernization agenda, CIC has implemented an electronic IME Web-based processing system called eMedical. eMedical is a joint Canada-Australia information technology project that will result in significant savings in processing time, strengthen overall program integrity, and provide many other benefits for clients, panel members and CIC. Panel members working in countries where eMedical is implemented will need to complete and transmit all IMEs through this Web-based system.

This Handbook provides instructions, information and reference material related to the work of panel members and to the IME process. Panel members may include physicians, radiologists, laboratories and other designated health care professionals involved in the IME process. Together, they make up CIC’s network of panel members.

You can visit the Department’s website at cic.gc.ca for further information on Canada’s immigration program.

Issues affecting the health of immigrants and the immigration process itself are subject to change. Periodic updates of this Handbook will be issued when required. These updates will supersede the text they replace. In all cases, the online version of the Handbook will be the most current and is the version that should be consulted.

Chapter 1: Acronyms and Definitions

The following list provides definitions for acronyms and technical terms found in this Handbook:

ADL
Activities of daily living
Biodata
Information that establishes each client’s identity
CECD
Chart of Early Childhood Development
CIC
Citizenship and Immigration Canada
Chief Radiologist:
Licensed radiologist designated by CIC to perform, grade and submit chest x-rays for Canada’s immigration medical examinations (IMEs).
Client
A foreign national who is seeking to enter Canada, and in accordance with the Immigration and Refugee Protection Act and its Regulations, is required to submit to an IME.
Clinic staff
Persons who are working in the panel member’s clinic and may be involved in the immigration medical process.
CXR
Chest x-ray
DIAC
Department of Immigration and Citizenship (Australia)
DICOM
Computer disk with x-ray image
DOT
Directly observed therapy
ED
Excessive demand, i.e., a demand placed by a client on Canadian health or social services.
EDE
Excessive demand exempt is a category of client who is exempt from assessment of excessive demand.
ELISA
Enzyme-linked immunosorbent assay, also known as enzyme immunoassay, which is a blood test for HIV.
eMedical
An online application that provides a paperless process for electronic recording, transmission and storage of immigration health examination results.
Furthered cases
Cases that require supplemental medical reports to complete the medical assessment.
GAF
Global assessment of functioning
Guardian
A legal guardian is a person who has custody or who is empowered to act on behalf of another person and has been recognized as such by the competent authorities in the jurisdiction where the status was either recognized or granted.
Handbook
This Handbook is the standard reference for the orientation and training of panel members. All panel members must ensure that they remain familiar with it and with departmental instructions, including interim changes and updates provided by CIC.
HIV
Human immunodeficiency virus
IFHP
Interim Federal Health Program: a program funded by CIC that provides limited, temporary coverage of costs related to health care for specific categories of people, including protected persons, refugee claimants, rejected refugee claimants, certain persons detained under the Immigration and Refugee Protection Act (IRPA) and other specified groups.
IMA
Immigration medical assessment, i.e., the medical determination made by a CIC edical officer of a client’s admissibility to Canada.
IME
Immigration medical examination: the examination is conducted by a panel member. The results of these examinations are sent to CIC medical officers who conduct IMAs.
IME number
Immigration medical examination number
IMEIs
Immigration medical examination instructions, i.e., the instructions for completion of the IME.
IMM 0535
Medical Surveillance Undertaking Form, issued to individuals who have undergone their IME in Canada or abroad and have been determined to require medical surveillance by Canadian Public Health Authorities.
IMM 1017
An IME form containing the client’s biodata, IME grading and panel physician declaration.
IMM 5419
An IME form containing the client’s medical history, physical examination findings, laboratory, chest x-ray requisition results and the client’s consent and declaration.
IMM 5544
Supplemental medical and resettlement needs assessment form providing information on the special needs a client may have while settling in Canada.
IOM
International Organization for Migration
IRPA and IRPR
Immigration and Refugee Protection Act and the Immigration and Refugee Protection Regulations, i.e., Canadian federal legislation setting out the requirements for immigrating to or visiting Canada, including the requirement to have an IME and be medically admissible. The Act and Regulations can be found at http://laws-lois.justice.gc.ca/eng/acts/I-2.5/.
LFT
Liver function test
Locum tenens
Medical practitioners who replace panel physicians for a short period while they are on vacation, taking training or unable to provide service for other reasons.
LTBI
Latent tuberculosis infection
Nominated Radiologist
Licensed radiologist nominated by a Chief Radiologist located in the same clinic to perform, grade and submit chest x-rays for Canada’s IMEs in support of and under the management of a Chief Radiologist.
Panel clinic
A clinic where designated physicians and radiologists conduct IMEs.
Panel member
A general term that refers to a panel physician, panel radiologist or panel laboratories or specialists authorized by CIC to perform IME-related activities.
Panel physician
A licensed medical doctor designated by CIC to perform, grade and submit IMEs. Designated medical practitioner (DMP) was the previously used term.
P number
A unique identifier for each panel member issued by the Health Branch.
PHLU
Public Health Liaison Unit, located in the Health Branch, CIC (the former term was Medical Surveillance Unit).
Protected person – In Canada
People who have been determined to be protected persons by the Immigration and Refugee Board of Canada (IRB), or in a Pre-Removal Risk Assessment, and who have been granted permanent residence as a result.
PTB
Pulmonary tuberculosis
PTC
Post test counselling
Radiologist
Refers to both Chief and Nominated Radiologists.
Refugee overseas
Convention refugee overseas
RMO
Regional medical office is the location of operations for medical officers who are CIC officials with responsibility for the Canadian immigration health program in a given region.
TB
Tuberculosis
TST
Tuberculin skin test
UCI
Unique client identifier
UFM
Upfront medical
UMI
Unique medical identifier
VDRL
Venereal Disease Research Laboratory test, which is a blood test for syphilis.
VO
Visa office, where immigration and other applications are processed.
WHO
World Health Organization

Chapter 2: Legislation related to the Immigration Medical Examination

Immigration is a shared federal/provincial responsibility. Panel members should be aware of the following legislation as it relates to immigration and the requirements with respect to medical examinations and inadmissibility on health grounds.

2.1 Immigration and Refugee Protection Act

The Immigration and Refugee Protection Act (IRPA) is a federal act. One of the objectives is to ensure that the movement of people into Canada contributes to the country’s cultural, social, and economic interests and affirms its humanitarian commitments, while protecting the health, safety and security of Canadians.

The IRPA and its accompanying regulations set out the medical requirements that clients must meet in order to come to Canada as temporary or permanent residents.
In addition, the legislation sets out the grounds on which a person may be found to be inadmissible to Canada, including inadmissibility on health grounds.

A foreign national is inadmissible on health grounds if his/her health condition:

  • is likely to be a danger to public health;
  • is likely to be a danger to public safety; or
  • might reasonably be expected to cause excessive demand on health or social services.

The IRPA may be viewed at http://laws-lois.justice.gc.ca/eng/acts/I-2.5/index.html.

2.2 Privacy Act

The purpose of this Act is to protect the privacy of individuals with respect to personal information collected by the government and to provide individuals with a right of access to their personal information.

The Privacy Act may be viewed at http://laws-lois.justice.gc.ca/eng/acts/P-21/index.html.

2.2.1 Collection of Panel Members’ personal information pursuant to IRPA

CIC’s Migration Health Branch (MHB) is responsible for the administration and delivery of the Department’s health admissibility screening. These responsibilities include management of the panel members (which includes panel physicians and chief radiologists) who perform immigration medical examinations (IMEs) in Canada and abroad. As part of health admissibility screening, the Branch collects and creates personal information about panel members, including:

  • Name;
  • Business name;
  • Provider type/Specialty;
  • Professional affiliation, Licensing or Certification;
  • Contact information (address, postal code);
  • Languages spoken;
  • Sex;
  • Signature;
  • Photograph;
  • Evaluations performed by the Branch; and
  • Evaluations shared with Canada by the governments of Australia, New Zealand, the United Kingdom and the United States of America.

2.3 Access to Information Act

The Access to Information Act gives every Canadian citizen, permanent resident and individual or corporation present in Canada the right to access records, in any format, held by a government institution, subject to certain exceptions. The Access to Information Act may be viewed at http://laws-lois.justice.gc.ca/eng/acts/A-1/index.html.

The Act is used to access information held by the government apart from an individual’s own personal information. A client’s family or representatives in Canada often use the Act, with the client’s permission, to request information about the client’s immigration medical file.

It is not necessary for clients to use the Act to obtain a copy of the results of their own IME. Panel physicians are authorized to provide clients with a copy of their own IME upon the clients’ request.

Chapter 3: The Work of Panel Members

A panel member cannot be designated until all the requirements of the designation process have been met:

  • Completion of all required forms:
    • application form;
    • consent to share information;
    • consent to use eMedical where available;
    • acknowledgment of having read the Handbook; and
    • acceptance of designation.
  • Provision of all required documents, such as proof of professional licence, certification and resumé;
  • Completion of orientation, which includes reading and understanding this Handbook and participating in discussions with CIC medical personnel. Panel members are not authorized to perform IMEs for CIC during the orientation phase; and
  • Completion of training, including eMedical training where and when relevant, which may be done individually or through group activities involving several panel members in locations where they operate in geographic proximity.

Once all forms and documents are received, the regional medical office (RMO) advises the panel member that he/she is approved as a panel member and a unique identifier number is provided.

Designation is not a permanent status and completing the designation process does not create any contract or agency relationship with CIC. A panel member’s designation may be terminated on 30 days’ notice.

CIC does not guarantee that you will receive a specific number of cases per year.

CIC immigration officials and medical officers consult one another regularly in order to determine the number of panel members required in a given location. Based on CIC’s operational requirements, the number of designated panel members in any given location may be reduced or increased.

If a panel member relocates his or her practice, that relocation must be brought to the attention of the RMO, as designation as a panel member is related to your location. Panel member status may be revoked because of the relocation. Upon examination of the new location of the practice and an assessment of the operational requirement for panel members in that location, the affected panel member will be informed of a decision confirming his or her status and given an opportunity to respond.

Complaints or disputes regarding a panel member’s performance may result in termination, depending on the situation. Sections 3.1.8, 3.4.9, and 3.4.10 of this chapter provide additional information on performance evaluations, complaints and the resolution process.

3.1 Responsibilities

Panel members, depending on their field of work, are authorized to perform IMEs, arrange for diagnostics and investigations, and complete immigration medical forms. They do not have the authority to assess or determine whether the medical conditions of clients are grounds for inadmissibility. More specifically, panel members do not have authority to give clients an opinion on their medical admissibility. That determination rests solely with Canadian immigration officers.

Panel members performing IMEs should ensure that they meet CIC-mandated service standards and that there are no conflicts of interest in providing services. They are also required to help prevent fraud and abuse of Canada’s immigration laws, submit to performance evaluations, follow proper procedures for absences, and use English or French in their communications with CIC.

For all clients, the Canadian IME will include an examination by a panel member and a medical assessment by a CIC medical officer. Where necessary to establish compliance with the IRPA and the Immigration and Refugee Protection Regulations, clients will be asked to undergo further medical examinations.

The assessment of whether or not a client is inadmissible on health grounds is based on the health findings identified during the examination by a panel member. This process is called the immigration medical assessment (IMA).

3.1.1 General

Although the Immigration medical exam constitutes a third party examination, panel members are expected to always follow the code of ethics of physicians and they must carry out their professional obligations with competence, integrity and loyalty, the same way they would do with other patients. Panel members must also ensure that the persons they employ or with whom they are associated in the practice of their profession also comply with these requirements.

Equal Rights for Applicants
  • Race, national or ethnic origin, colour, religion;
  • Gender or sexual orientation;
  • Age, mental or physical disability.

Panel members must be courteous and respectful towards all applicants. They must be mindful of applicants’ time, dignity, privacy and cultural practices. As well as display integrity in professional practice particularly in relation to conflict of interest. Discriminatory experiences, whether perceived or real, may cause the applicant to be reluctant to share personal information and the panel member should offer reassurances of confidentiality and use respectful language with all applicants.

Canada protects the right of an individual to identify in the gender of their choice and the freedom of gender expression. Panel members are expected to show the same respect for applicants who see them for an immigration medical exam, regardless of their gender. This includes using proper gender pronouns and preferred names when addressing the applicant.

Conflict of interest and ethical responsibilities

Panel members may become involved in situations where their loyalties are different than those of the client or the client’s personal interests conflict with the panel member’s responsibilities. Panel members are expected to exhibit professional behavior and perform their IME-related activities in a manner that is in keeping with the principles of proper medical practice and with CIC policy.

  • Perform the duties of his/her practice impartially, uninfluenced by fear or favour
  • Avoid situations in which their private, financial or other interests, conflict, might reasonably be thought to conflict with conducting IMEs for Canadian applicants

Panel members are to provide appropriate and timely advice to the client when they discover a serious disease not known to the client.

  • In doing so, they are to uphold professional and ethical standards by referring back to the client’s usual physician or to an appropriate specialist, upon request.
Good standing with local medical authority

If the following issues or events arise, panel members must notify the responsible RMO immediately:

  • The panel member is suspended, or comes under investigation by his or her respective medical or regulatory authorities or is charged or convicted of a criminal offence or offences by medical or regulatory authorities; and
  • The panel member discovers inappropriate activity relative to the provision of IMEs by clinic, office, laboratory or radiology centre staff.

Depending on the event reported, CIC may suspend designation (refer to Section 3.4.10) pending results of the investigation by the medical or regulatory authorities.

Requests for Accommodation

Panel members must be aware that some clients may request special accommodation during the IME due to personal or cultural sensitivities. As good practice, panel physicians should always offer to have a chaperone present while examining clients. Female clients, for example, may be uncomfortable with a male examiner (and vice versa), in which case panel members must offer to have a chaperone present during the examination.

Panel members should accommodate personal and cultural sensitivities, while keeping in mind that IME standards must be respected. In such cases, panel members will indicate on the examination form the type of accommodation provided and the names of other persons present during the examination.

Should a panel member not be comfortable examining a client for any reason, be it due to a conflict of interest, dispute, religious reason, personal belief, etc., it is their responsibility to inform the client and the RMO. They must also ensure that the client is not disadvantaged and that alternative means of completing the IME are available.

All panel members are required to:
  • maintain familiarity with the latest version of this Handbook and all associated administrative and IME instructions;
  • follow instructions regarding verification of the client’s identity;
  • hold current professional registration and licensing issued by local or national regulatory authorities and provide proof thereof when requested by the RMO;
  • maintain the confidentiality of all immigration medical information in their control and store that information securely;
  • ensure that the fees charged for immigration medical services fairly represent the services performed and comply with local guidelines or those of a medical association or group;
  • ensure that a list of fees and charges for the IME and related expenses is posted in the clinic or office. The list should include fees for required radiological and laboratory investigations, for postage or courier charges, and for other services. Any special fees for groups or large families should also be listed. Copies should be available for clients on request and all clients should receive a receipt for services;
  • ensure that all panel clinic staff members under their supervision are aware of the requirements and standards for the IME and its procedures;
  • ensure that panel clinic staff understand the role and obligations that pertain to panel members;
  • ensure that individual and clinic contact information is up-to-date. eMedical users must keep their contact information updated in the system, while those who use paper-based forms must inform the RMO of changes in contact information; and
  • ensure high quality of work by all professionals involved in conducting IMEs, including staff members and specialist consultants.
Panel physicians must:
  • obtain client consent and declaration (see details in Section 4.2 and in Appendix II);
  • follow their country’s public health regulations for notification of conditions of public health concern, such as tuberculosis (TB), syphilis, Human immunodeficiency virus (HIV) and hepatitis;
  • conduct a complete IME, including physical and mental examinations, routine tests and appropriate pre- and post-test counselling for clients who undergo HIV testing, according to Health Branch immigrant medical examination instructions (IMEIs) (see links for each IMEI in Appendix IV); and
  • coordinate all the IME results and the IME report to be submitted to CIC, including lab results and chest x-rays as well as reports from referred consultants and specialists when required by CIC.
All Chief Radiologists are responsible for:
  • Ensuring that all Nominated Radiologists undertaking Canadian immigration radiological examinations are suitably qualified as a specialist in radiology, that their license is and remains valid, and that they are registered to work in their country of practice;
  • Providing the RMO with names, dates of birth, gender and unique email addresses of all their Nominated Radiologists;
  • Adding Nominated Radiologists to the clinic profile in eMedical and notifying IRCC of these changes so that access to submit Canadian cases can be granted;
  • Supervising all Nominated Radiologists (including ensuring accuracy and quality control of the Chest X-Ray Requisition and report);
  • Ensuring that all Nominated Radiologists complete any training provided by IRCC;
  • The performance of all Nominated Radiologists and their staff and working with IRCC to resolve cases or issues of concern related to Nominated Radiologists;
  • Ensuring that radiological examinations are conducted only at the agreed site(s);
  • Implementing and monitoring the procedures for checking the identity of applicants;
  • Circulating any communications from RMOs/IRCC to Nominated Radiologists and staff;
  • Advising IRCC of any anticipated interruption of services and any change related to list of nominated radiologists; including absences, changes to staff, clinic contact details, capabilities and working arrangements;
  • Ensuring that chest x-rays (postero-anterior view only for applicants 11-years-old and older) are conducted according to the instructions laid out in the IRCC Panel Member’s handbook;
  • Ensuring the quality and integrity of the IME process related to radiology;
  • Ensuring that the associated Panel Physician (PP) is informed of all suspected cases of active TB so that further investigations may be undertaken; and
  • Ensuring that procedures as indicated in the IRCC Panel Member’s handbook are properly adhered to.
All Nominated Radiologists are responsible for:
  • Managing their caseload and submitting chest x-rays for IMEs to CIC in a timely manner.
Both Chief and Nominated Radiologists are responsible for
  • Conducting chest x-rays (postero-anterior view only for applicants 11-years-old and older) in accordance with the instructions laid out in the IRCC Panel Member’s handbook.
  • Ensuring that the associated Panel Physician (PP) is informed of all suspected cases of active TB so that further investigations may be undertaken; and
  • Following procedures as indicated on the IRCC Panel Member’s handbook.
Panel laboratories:

Until laboratories are designated by CIC, panel physicians are responsible for ensuring that the laboratories they use:

  • are aware of the requirements and standards for the Canadian IME;
  • are in good standing and hold current registration and licensing issued by local or national regulatory authorities and can provide proof thereof when requested by the RMO;
  • follow instructions for verifying the client’s identity described in Section 4.1; and
  • comply with administrative requirements (see Section 3.4 below) and complete the “Laboratory Requisition and Report” section of the IMM 5419 accurately and prevent fraudulent substitution.

Once CIC has designated a laboratory in your area, panel physicians will be required to use this facility.

3.1.2 Consultant or specialist referrals

Panel physicians should ensure that:

  • consultants, specialists and facilities providing supplemental tests understand that the request for additional information is only for a medical evaluation in the immigration process, and not for therapeutic purposes or to establish fitness to fly;
  • consultants or specialist practitioners are currently registered, certified or licensed by national regulatory bodies; and
  • consultants and other practitioners are aware of CIC’s requirements, particularly regarding verification of the client’s identity.

3.1.3 eMedical responsibilities

The eMedical system is a Web-based system implemented by CIC and the DIAC for the electronic recording and transmission of IMEs. In regions where eMedical is available, panel members and their clinic staff will be required to complete all IMEs and enter the results in the eMedical system, unless otherwise specified by the responsible RMO.

Where eMedical is available, all panel members are required to:

  • complete and submit all IMEs and related documents through the eMedical system;
  • maintain and keep secure their eMedical account, including user ID, password, and secret questions and answers;
  • notify CIC immediately if their password becomes known by an unauthorized person;
  • ensure that their personal and business information in the system is updated and accurate at all times;
  • take all reasonable steps to guarantee the security of clients’ personal information contained in eMedical;
  • ensure that clients’ personal information contained in eMedical is treated in a manner consistent with Canadian privacy laws. This includes, but is not limited to, protecting collected information against loss and unauthorized access, use, modification, disclosure and other misuse; and
  • ensure that all panel clinic staff under their supervision are aware of and abide by the requirements and standards for completing IMEs in the eMedical system.

3.1.4 Performance guidelines

Activities Time frame (in calendar days)
Appointment with panel physician, including cases where client is furthered 14 days; for upfront medicals, within 2 business days
Obtain lab results 7 days after date of the exam
Obtain x-ray results 7 days after date of the exam
Submission of the IME to RMO by the panel physician 10 days of date of the exam
Responding to correspondence from RMO 48 hours
Forwarding inactive immigration medical files to the RMO Paper-based: 8 week old IMEs eMedical users: Files are auto deleted after 365 days of inactivity
Notifying the responsible RMO of any change in practice location or contact information At least 14 days before the change takes place
Notifying the responsible RMO of any absence of 7 days or more At least 14 days’ notice, (preferably by email)
Being available for RMO visits and for provision of performance and technical information related to the IME process (e.g., quality assurance visits, annual audits) 7 days notice

3.1.5 Conflict of interest and ethical responsibilities

  • Panel members may become involved in situations where their loyalties are divided or the client’s personal interests conflict with the panel member’s responsibilities. Panel members are expected to exhibit professional behaviour and perform their IME-related activities in a manner that is in keeping with the principles of proper medical practice and with CIC policy.
  • Panel physicians are to provide appropriate and timely advice to the client when they discover a serious disease not known to the client.
    • In doing so, they are to uphold professional and ethical standards by referring back to the client’s usual physician or to an appropriate specialist, upon request.
  • If the following issues or events arise, panel members must notify the responsible RMO immediately:
    • The panel member is suspended, or comes under investigation by his or her respective medical or regulatory authorities, or is charged, or convicted of a criminal offence or offences by medical or regulatory authorities; and/or
    • The panel member discovers inappropriate activity relative to the provision of IMEs by clinic, office, laboratory or radiology centre staff.

Depending on the event reported, CIC may suspend designation (refer to Section 3.4.10) pending results of the investigation by the medical or regulatory authorities.

3.1.6 Fraud prevention

To support fraud prevention and the integrity of the IME process, panel members must confirm the identity of the client using an identification document acceptable for the Canadian Immigration medical examination. All documents must be valid ( not expired).

Approved identification documents include the following:

  • Original passport or a copy of passport certified by a Canadian Visa Office
  • National ID card (an original Birth Certificate is an acceptable national ID document for minors under the age of consent only.)
  • Driver’s licence (in Canada only)
  • Refugee travel document
  • Red Cross travel document
  • United Nations (UN) laissez-passer
  • Seaman’s book
  • Organization of American States travel document
  • Refugee Protection Claimant Document

If personal details, including the photograph, are inconsistent with the identity documents submitted, panel members must inform CIC (see Section 4.1.3 for additional information).

Panel members or clinic staff must also inform CIC if they suspect that clients are providing false information or attempting to falsify any aspect of the IME.

Panel members can proceed with the IME, and CIC will follow up on the concern raised about the individual’s identity and any other report of possible fraud.

Panel members should help prevent fraud by educating their staff on procedures used to verify client identity (refer to Section 4.1 for additional information).

3.1.7 Cultural sensitivities

Panel members must be aware that clients from some cultures may request special accommodation during the IME. Female clients, for example, may be uncomfortable with a male examiner, in which case panel members should offer to have a chaperone present during the examination.

Panel members should try to accommodate personal and cultural sensitivities, while keeping in mind that IME standards must be respected. In such cases, panel members will indicate on the examination form the type of accommodation provided and the names of other persons present during the examination.

3.1.8 Performance evaluation

A panel member who fails to meet the IME performance standards reflects badly on the immigration medical program. Consequently, the panel member’s inclusion in the panel member network may be terminated. The performance of panel members is subject to regular evaluation and review.

Panel members should complete and provide, in a timely fashion, the required forms and documents requested by the RMO (e.g., panel member appointment forms, quality assurance activities, etc.). The procedure for completing the IME is discussed in Chapter 4 and is also subject to performance evaluation.

When requested by the RMO, panel members should make themselves and their staff available, within 7 days, for evaluation, monitoring, training, quality assurance, and/or educational activities and visits.

All complaints and disputes related to panel members’ performance in conducting IMEs will be evaluated (see Sections 3.4.9 and 3.4.10 for more information).

3.1.9 Absences from IME activities

  • All anticipated absences from IME activities over 7 calendar days must be brought to the attention of the RMO and, where possible, an estimated date
    of return to work should be provided to ensure that appropriate information is provided for the clients.
  • If the panel member will have a locum tenens replacing him or her during extended absences, the panel member must give the RMO at least 14 days’ notice, preferably by email. This will allow the RMO to activate the locum’s P number allowing him or her to use eMedical. Section 3.1.10 provides additional information on locum tenens.
  • Panel members cannot submit IMEs if their leave information indicates that they are on leave.
  • Extended or repeated unapproved absences may result in termination of a panel member’s status.
  • After notification of the absence to the RMO:

eMedical-enabled Panel Clinics

  • They are required to keep their contact information updated in the system.
  • For personal and program integrity, they must enter leave dates directly in their personal record.

Paper-based Panel Clinics

  • The RMO will update the information in their record in order to track the leave in their system.

3.1.10 Locum tenens

  • Panel members who are planning to have persons replace them while they are away or assist them during high volume periods may request a locum tenens as follows:
    • Contact the RMO to obtain medical officer approval;
    • Submit the proposed substitute physician’s name and contact information, current resumé and a copy of the substitute physician’s medical registration/licence; and
    • A statement from the proposed locum indicating that he or she has read this Handbook and agrees with the standards and requirements defined herein.

Note: Prior to recommending a particular physician or radiologist as a prospective locum, the panel member must be satisfied that the proposed locum has the qualifications and experience to perform IMEs.

  • If the RMO approves the request, a written response (by letter or email) will be sent to the panel member. The panel member will then notify the locum that he or she has been authorized to provide services.
  • The panel member must give the RMO at least 14 days’ notice, preferably by email, for every period of time where the locum will be acting on behalf of the panel member. This will allow the RMO to activate the locum’s P number allowing him/her to use eMedical.
  • Panel members must ensure that the locum has adequate training in IME requirements, reporting procedures and any updates.
  • CIC will provide the locum with a unique identifier (refer to Section 3.2).
  • The termination of a panel member will automatically cancel prior approvals of a locum for this panel member.
eMedical-enabled Panel Clinics
  • The locum will have his/her own password because the panel member’s password should not be shared. The system will be updated with appropriate information for locums.
Paper-based Panel Clinics
  • The locum must sign the Medical Report (IMM 1017) “for and on behalf for Dr. ,” and use his or her personal wet stamp as required in Section 3.2.2 below.

3.1.11 Official languages

  • English and French are the official languages of Canada and panel members must be able to communicate with Canadian officials in at least one official language.
  • Panel members should inform CIC of the official language they prefer to use in correspondence.
  • Panel members should inform CIC of the official language and any other language they speak. The IME must be completed in the Canadian official language requested by the client.

For eMedical users:

  • Panel members must select either English or French prior to processing an IME in eMedical.
  • Panel members should also indicate in the drop-down list in eMedical other languages they speak.

3.1.12 Use of interpreters

  • When performing IMEs, panel physicians may examine clients who speak neither of the two official languages, nor any other language that the panel physician speaks. In these cases, an interpreter will be required.
  • If an interpreter is used, panel members must select and ensure that the interpreter is unbiased and has no connection to the client. Family members or friends cannot act as an interpreter for a client. The use of a professional interpreter is at the client’s expense.

3.2 Unique identifiers for panel members

All panel members are given unique identifiers. These identifiers allow CIC to perform quality assessments of their work.

The unique identifier starts with the letter “P” followed by 8 or more digits (e.g., P12345678). This unique identifier will replace the designated medical practitioner stamp that was previously used. The panel member’s unique identifier will be embedded electronically in each IME or chest x-ray they submit through eMedical. For paper-based IMEs, the unique identifier must be clearly readable on each Medical Report (IMM 1017) and on each chest x-ray completed by a panel member (refer to Section 3.2.2 for additional information).

The panel member’s unique identifier should be included in all correspondence with CIC.

3.2.1 eMedical user identification

All eMedical users will have a unique logon ID and password to access the system. For panel members, the eMedical logon information will be linked electronically to the panel member’s unique identifier. The eMedical logon ID must not be disclosed to any other person or used by any other person to submit IMEs or chest x-rays.

3.2.2 Paper-based IME user identification

  • For panel members or their locum tenens performing a paper-based IME, the unique identifier, along with their name, must be clearly readable on each Medical Report (forms IMM 1017 and IMM 5419) and on each chest x-ray.
  • The panel member or their locum tenens must secure a stamp that features his/her name, the P#, the city and the country and must use that stamp in all correspondence with CIC. For example:

    Name:
    P#:
    City, Country:

  • The unique identifier is used to identify each IME. It must be used on the front page of the IMM 1017 form “Client Biodata and Summary,” as well as on the “Laboratory Requisition and Report” and “Chest X-Ray Requisition and Report” sections of the IMM 5419 form.
  • Each photo attached to the Medical Report (IMM 1017) must be stamped to confirm the identity of the client. Make sure that each IME is stamped and signed properly. In cases where the IMEs are not properly stamped and/or signed, CIC will refuse them and return the IMEs to the panel physician’s office.
  • Panel radiologists may embed this information on the chest x-ray along with other required information about the client.

3.3 Guidelines for records management

Forms, documents and results of investigations required for the completion of IMEs are the property of CIC.

Panel members who perform IME-related activities must follow the procedures below for copies and files as well as for original documents and information. When documents are sent by courier, panel physicians must ensure that the IME forms and results are sent in appropriate order (refer to Appendix V for instructions) and should retain shipment tracking numbers for six months.

Information collected during the IME is for immigration medical purposes only. It may not be used for other purposes, including research, clinical studies or investigations, without appropriate consent of the client and CIC. Consent requests from CIC should be directed to:

Director of Operations
Health Branch
Citizenship and Immigration Canada
219 Laurier Ave. West, 3rd floor
Ottawa, ON K1A 1L1

eMedical-enabled Panel Clinics

  • Original documents and information related to an IME must be forwarded to the responsible RMO electronically. Panel physicians are encouraged to save a full copy or a summary of the IME for their own records (e.g., in PDF format) and print out a full copy or a summary of the IME to give to the client (or the client’s parent or guardian), if the client wants a copy, before submitting it to the RMO, unless it would be injurious to the client’s physical or mental health.
  • The panel physician can access the IME for 365 days after submitting the case. The panel physician can print a copy of the IME by clicking the “PRINT SUMMARY” button located at the bottom of the Health Case details window.

Paper-based Panel Clinics

  • Original documents and information related to an IME must be forwarded to the responsible RMO by regular mail or commercial courier and must never be given to the client for delivery to the RMO.
  • Panel physicians are encouraged to give a copy of the IME to the client (or the client’s parent or guardian) unless it would be injurious to the client’s physical or mental health.
  • Panel physicians are required to keep copies and records of files for at least 2 years and in compliance with their local regulatory and licensing requirements.

3.4 Administrative instructions

CIC has instructions to guide panel members in various situations. These instructions cover a number of topics, such as the following:

  • Communicating with the RMO;
  • Advertising;
  • Answering a client’s questions about the IME and about the immigration process;
  • Responding to media inquiries;
  • Resolving technical questions about eMedical;
  • Establishing fees for IMEs; and
  • Handling client complaints about the IME process or other immigration matters.

3.4.1 Communication with the regional medical offices

Regular contact will be maintained between panel members and RMOs regarding both medical and administrative issues. RMOs are the points of contact for panel members to address inquiries, questions and comments about individual immigration medical cases, examinations and about the immigration medial program. RMOs will also periodically update their panel members on IME processes. Questions and information on specific cases should always include identification details, such as the IME, unique medical identifier (UMI) or unique client identifier (UCI) number along with the client’s date of birth. To avoid possible breaches of confidentiality, information requests should never identify a client by name.

Written correspondence, such as letters, faxes or email, is preferred, but the telephone can be used when necessary (see Appendix I for RMOs’ addresses and contact information).

3.4.2 Advertising

Panel members may wish to advertise their IME services by creating their own website or distributing printed material, in which case the following instructions apply:

  • No Canadian flag may be associated with the clinic;
  • No CIC insignia may be associated with the clinic;
  • No summary of the information on the CIC website may be provided, although links to the website are allowed;
  • No eMedical insignia or logo may be included in the panel clinic advertisement; and
  • Information about IME fees, services included in the fees, clinic’s address and contact information may be included in the advertisement.

3.4.3 Issues not related to immigration medical activities

From time to time, panel members may be contacted by other Canadian government officials. These officials may be seeking information about local health conditions, medical resources for consular services or help with a personal medical condition. Such requests are not related to the immigration medical program and panel physicians may respond to these inquiries as they choose. Fees for such services are at the member’s discretion. If in doubt, panel members may contact an RMO for guidance.

3.4.4 Communication with the media

On occasion, the media may become interested in the IME of a particular individual and contact the panel member for information. Under no circumstances should a panel member provide the media with information about a particular case.

Panel members should never communicate confidential information they are privy to with respect to the immigration system or to individual clients.

Panel members should refer all requests for comment or information to the RMO.

3.4.5 Communication issues related to clients

Clients may have questions about the immigration process, particularly when CIC officials request additional medical information or investigations. However, panel members are not authorized to explain or justify such requests. They should simply explain that the request came from CIC, that the panel physician is only a contact person between CIC and the client, and that the client should contact his/ her visa office to obtain additional information.

Specific questions about the IME process could include the following:

  • total amount of time that CIC requires to complete the medical assessment process;
  • amount of time between completion of the IME and subsequent steps of the immigration process or the issuing of a visa;
  • administrative or policy aspects of the program; and
  • other immigration-related issues.

These questions should be addressed to the immigration or visa office responsible for the case. The panel member may refer the client to the list of immigration and visa offices.

The panel member should never direct clients to the RMO. RMOs will not have all the information required to reply to most types of enquiries.

The panel member should never direct clients to the eMedical help desk. Panel members should ensure that their staff are aware of these instructions.

3.4.6 Enquiries about completing an IME

If panel members have non-eMedical-related questions regarding IMEs, they may contact their RMO listed in Appendix I. The panel member should have key information available to assist RMO staff, including the following:

  • client’s full name;
  • Date of birth;
  • IME number, UMI number, and/or UCI number; and
  • specific details of the question.

3.4.7 General eMedical system enquiries

Panel members who have questions about eMedical should consult the eMedical System User Guides and Quick Reference Guides.

For contact information related to eMedical, refer to Appendix I.

3.4.8 Fees for IMEs

Clients are responsible for paying all fees and costs associated with their IME. These fees include the following:

  • panel physician services;
  • radiological and laboratory services;
  • consultations with specialists;
  • investigations and treatment (e.g., when referred for treatment of TB or syphilis); and
  • costs related to the sending of medical documents to the RMO.

Panel members may also charge a reasonable fee for the following:

  • Follow-up visits in the case of furtherances;
  • providing copies of the IME to the client upon request; and
  • missed appointments in accordance with local standards of practice.

Panel members should charge reasonable fees and post a fees list in the clinic. Fees will reflect local conditions and service charges. Consequently, the fees for IMEs may vary from country to country and even within a country. If a panel member is completing a paper-based IME that must be mailed to the RMO, he or she should discuss the method and cost of sending the documents with the client beforehand.

Panel members in Canada should refer to Chapter 5 for instructions regarding requirements and fees for refugee claimants under the Interim Federal Health Program (IFHP).

Questions regarding fees and charges should be directed to the panel member’s RMO.

3.4.9 Incidents, complaints and quality assurance concerns

Clear and transparent procedures for responding to complaints and resolving disputes improve client service and the integrity of the immigration medical program. This section explains how CIC will deal with incidents, complaints and quality assurance concerns.

Incidents occurring during the IME process

If, during an IME, a panel member has a disagreement with a client, or confusion arises or an event occurs that might compromise client service, panel members should report these incidents to the RMO.

The following are examples of incidents that should be reported:

  • The client becomes angry, threatening or violent toward the panel member or staff;
  • The client claims that the panel member is deliberately delaying the IME process or requesting unnecessary investigations for personal gain;
  • The client refuses to undergo parts of the examination or investigation;
  • The panel member or clinic staff become aware of attempts by the client to falsify certain aspects of the IME, or clinical or laboratory investigations;
  • The panel member or clinic staff are asked to overlook or alter some aspects of the IME, or of clinical or laboratory investigations;
  • The client threatens to complain about the IME service or the IME process itself; or
  • The panel member feels that reporting a one of a kind situation may benefit the program or increase other panel members’ knowledge.

Reports to the RMO should include the date of the incident, the client’s IME, UMI or UCI number and a brief description of the incident.

Complaints

Complaints are common in any client service procedure. Complaints regarding the IME and related services may arise from clients or other persons outside CIC. In addition, CIC personnel may provide critical comments or notifications of errors, performance issues or situations of concern regarding the IME and related services. Affected panel members will receive a letter of concern from the RMO and be given an opportunity to reply to the complaint. In accordance with the principles of natural justice and procedural fairness, privacy rules will not be breached when sharing the content of the complaint.

CIC’s Health Branch will consider the opinions and viewpoints of panel members and of anyone submitting a complaint or critical comment.

Quality assurance concerns

Health Branch officers will occasionally visit panel members to ensure the quality of their work. If concerns are found, the panel members will be asked to address them in a timely manner.

3.4.10 Resolution process for complaints or performance issues

Failure to meet performance standards may result in termination of the panel member’s designation. The following are examples of situations where panel members or their clinic staff would be seen to be failing to meet performance standards:

  • Unacceptable behaviour or demonstrated misconduct:
    • unprofessional or unethical conduct or activities;
    • illegal activities; and
    • loss or suspension of medical licence.
  • Continued failure to maintain an acceptable level of performance as set out in this Handbook or in accordance with written instructions from the RMO. This includes continued or repeated deficiencies after notification, in the following:
    • timely and correct completion of IMEs (including errors or omissions in the medical history and physical examination of clients);
    • appropriately providing requisite laboratory and clinical investigations and activities;
    • gathering and management of medical information;
    • timely transfer of information and communication with the CIC Health Branch; and
    • following the instructions in this Handbook.
Resolution of issues

Minor incidents and/or performance deficiencies will be addressed by the RMO in a letter outlining the necessary remedial or corrective measures, which may include additional training.

For serious complaints, such as harassment, sexual misconduct or illegal activities, the RMO will suspend the panel member, issue a letter summarizing the facts that gave rise to the complaint and provide the panel member with an opportunity to reply. While the panel member’s designation is suspended, IME activities by the panel member cease until the panel member is notified that he or she has been reinstated by CIC.

Upon receipt of the panel member’s reply, the RMO will conduct an assessment. If the response is deemed satisfactory, the panel member will be informed of the decision and be reinstated with appropriate recommendations. If the response is unsatisfactory, the panel member’s designation will be terminated.

Termination

CIC retains complete authority over the management of the panel member network. The number of panel members required may change in response to the local demand for IMEs. Panel physicians who are terminated because of operational needs will be notified in writing by the RMO at least 30 days prior to any such change in the network.

However, if the panel member’s designation is terminated because of performance deficiencies or complaints, there is no transition period and the termination is effective as of the date of the notification letter sent by the RMO.

Retirement and resignation

Panel members may retire or request removal from the panel network at any time. Panel members should send written notification to the RMO, including the anticipated date on which activity will cease.

Request for reconsideration

Panel members may request a reconsideration of a termination letter. Panel members should submit their request for reconsideration in writing within 30 days of receipt of the termination letter to:

Director of Operations Health Branch, CIC Canadian Building
219 Laurier Ave., West
Ottawa, ON K1A 1L1

CIC will consider all requests for reconsideration and make every effort to provide panel members with a written reply within 30 days of the receipt of their request for reconsideration. This decision is final.

Chapter 4: Immigration Medical Examination (IME)

This chapter provides panel members with a step-by-step method for completing an IME and associated forms.

The IME consists of a medical history, physical examination, age-specific laboratory tests and age-specific chest x-ray.

Mandatory age-specific laboratory and radiologic tests include:

  1. Urinalysis – clients ≥ 5 years
  2. Chest x-ray (postero-anterior view) – clients ≥ 11 years
  3. Syphilis – clients ≥ 15 years
  4. HIV – clients ≥ 15 years

Note: Screening of clients below the ages indicated may also be required. Consult the IMEI’s for more information.

With the launch of eMedical, the IME will be conducted, where technologically feasible, in a Web-based computer program designed for the electronic recording, transmission, processing and temporary storage of the IME and its associated results.

Panel members performing IMEs in a region where eMedical has been implemented must use the system to complete and submit all IMEs. Designation as a panel member is dependent on the ability to use the eMedical system. Only in the event of a system outage should paper IMEs be used by eMedical-enabled panel members.

Differences between the paper process and the eMedical process have been pointed out throughout this document.

IME paper forms have been redesigned to ensure consistency between eMedical IMEs and paper-based IMEs.

4.1 Verification of identity

4.1.1 Client identity confirmation

Client photographs are essential for ensuring that there is no substitution at any time during the lifecycle of the IME and that the person who undergoes the IME is the same person who is applying for entry to Canada. Photographs must be attached and submitted with the IME whether the IME is completed in eMedical or on paper.

eMedical-enabled Panel Clinics
  • A live digital photograph of the client is taken in the clinic and uploaded in eMedical.
  • Photographs must meet CIC’s photographic specifications standards (PDF, 505.82KB).
  • The eMedical system will include the photograph on all requisitions and referrals (laboratory, radiology, specialists and others).
Paper-based Panel Clinics
  • The client must provide four photographs to the panel clinic.
  • Photographs must meet CIC’s photographic specifications standards (PDF, 505.82KB).
  • If the photographs do not meet the specifications, ask the client to provide new photographs before their IME can be completed.
  • A photograph must be attached to the Medical Report (IMM 1017) and to the laboratory and radiology requisitions/report forms (IMM 5419).
  • The photograph on the Medical Report (IMM 1017) must be stamped in the top right corner with the panel physician’s ID stamp.

4.1.2 Identity documents

The client must submit a passport or other identification document acceptable for the Canadian Immigration medical examination. All documents must be valid (not expired).

Approved identification documents include the following:

  • Original passport or a copy of passport certified by a Canadian Visa Office
  • National ID Card (an original Birth Certificate is an acceptable national ID document for minors under the age of consent only.)
  • Driver’s licence (in Canada only)
  • Refugee travel document
  • Red Cross travel document
  • UN laissez-passer
  • Seaman’s Book
  • Organization of American States travel document
  • Refugee Protection Claimant Document

Important: To ensure the integrity of the IME process, the same identity document must be used for all components of the IME, including laboratory, radiology and specialist referrals. The panel physician must inform the client accordingly.

4.1.3 Identity concerns

If the client provides personal details that seem inconsistent with the information on the submitted identity documents, panel members must identify the concern in the eMedical system or on the IMM 1017 – Medical Report (Client Biodata and Summary) for paper-based IMEs. A copy of the identity document of concern should be attached to the IME.

Panel members should complete the IME according to customary procedures. CIC will investigate the concern about the client’s identity.

eMedical-enabled Panel Clinics
  • The identification document must be scanned and attached to the health case. The document will be submitted to CIC once the IME is completed.
Paper-based Panel Clinics
  • Photocopies of the identification document concerned must be attached to the IME and submitted to CIC.

4.2 Client Consent and Declaration (IMM 5743)

See sample Client Consent and Declaration form in Appendix II.

Completion of the Client Consent and Declaration form is mandatory for all clients. If the client is under 16 years of age or is unable to provide consent (because of reduced mental capacity, for example), a parent or guardian may provide consent on his/her behalf.

eMedical-enabled Panel Clinics

The eMedical Client Consent and Declaration form includes the following:

  • Declaration that all information provided during the IME is true, correct and complete;
  • Declaration understanding that the IME information will be collected and temporarily stored on segregated databases located in Australia; and
  • Consent for the collection and release of IME information related to the administration of Canada’s IRPA or to the protection of the health and safety of Canadians.

Paper-based Panel Clinics

The Client Consent and Declaration form for paper-based IMEs include the following:

  • Declaration that all information provided during the IME is true, correct and complete; and
  • Consent for the collection and release of IME information related to the administration of Canada’s IRPA or to the protection of the health and safety of Canadians.

If a client does not give consent, the IME cannot be carried out and the panel physician must notify the responsible RMO.

eMedical-enabled Panel Clinics

  • eMedical will enter the client information on the Consent and Declaration form beforehand.
  • The form should be printed from eMedical and provided to the client.
  • Clinic staff or a panel member should review the Consent and Declaration form with the client and answer any questions.
  • The client (or parent/guardian) must sign and date the document.
  • The form must be scanned and uploaded to eMedical.
  • Consent and Declaration check box must be ticked
  • The IME cannot be submitted without the Client Consent and Declaration form appended.

Paper-based Panel Clinics

  • Clinic staff must print and provide the form to the client.
  • Clinic staff or a panel member should review the Consent and Declaration form with the client and answer any questions.
  • The client (or parent/guardian) must sign and date the document.
  • Clinic staff must attach the form and submit it along with the IME.
  • The IME must not be submitted to the RMO without a completed Consent and Declaration form.

4.3 Medical Report: Client Biodata and Summary (IMM 1017)

See sample IMM 1017 form in Appendix III.

CIC has implemented one standard form, the Medical Report: Client Biodata and Summary (IMM 1017), for all immigration categories. This form displays the following:

  • Client information (biodata);
  • Immigration information;
  • IMM Type: Excessive Demand Exempt (EDE); Non-EDE; refugee overseas
  • IME grading; and
  • Panel physician declaration.

The Medical Report (IMM 1017) issued by CIC includes information on the type of immigration category (IMM Type):

  • EDE;
  • Non-EDE; and
  • Refugee overseas.

EDE

EDE clients are those who are exempted from assessment of excessive demand on the Canadian health care system.

However, EDE clients are assessed for:

  • Danger to public health;
  • Danger to public safety.

Non-EDE

Non-EDE clients are assessed for:

  • Danger to public health;
  • Danger to public safety;
  • Excessive demand on the Canadian health care system.

Refugee overseas

Refugee overseas clients are also EDE.

Note: Panel physicians must complete and submit, either electronically or on paper, the IMM 5544 Resettlement Needs Assessment Form. See sample form in Appendix III.

Note: EDE clients include refugees, refugee claimants and certain family classes and individuals with protected person status.

The Medical Report (IMM 1017) form is typically issued by CIC with the client information and immigration information sections completed.

Clients who have been issued a Medical Report (IMM 1017) must present the form to the panel clinic when presenting themselves for their IMEs. The form will include two client identifiers: IME number and UCI number. (Note: This form may not include a client photo).

eMedical-enabled Panel Clinics

  • Clinic staff will search for the client health case in eMedical using the IME# (search may also be done using client name and passport number, or UCI# or UMI#).
  • Clinic staff should confirm the client’s identification by comparing the client’s information with the approved identification document (see Section 4.1.2).
  • A live photo of the client is taken and uploaded to eMedical to verify identity throughout the life cycle of the IME.
  • The IME and all of its components are then completed in the eMedical system

Paper-based Panel Clinics

  • Clinic staff should confirm client’s identification by comparing the client’s information with the approved identification document (see Section 4.1.2).
  • Clinic staff must attach a client photo (provided by the client) to the Medical Report (IMM 1017).
  • The Medical Report (IMM 1017) will be completed and submitted along with all other IME forms.

4.3.1 Resettlement Needs Assessment (IMM 5544)

Clients who are being processed as refugees overseas will have a Resettlement Needs Assessment (IMM 5544) form issued to them along with their IMM 1017 by a Visa Office (VO). The form is available electronically in eMedical. Panel physicians must complete this form for all clients in the refugee overseas category.

Refer to the IMEI on the Resettlement Needs Assessment (PDF, 3.44MB) (IMM 5544) for detailed instructions on completing the form.

eMedical-enabled Panel Clinics
  • VO issues IMM 1017 with IMM category of refugee overseas.
  • IMM 5544 is included in medical instructions sent to client by VO as part of the IME.
  • IMM 5544 will be automatically attached to the immigration medical examination in eMedical
  • Submission of IME will include IMM 5544.
Paper-based Panel Clinics
  • VO issues IMM 1017 with IMM category of refugee overseas.
  • IMM 5544 is included in medical instructions sent to client by VO as part of the IME.
  • Panel physician will complete the IMM 5544 along with the IME and submit them.

4.3.2 Upfront Medical (IMM 1017B Upfront)

UFM examinations are performed when clients report to a panel physician for their IME before a visa application has been submitted to CIC. Clients who are eligible for UFM examinations will not have a Medical Report (IMM 1017) issued by CIC nor will they have an existing file in the eMedical system.

Panel physicians should not refuse to examine these clients.

Panel physicians must ensure that they provide the client with the proof of having completed their upfront medical examination. For eMedical, the proof is the “Information Sheet” letter that they will print. For paper-based upfront medicals, it is the top page of the IMM 1017B Upfront form. Clients must include this proof when submitting their visa application.

Since an IME is valid for 12 months, panel physicians should remind clients to submit their visa application along with the proof of having completed their upfront medical examination well before the expiration of the 12 months; otherwise, the client may have to undergo a second IME.

eMedical-enabled Panel Clinics
  • Panel physicians must first search eMedical for the client by their name and identity document number (e.g., passport number) to confirm that the client does not already exist in the system.
  • If the client does not exist in eMedical, click “create case.”
  • Enter the Client personal details (mandatory fields include Title, Family name, Gender, Date of birth and Country of birth).
  • Enter the Identity Document Details. Clinic staff will check identity with the approved identification document. (Note: a live photo of the client must be taken and uploaded to eMedical at a later step during the IME.)
  • Enter the Client’s Preferred Language.
  • In the “Proposed Visa Application Details” section, select the appropriate upfront category from the drop down list (student, worker, visitor or family EDE). Note: For refugee claimants in Canada, select the category family EDE, and scan and attach the document provided by the client.
  • Click “Create.”
  • Proceed to upload and attach client photograph.
  • Complete Identity Confirmation.
  • An “Information Sheet” letter will be system generated and must be printed and given to the client for submission to CIC along with the visa application.
Paper-based Panel Clinics
  • Panel physicians will use IMM 1017B Upfront paper forms, which have been provided to them and that are pre- populated with a UMI# and a barcode (see sample form in Appendix III).
  • Clinic staff will check identity with a valid government-issued ID.
  • Clinic staff must attach a client photo (provided by the client) to the form.
  • Clinic staff must select the immigration category by checking the appropriate box (student, worker, visitor, family EDE or refugee claimant (in Canada only)).
  • Page 1 of the IMM 1017B Upfront form “Copy to Client” must be completed and provided to the client for submission to CIC along with the visa application.
  • Page 2 of the IMM 1017B Upfront form “Copy to Health Branch” must be completed and submitted to the RMO along with all other IME forms (e.g., IMM 5419, chest x-rays, lab results, etc.).

Note: It is very important to ensure the correct page goes to the client and the correct page goes to your RMO.

Page 1 — Client
Page 2 — RMO

4.4 IME grading

Prior to submitting the IME, the panel physician must provide a grade for the IME.

eMedical-enabled Panel Clinics

  • An IME grade will be provided automatically by the system based on the reported findings.
  • Grade A indicates that there are no abnormal findings present and no significant abnormal history.
  • Grade B indicates that there are significant abnormal findings present and/or an abnormal history.
  • If the system has provided an A-grade and the panel member believes that there are significant abnormal findings, he/she may change the grade to B.
  • If the system has provided a B-grade, it cannot be changed to an A-grade.
  • No comments are permitted for A-grade IMEs.
  • Comments are mandatory for B-grade IMEs.

Paper-based Panel Clinics

  • Panel members must provide an IME grade based on the reported findings.
  • Grade A indicates that there are no abnormal findings present and no significant abnormal history.
  • Grade B indicates that there are significant abnormal findings present and/or an abnormal history.
  • Comments should not be included for A-grade IMEs.
  • Comments are mandatory for B-grade IMEs.

4.5 Panel physician declaration

The panel physician declaration confirms the following:

  • The client’s identity has been verified; and
  • The IME and Medical Report are an accurate record of their findings.

eMedical-enabled Panel Clinics

  • Panel physician’s declaration is provided electronically.

Paper-based Panel Clinics

  • Panel physician’s declaration is provided in writing on the Medical Report (IMM 1017) and includes the panel physician’s name, signature, number and the date of the IME submission.

4.6 Medical History (IMM 5419)

See sample IMM 5419 form in Appendix III.

The panel physician uses the medical history to assess the client’s health. The medical history may be completed by the client or the clinic staff. If the client or clinic staff completes it, the panel physician must review and confirm the information provided.

Panel physicians must provide details with all “Yes” answers to medical history questions. CIC requires the following information:

  • date of diagnosis;
  • date of treatment or surgery;
  • relevant medications; and
  • current status of the condition (and, if applicable, the prognosis).

Panel physicians must provide this information in the comments section or they may attach a report to the IME.

The following table lists additional requirements when the answers to medical history questions show abnormality, whether the IME is completed in eMedical or on paper. Refer to the IMEIs for additional details.

Medical History Questions Related IMEI IMM type Requirements if abnormal
Tuberculosis (TB), treatment for tuberculosis TB IMEI EDE and
non-EDE clients
Chest x-ray (CXR), HIV, Hepatitis B and C, regardless of age
Close household or work contact with tuberculosis TB IMEI EDE and
non-EDE clients
TST and then CXR if TST is positive regardless of age (if CXR not already done)
Prolonged medical treatment and/or repeated hospitalization for any reason, including a major operation or mental illness EDE and
non-EDE clients
Medical report
Psychological/psychiatric disorder (including major depression, bipolar disorder or schizophrenia) Psychiatric Conditions IMEI EDE and
non-EDE clients
Psychiatrist's report
History of HIV HIV IMEI EDE and
non-EDE clients
HIV, CXR, Hepatitis B and C, syphilis, regardless of age, and HIV specialist report including CD4 count, HIV viral load, and when antiretroviral medications will be needed
An abnormal hepatitis B or C blood test Hepatitis / Liver
Disease IMEI
EDE and
non-EDE clients
HIV, CXR, Hepatitis B and C, syphilis, regardless of age
Cancer or malignancy in the last five years Cancer IMEI EDE and
non-EDE clients
Oncology report
Diabetes Diabetes IMEI EDE and
non-EDE clients
Screen for signs or symptoms and presence of end-organ damage. Urinalysis, serum creatinine (eGFR if abnormal) and HbA1c; regardless of age
Heart condition including coronary disease, hypertension, valve or congenital disease Cardiac Disease IMEI and Hypertension IMEI EDE and
non-EDE clients
Screen for signs or symptoms (including blood pressure) and presence of end-organ damage. Serum creatinine, regardless of age
Blood condition (including thalassemia) EDE and
non-EDE clients
Check for history of admission
Kidney or bladder disease Renal disease
IMEI
EDE and
non-EDE clients
Urinalysis, serum creatinine (eGFR if abnormal)
regardless of age
An ongoing physical or intellectual disability affecting your current or future ability to function independently or be able to work full-time (including autism or developmental delay) Psychiatric Conditions IMEI and Cognitive Impairment IMEI EDE and
non-EDE clients
Activities of daily living (ADL), Global assessment of functioning (GAF), Chart of Early Childhood Development (CECD) and/or an assessment of cognitive functioning
Addiction to drugs or alcohol Psychiatric Conditions IMEI EDE and
non-EDE clients
Psychiatrist’s report and if evidence of IV drug use, HIV, Hepatitis B and C, regardless of age
Prescribed pills or medication (excluding oral contraceptives, over- the-counter medication and natural supplements)   EDE and non-EDE clients List relevant medications and mention the indication
For female clients:
a) Are you pregnant?
EDE and non-EDE clients  
b) If yes, what is the expected date of delivery? Attach IMM 5733 Instructions for Pregnant Client − X-Ray Deferred for paper based IME’s. eMedical generates this Pregnancy Deferral Letter.
c) If yes, do you wish to defer your chest x-ray at this time?

4.6.1 Pregnant client

If the client chooses to defer her CXR because of pregnancy:

eMedical-enabled Panel Clinics
  • CIC is informed electronically by eMedical when a CXR is deferred and the health case is put on hold when a client is pregnant and chooses to defer her CXR;
  • CXR requisition and instructions are generated by eMedical and provided to the client;
  • eMedical generates a “Pregnancy deferral letter” with instructions for the client;
  • All other components of the IME are completed and the IME is put on hold status until the CXR is completed;
  • The IME will be submitted to CIC along with the CXR results when available.
Paper-based Panel Clinics
  • The CXR requisition is completed by the panel physician and given to the client;
  • The IMM 5733 Instructions for Pregnant Client Letter is completed by the panel physician and given to the client;
  • The client may forward a copy of the IMM 5733 Instructions for Pregnant Client Letter to the visa office as proof that the IME has been started and that the CXR has been deferred because of pregnancy;
  • The panel physician may complete the IME, except for the CXR; and
  • The IME is only submitted once the post partum CXR is returned to the panel physician;
  • See sample of the IMM 5733 Instructions for Pregnant Client − X-Ray Deferred form in Appendix III.

4.7 Physical Examination (IMM 5419)

See sample IMM 5419 form in Appendix III.

The physical examination must be completed by the panel physician.

Panel physicians must provide details of all abnormal findings during the physical examination. CIC requires the following information:

  • history;
  • diagnosis;
  • treatment details (including dates and medications);
  • lab results;
  • specialist reports (as required);
  • current status; and
  • prognosis.

Panel physicians may enter this information in the comments section or attach a report to the IME.

The following table lists the additional requirements when the answers to physical examination questions show abnormality, whether the IME is completed in eMedical or on paper. Refer to the IMEIs for additional details.

Physical Examination Related IMEI IMM type Requirements if abnormal
Was a chaperone offered? Breast Exam IMEI EDE and non-EDE clients  
Height (cm) (all clients) Percentile IMEI EDE and non-EDE clients HIV testing, specialist pediatrician and school reports (if applicable)
Height percentile (clients ≤ 2 years of age)
Weight (kg) (all clients) Percentile IMEI EDE and non-EDE clients HIV testing, specialist pediatrician and school reports (if applicable)
Weight percentile (clients ≤ 2 years of age)
BMI (clients ≥ 18 years) BMI IMEI EDE and non-EDE clients If underweight: refer to HIV IMEI
If overweight: refer to IMEIs on cardiac disease, hypertension, diabetes, renal disease, serum creatinine and urinalysis
Head circumference (cm) (clients ≤ 2 years of age)      
Head circumference percentile (clients ≤ 2 years of age) Percentile IMEI EDE and non-EDE clients Specialist pediatrician and school reports (if applicable)
Ear/nose/throat/mouth EDE and non-EDE clients
Hearing Hearing impairment and deafness IMEI EDE and non-EDE clients Provide specialist report(s)
Eyes (including fundoscopy) EDE and non-EDE clients
Best distance visual acuity (with or without correction) EDE and non-EDE clients
Blood pressure (clients ≥ 15 years of age)
Normal readings
  • <140 systole and
  • <90 diastole
Hypertension IMEI EDE and non-EDE clients Repeat blood pressure
Repeated blood pressure (clients ≥ 15 years of age)
Normal readings
  • <140 systole and
  • <90 diastole
Hypertension IMEI EDE and non-EDE clients Screen for signs or symptoms (including blood pressure) and presence of end-organ damage serum creatinine regardless of age
Cardiovascular system Cardiac disease IMEI EDE and non-EDE clients Serum creatinine regardless of age and cardiologist report when required
Respiratory system TB IMEI EDE and non-EDE clients If signs of TB: CXR, HIV, Hepatitis B and C regardless of age
Nervous system: sequelae of stroke or cerebral palsy, other neurological disabilities Debilitating conditions, ADL, GAF and/or CECD IMEIs EDE and non-EDE clients ADL, GAF, CECD and/or an assessment of cognitive functioning
Mental and cognitive state Cognitive impairment, ADL, GAF and/or CECD IMEIs EDE and non-EDE clients ADL, GAF, CECD and/or an assessment of cognitive functioning
Intellectual ability Cognitive impairment, ADL, GAF and/or CECD IMEIs EDE and non-EDE clients ADL, GAF, CECD and/or an assessment of cognitive functioning
Developmental milestones (clients ≤ 5 years of age) CECD IMEI EDE and non-EDE clients CECD and pediatrician report (optional)
Gastrointestinal system Hepatitis / Liver Disease IMEI EDE and non-EDE clients If hepatomegaly: Hepatitis B and C screening, and then ALT and specialist report if positive
Musculoskeletal system Debilitating conditions IMEI and ADL IMEI EDE and non-EDE clients ADL regardless of age
Skin and lymph nodes Cancer IMEI and HIV IMEI EDE and non-EDE clients Screen for skin cancer, leprosy, surgical scars, tattoos and piercings. Inspect neck, axilla and groin for lymphadenopathy
Evidence of substance abuse
(e.g., venous puncture marks)
Psychiatric Conditions IMEI EDE and non-EDE clients Psychiatrist’s report and if evidence of IV drug use HIV, Hepatitis B and C, regardless of age
Breast examination Breast Exam IMEI EDE and non-EDE clients Investigate (e.g., ultrasound, mammogram, specialist report)
Endocrine system (such as evidence of complications from diabetes) Diabetes IMEI EDE and non-EDE clients If diabetes, proceed with screening
Are there any physical or mental conditions that may prevent this person from attending a mainstream school, obtaining full-time employment or living independently now or in the future? Psychiatric Conditions IMEI and Cognitive Impairment IMEI EDE and non-EDE clients ADL, GAF, CECD and/or an assessment of cognitive functioning

4.8 Laboratory Requisition and Report

See sample Laboratory Requisition and Report (in form IMM 5419) in Appendix III.

eMedical-enabled Panel Clinics

  • eMedical will generate laboratory requisitions with client biodata and photograph already printed on them.
  • Mandatory tests will be system generated according to client’s age and clinical findings.

Paper-based Panel Clinics

  • The Laboratory Requisition and Report should be completed with client’s personal information entered: surname, given name, date of birth, IME# or UMI# (if applicable).
  • Client photograph must be attached to ensure IME integrity for laboratory testing.
  • Indicate with a checkmark (R) the tests required.

Laboratory staff are required to confirm the client’s biodata/identity by comparing the photograph on the Laboratory Requisition and Report, the photograph on the client’s approved identity document and the client reporting for laboratory tests.

Any identity concerns must be documented either in eMedical or on the paper laboratory requisition forms. Laboratory testing may continue and the panel physician will report the concerns to CIC for follow-up.

Laboratory staff must fill out the declaration to confirm the following:

  • The requested laboratory tests have been performed; and
  • The sample for testing was collected from the client identified on the requisition.

4.8.1 Urinalysis

A urinalysis is mandatory for all clients five years of age or older.

Refer to the urinalysis IMEI (PDF, 475.73KB) for detailed recommendations on screening.

4.8.2 Syphilis serology

Syphilis is endemic in many regions of the world from which CIC clients originate i.e., South and Southeast Asia, sub-Saharan Africa, Latin America and the Caribbean.

Panel physician must pay special attention during IME for all clients that have risk factors for syphilis, particularly those originating from the regions of high incidence of syphilis mentioned above.

Syphilis testing is mandatory for all clients 15 years of age or older. Testing is also necessary for all clients below the age of 15 who have any of the following risk factors:

  • signs and symptoms compatible with syphilis diagnosis;
  • history of unprotected anal or vaginal sex or pregnancy;
  • history of another sexually transmitted infection such as HIV, herpes, chlamydia, gonorrhoea or bacterial vaginosis; or
  • history of being born to a syphilitic mother.

Refer to the syphilis IMEI (PDF, 177.74KB) for detailed recommendations on screening.

For confirmation purposes, a test should be repeated if the result is indeterminate. For positive syphilis serology results, panel physicians will:

CIC requires the following treatment information:

  • dates;
  • medications; and
  • dosages.

Proof of treatment information may either be included in the General Supporting comments of the syphilis test section or a report may be attached to the IME.

4.8.3 HIV serology

HIV screening is required for all clients 15 years of age or older undergoing an IME. Panel physicians must also request HIV screening for clients below the age of 15 who have any of the following risk factors:

  • signs and symptoms compatible with HIV diagnosis;
  • history of unprotected anal or vaginal sex or pregnancy;
  • history of another sexually transmitted infection such as syphilis, herpes, chlamydia, gonorrhoea or bacterial vaginosis;
  • history of sharing needles, syringes and other equipment and drug solutions for injecting drugs;
  • history of receiving unsafe injections, blood product transfusions or medical procedures that involve unsterile cutting or piercing;
  • accidental needle stick injuries, including among health workers;
  • suspected active TB or hepatitis B or C;
  • tattooing, piercing or having received acupuncture;
  • history of being born to an HIV positive mother; or
  • any child showing failure to thrive.

Refer to the HIV IMEI (PDF, 612.76KB) for detailed recommendations on screening and pre- and post-test counselling.

All HIV positive results must be confirmed with a Western blot test or a second ELISA from a different manufacturer. Panel physician must provide post-test counselling to all HIV positive cases and must have the client sign the IMM 5728: Acknowledgment of HIV Post-Test Counselling form (see Appendix III).

HIV specialist reports including CD4 and Viral Load are required for all HIV positive clients.

4.9 Chest X-Ray Requisition and Report

See Chest X-Ray Requisition and Report (in form IMM 5419) in Appendix III.

Routine postero-anterior chest x-rays are mandatory for clients 11 years of age or older. A panel physician should request a chest x-ray, regardless of age, if the medical questionnaire reveals a past history of TB infection or treatment in the client or his/her close contacts.

Chest x-rays must be examined for general radiological findings and, more specifically, for evidence of active or inactive TB disease.

Radiology clinic staff are required to confirm client identity and biodata by comparing the photograph on the radiology requisition and report, the photograph in the eMedical system (for eMedical-enabled panel clinics), the photograph on the client’s approved identity document and the client reporting for chest x-rays.

Any identity concerns must be documented either in eMedical or on paper forms. The panel radiologist may continue with the chest x-ray and the panel physician will report the concerns to CIC for follow up.

The chest x-ray must contain the following information:

  • client’s name;
  • client’s date of birth;
  • client’s gender; and
  • date of the chest x-ray.

eMedical-enabled Panel Clinics

  • Clients must bring their IME#, UMI#, UCI# with them in order to undergo their chest x-ray; and
  • Panel radiology clinic staff will use the IME#, UCI#, UMI# or the client’s name and passport # to retrieve the client’s health case in eMedical.

Paper-based Panel Clinics

  • Panel physician must enter the client’s personal information on the chest x-ray requisition form: surname, given name, date of birth, IME# or UMI# (if applicable); and
  • The client’s photograph must be attached to the radiology requisition.

There may be cases where a client may not be pregnant at the time of the IME, but is pregnant at the time of the x-ray examination. If a client is pregnant and elects to proceed with the chest x-ray examination, there are no changes to the chest x-ray procedures.

If the client chooses to defer her chest x-ray because of pregnancy:

eMedical-enabled Panel Clinics

  • CIC is informed electronically by eMedical that the client is pregnant along with her estimated date of delivery;
  • eMedical generates a “Pregnancy deferral letter” with instructions for the client;
  • The IME is put on hold status until the chest x-ray is completed; and
  • The IME will be submitted to CIC along with the CXR results when available.

Paper-based Panel Clinics

  • The radiology clinic must notify the panel physician that the chest x-ray has been deferred;
  • The panel physician may complete the IME, except for the chest x-ray; and
  • The IME is only submitted once the post partum chest x-ray is returned to the panel physician.
  • See sample of the IMM 5733 Instructions for Pregnant Client − X-Ray Deferred form in Appendix III.

4.9.1 Chest x-rays indicating active tuberculosis

eMedical-enabled Panel Clinics
  • Panel radiologist’s indication of suspected active TB in the client’s chest x-ray will generate an Active TB warning flag for the panel physician.
  • Panel physicians must arrange for immediate referral for TB investigation.
  • For all confirmed active TB cases, panel physicians must notify their public health authorities according to the country’s or region’s public health guidelines and directives as well as ensure that treatment provided follows WHO recommendations and protocols (http://whqlibdoc.who.int/publications/2010/9789241547833_eng.pdf ).
  • Panel physicians can now submit the health case in eMedical.
  • For all confirmed active pulmonary TB cases, panel physicians must conduct screening for hepatitis B and C, as well as HIV (if not already done), and proceed with contact screening for all family members or close contacts who are also CIC clients. Treatment for latent TB should be recommended for contacts as per instructions. If health case has been submitted this screening will be requested as a furtherance process by the RMO.
  • Refer to the TB IMEI (PDF, 502.21KB) for more information.
Paper-based Panel Clinics
  • A panel radiologist who indicates suspected active TB in the client’s chest x-ray must notify the panel physician immediately.
  • The chest x-ray and report are sent to the panel physician for submission to CIC along with the panel physician’s examination results.
  • Panel physicians must arrange for immediate referral for TB investigation.
  • For all cases of active TB, panel physicians must notify their public health authorities according to the country’s or region’s public health guidelines and directives as well as ensure that treatment provided follows WHO recommendations and protocols (http://whqlibdoc.who.int/publications/2010/9789241547833_eng.pdf ).
  • For all confirmed active pulmonary TB cases, panel physicians must conduct screening for hepatitis B and C, as well as HIV (if not already done), and proceed with contact- screening for all family members or close contacts who are also CIC clients. Treatment for latent TB should be recommended for contacts as per instructions.
  • Refer to the TB IMEI (PDF, 502.21KB) for more information.
  • Panel physicians must complete the IME and submit it to CIC.

4.9.2 Radiology grading

Prior to submitting the chest x-ray, the radiologist must provide a grade for the radiography.

eMedical-enabled Panel Clinics
  • A radiology grade will be provided automatically by the system based on the reported findings.
  • Grade A indicates that there is no evidence of TB or abnormalities suggestive of other significant diseases identified.
  • Grade B indicates that there is evidence of TB or abnormalities suggestive of other significant diseases identified.
  • If the system has provided an A-grade and the radiologist believes that there is evidence of TB or abnormalities suggestive of other significant diseases, they may change the grade to B.
  • If the system has provided a B-grade, it cannot be changed to an A-grade.
  • No comments are permitted for A-grade chest x-rays.
  • Comments are mandatory for B-grade chest x-rays.
Paper-based Panel Clinics
  • Radiologists must provide a radiology grade based on the reported findings.
  • Grade A indicates that there is no evidence of TB or abnormalities suggestive of other significant diseases identified.
  • Grade B indicates that there is evidence of TB or abnormalities suggestive of other significant diseases identified.
  • Comments should not be included for A-grade chest x-rays.
  • Comments are mandatory for B-grade chest x-rays.

4.9.3 Radiologist declaration

The radiologist declaration confirms the following:

  • The client’s identity has been verified; and
  • The radiology report is an accurate record of the radiologist’s findings.
eMedical-enabled Panel Clinics

Important information:

  • Radiologist declarations are provided electronically; and
  • Radiology Support staff can declare on behalf of a radiologist.
Paper-based Panel Clinics
  • Radiologist declarations are provided in writing on the radiology report and include the panel radiologist’s name, signature, number and the date of the chest x-ray report.

4.9.4 Submission of chest x-rays

eMedical-enabled Panel Clinics
  • Digital chest x-rays are uploaded to the eMedical system.
  • The radiologist or authorized radiology support staff enter the general and special findings in the eMedical system.
  • The chest x-ray is graded in the eMedical system and submitted to the client’s IME.
  • The panel physician clinic is notified of the completion of the chest x-ray examination.
  • The panel physician reviews the radiologist report and grading.
  • Once all examinations are completed, the IME is then submitted to CIC by the panel physician.
Paper-based Panel Clinics
  • The radiologist provides the general and special findings and grades the digital chest x-rays or film using the proper form.
  • The radiologist or authorized radiology staff forward the chest x-rays and the report to the panel physician.
  • The panel physician reviews the radiologist’s report and grading.
  • Once all examinations are completed, the IME is sent to CIC by the panel physician.

4.10 Furtherance process

RMOs may require additional information to complete the medical assessment. This additional information is obtained through the furtherance process. Additional cost to the client may occur if e.g the initial IME was not done by the panel physician involved in the furtherance.

Panel physicians are responsible for the following:

  • Referring the client for additional testing or to an appropriate specialist for consultation (see sample IMM 5734 Specialist’s Referral Form in Appendix III);
  • Selecting the specialist (the client may not select his/her own specialist, although the client’s previous medical records may be provided along with the additional requested reports); and
  • Completing the furtherance requirements and submitting results to the RMO.

eMedical-enabled Panel Clinics

  • The RMO issues a client letter with instructions to return to a panel physician for further investigations.
  • The furtherance request is transferred to eMedical.
  • The panel physician retrieves the furtherance request from eMedical by carrying out a search using the IME# or UCI# indicated in the client’s letter.
  • The panel physician completes the additional examination(s) or generates a referral letter containing the information that will be sent to a specialist for the required investigation(s).
  • The panel physician enters the information in eMedical and submits the information to CIC.

Paper-based Panel Clinics

  • The RMO issues a client letter with instructions to return to the panel physician and also provides the client with a sealed letter for the panel physician along with detailed instructions for further investigations.
  • NOTE: IF a furtherance is issued on paper it cannot be completed in eMedical.
  • The panel physician completes the additional examination(s) or refers the client to a specialist for the required investigation(s).
  • The referral letter must include the client’s biodata and photograph and clearly indicate the required investigations requested by CIC.
  • Once all the required investigations have been completed, the panel physician returns the reports to CIC.

4.11 Additional forms and information

Chapter 5: Panel Members’ Activities in Canada

This chapter of the Handbook provides information, instruction and reference material for panel members operating in Canada. It does not apply to panel members who perform Canadian IMEs in other countries.

5.1 Providing primary care for IME clients

If the panel physician is asked to become the personal physician of an immigration client, he or she should make sure that the client understands the different duties and responsibilities of panel physicians and personal physicians. It must also be understood that any medical services not related to the IME or covered under the IFHP will not involve CIC.

5.2 Providing services in Canada’s official languages

In Canada, CIC is committed to providing clients with the opportunity to receive their IME in their preferred official language, either English or French. If a panel physician is unable to provide service in the preferred official language of the client, he/ she should refer the client to the nearest panel physician who can. If there is no panel physician nearby who is able to do so, the panel physician should advise the client or his/her representative to contact the CIC Call Centre at 1-888-242-2100 for more information.

5.3 Protection of personal information

In addition to the Privacy Act, the Access to Information Act, the Canadian Charter of Rights and Freedoms and the Library and Archives Act, personal information in Canada is protected under the Personal Information Protection and Electronic Documents Act (PIPEDA) and under provincial and territorial privacy legislation. The laws of other jurisdictions where the information is collected may also apply. Panel physicians must
comply with these laws when collecting information because the laws set out principles for the collection, use, disclosure, retention and disposal of personal information.

In order to comply with legislation, the IME forms, in some instances, require clients to consent to the disclosure of their personal health information to third parties. In addition, personal health information must be collected and stored in such a way that it is protected from unauthorized disclosure. Panel physicians in Canada receive advice from their professional organizations or regulating bodies on how the PIPEDA and provincial or territorial privacy legislation are to be applied, as well as on the steps required to properly manage information. The PIPEDA can be viewed at http://laws.justice.gc.ca/en/P-8.6/.

5.4 Refugee determination system in Canada

Refugee claimants (often referred to as asylum seekers) are individuals who, following their arrival in Canada, make a formal claim to a CIC or Canada Border Services Agency officer requesting Canada’s protection.

Under the IRPA, all persons claiming refugee protection must undergo an IME. The IME forms and requirements for this refugee group are the same as for other immigrants.

As stated earlier in this Handbook, immigrants are examined in order to identify medical conditions that might affect their admissibility to Canada under the IRPA (see Section 2.1). Refugee claimants are EDE. This means that they are examined primarily to identify conditions that might pose risks to public health and public safety; however, any additional services required by the IMEIs may also be provided.

Refugee claimants are referred for their IME when they file their claims. They are given medical instructions and a list of panel physicians. They must undergo their IME within 30 days following their claim for refugee status.

Refugee claimants who have been granted protected person status by the Canadian authorities become eligible to apply for provincial or territorial health insurance. They must undergo a second IME as part of their application for permanent residence.
They are also given medical instructions and a list of panel physicians. The medical examination is to be undertaken within 90 days of issuance of the IME form IMM 1017.

Important Information

Verifying IFHP eligibility
  • Panel physicians must check with Medavie Blue Cross that their patient’s IFHP coverage is still current BEFORE the examination is carried out because client eligibility may be cancelled or modified without notice should their immigration status change. For example, if a beneficiary receives IFHP coverage as a detainee, once released from detention, their IFHP detainee coverage is terminated. They must then reapply to CIC to have their previous IFHP coverage reinstated in order to continue to be covered under the program. Please also note that because of normal delays between the production and uploading of the files, it can take 2 working days for an IFHP beneficiary’s coverage to become active in Medavie Blue Cross’ system.

Panel physicians cannot refuse to provide IMEs for persons covered by the IFHP but may charge for missed appointments in accordance with local standards of practice. This charge will not be reimbursed under the IFHP.

Coding benefits
  • CIC determines the fees for IMEs and related tests when reimbursed under the IFHP. The current IFHP codes and fees can be found in the IFHP Benefit Grid – IME and IME Tests at https://provider.medavie.bluecross.ca under section Benefit Grid/Drug Formulary.
  • Panel physicians submitting claims for IMEs and related tests must use the appropriate benefit codes listed in the IME Benefit Grid.
Billing for services
  • Invoices for services listed in the IME Benefit Grid must be sent to Medavie Blue Cross.
  • Panel physicians must not ask patients who are eligible for IFHP IME coverage to pay surcharges or additional costs, or ask for a deposit or any other fee in connection with the IME.

The IFHP provides coverage for more than the IME, as described in the IFHP Information Handbook for Health Care Professionals (Provider Handbook). Chapter 9 in the Provider Handbook contains important information for panel physicians who perform IMEs for refugee claimants.

The Provider Handbook, IFHP Benefit Grid and all other program information, including prior approval procedures, claim submission guidelines, provider terms and conditions as well as payment procedures can be found online at https://provider.medavie.bluecross.ca.

5.5 Public Health Liaison Unit

Note: The Public Health Liaison Unit (PHLU) was formerly known as the Medical Surveillance Unit (MSU).

Individuals who in the course of an IME are found to have inactive TB or treated syphilis must be placed under medical surveillance in Canada. The PHLU reports such cases to the appropriate provincial or territorial public health authorities.

Under the PHLU mandate, panel physicians in Canada are not released from their responsibility to notify provincial and territorial public health authorities of conditions and diseases that must be reported under the legislation of the province or territory in which they practise.

At no time should routine investigation or management of active or suspected active TB be deferred or delayed because of immigration medical activities. If a Canadian panel physician cannot contact a client suspected of having an active infectious disease, he or she should immediately inform the CIC Health Branch (see contact information in Appendix I).

Chapter 6: Interim Federal Health Program (IFHP)

6.1 IFHP in Canada

The IFHP provides limited, temporary coverage of health-care benefits in Canada to resettled refugees, asylum seekers, and certain other groups, such as victims of human trafficking and persons detained under the Immigration and Refugee Protection Act, until they become eligible for provincial/territorial (P/T) health-care coverage or, in the case of unsuccessful asylum seekers, leave Canada.

In Canada the IFHP covers the costs of one IME and IME related tests, per eligible client per lifetime.

Adjudication and payment of claims for the program is provided by IFHP Claims Administrator (currently Medavie Blue Cross).

A panel member and any other providers assisting with IME-related tests must register as an IFHP Provider with Medavie Blue Cross, comply with the provider’s terms and conditions.

Please refer to the IFHP Benefit Grid – IME and IME related tests for more information on what specific services and diagnostic tests are covered under the program, and the maximum dollar amount per service/test. The IFHP Benefit grids – IME and IME related tests are also available on IFHP Claims Administrator’s (currently Medavie Blue Cross) website under Resources for Health Professionals.

There are two types of documents that confirm IFHP eligibility of clients in Canada; the Refugee Protection Claim Document (RPCD) and the Interim Federal Health Certificate (IFHC). The IFHC or RPCD should be presented to health care providers at each visit.

Important Information

Verifying IFHP eligibility

Panel physicians must check with Medavie Blue Cross that their patient’s IFHP coverage is still current BEFORE the examination is carried out because client eligibility may be cancelled or modified with very limited notice.

It is important to note that it takes two business days from the day that the IFHP eligibility documents are issued for the eligibility information to be reflected in the Medavie Blue Cross system. Beneficiaries are still eligible during this two business day period.

In cases where an IFHP client is requesting services within two business days of the effective date indicated on the IFHP eligibility documents, providers are asked to:

  1. review the “effective date” on the certificate to confirm that it is within the two business day period
  2. render the service/product and delay the submission of the invoice to Medavie Blue Cross until the coverage has been updated in their system (i.e. 2-3 business days)

Providers have up to six months from the date of service to submit invoices.

Reminder: The IFHP is not designated to reimburse beneficiaries directly. If a beneficiary pays for services/products covered by the IFHP, the individual cannot be reimbursed.

Panel physicians may not refuse to provide IMEs for persons covered by the IFHP, but may charge for missed appointments in accordance with local standards of practice. This charge will not be reimbursed under the IFHP.

IME Benefits
  • IRCC determines the fees for IMEs and related tests reimbursed through the IFHP.
    • The current IFHP codes and fees can be found in the IFHP Benefit Grid – IME and IME Tests at: https://www.medaviebc.ca/en/health-professionals/resources;
      • Select Immigration, Refugees and Citizenship Canada (IRCC);
      • Then, select the provider type: “In Canada: IRCC Providers” and click on “IFHP Benefit Grid – IME and IME Tests”
  • Panel physicians submitting claims for IMEs and related tests must use the appropriate benefit codes listed in the IME and IME Tests Benefit Grid.
Billing for services
  • Invoices for services listed in the IME Benefit Grid must be sent to Medavie Blue Cross.

IFHP Fee policy:

  • Compensation is based on a fee-for-service model. The IFHP fee policy is to reimburse according to usual and customary fee rates in place on the date of service or as per fee rates established by the IFHP. A Provider must not collect from the client the difference between the total amount billed for the services and the amount to be reimbursed by Medavie Blue Cross, if any.
  • Fees for services rendered must not be dependent on method of payment nor influenced by whether the service is a covered benefit for the client.

Panel Members are invited to consult the IFHP Information Handbook for Health Care Professionals(Provider Handbook) for more information. The provider handbook is also available on Medavie Blue Cross website and includes the IFHP Benefit Grids and other related information that pertains to the IFHP – prior approval procedures, claim submission guidelines, provider terms and conditions as well as payment procedures.

Chapter 11 in the Provider Handbook contains important information for panel physicians who perform IMEs for refugee claimants in Canada.

6.2 IFHP overseas (Pre-Departure Medical Services)

On April 1, 2017, the Interim Federal Health Program (IFHP) was expanded to cover certain pre-departure medical services (PDMS) for individuals who have been identified for resettlement before they come to Canada.

The scope of the IFHP PDMS coverage is limited to:

  1. the cost of the Immigration Medical Examination (IME) and follow-up treatment for diseases that would affect a refugee’s medical admissibility to Canada under paragraph 38(1)(a) of the Immigration and Refugee Protection Act (i.e. active tuberculosis and untreated syphilis)
  2. communicable disease prevention and control through the provision of selected vaccinations aligned with Canadian immunization guidelines
  3. services and products to manage communicable disease outbreaks in refugee camps
  4. medical support required during travel to Canada, such as a medical escort or medical devices (e.g. oxygen, wheelchairs).
    • As the IFHP claims administrator, Medavie Blue Cross administers claims submitted by health care providers and institutions that render necessary services to clients eligible for PDMS. More information on PDMS is available on the Medavie Blue Cross website.
    • The benefits under each coverage are subject to certain limits as determined by IRCC, please refer to IFHP Benefit Grid for PDMS.

Eligibility groups for pre-departure medical services

  • Individuals identified for resettlement before they come to Canada (i.e. Government-assisted refugees, privately sponsored refugees and blended visa office referred refugees) are eligible for PDMS.
  • Eligibility may also be extended to groups or individuals who have been specially designated by the Minister of IRCC.
  • Certain people who are being resettled in Canada as a result of a public policy or humanitarian and compassionate considerations on the Minister’s own initiative.

Panel Members Registration and Billing for PDMS

Panel Members Registration
  • Panel members (panel physicians or radiologists), whether they are affiliated or not with the International Organization for Migration, and should register with the IFHP through Medavie Blue Cross.
  • IOM affiliated panel members, are required to register with IFHP, however they will receive reimbursements for their services directly from IOM. They are not required to submit the claims for reimbursements to Medavie Blue Cross.
  • Non-IOM affiliated panel members, are required to register with IFHP in order to claim reimbursement for their services directly from Medavie Blue Cross.
  • For registration procedures, please consult the PDMS provider handbook. This reference document is also available on the Medavie Blue Cross website.
Billing for PDMS 
  • Panel physicians cannot refuse to provide PDMS for persons covered by the IFHP, but may charge for missed appointments in accordance with local standards of practice. This charge will not be reimbursed under the IFHP.
  • Invoices for services listed in the IME Benefit Grid must be sent to Medavie Blue Cross.

IFHP Fee policy:

  • Compensation is based on a fee-for-service model. The IFHP fee policy is to reimburse according to usual and customary fee rates in place on the date of service or as per fee rates established by the IFHP. A Provider must not collect from the client the difference between the total amount billed for the services and the amount to be reimbursed by Medavie Blue Cross, if any.
  • Fees for services rendered must not be dependent on method of payment nor influenced by whether the service is a covered benefit for the client.
PDMS Coverage and Benefits

1. IME and related tests

IRCC determines the fees for IMEs and related tests. The current IFHP benefit codes can be found in the Benefit Grid for PDMS.

Panel physicians submitting claims for IMEs and related tests must use the appropriate benefit codes listed in the Benefit Grid for PDMS.

For more information please consult the PDMS provider handbook.

2. Pre-departure vaccination services

Panel physicians affiliated with the International Organization for Migration (IOM), can provide certain vaccination services covered by the IFHP to eligible clients. These vaccinations are provided on a voluntary basis, and do not impact the resettled refugee’s application for resettlement to Canada.

Immunizations can only be provided in countries where IOM has the capacity to deliver vaccinations. The Immunization Manual contains more information including: standard operating procedures, vaccine administration and schedule, the consent form and documentation worksheet.

3. Medical Support in Transit

The costs related to medical support in transit (medical escorts) are covered by the IFHP. This service requires prior approval by the Regional Medical Offices (RMO) and Migration Health Branch, IFHP Unit. If the service is approved, IRCC will inform the panel physician and advise the respective visa offices. Should you require further operational guidance or have any questions, please contact: IRCC.IFHP-PFSI.IRCC@cic.gc.ca.

The Medical Support in transit form is available in the Pre-Departure Provider Handbook (page 21).

4. Outbreak response;

The IFHP will reimburse the services and products related to diagnostic testing (rapid and serologic), post-exposure prophylaxis, (vaccines and drug therapy), pre-departure health screening and personnel cost including the cost of physician and nursing visits required to manage communicable disease outbreaks in refugee camps.

Requests for prior approval should be sent to RMOs by email or fax as soon as outbreak is detected. To expedite prior authorizations, the description and proposed response / recommendations should include specific control measures and activities including but not limited to the items identified further below.

a. Location and description

Provide a short description of population demographics and description of area/facility of outbreak site (i.e. camp, region, province, country etc.)

b. Confirmation of an outbreak – Epidemiological case definition, case finding. Lab confirmation (if any). How initially reported and steps taken to confirm it. How serious (potential for spread, mortality and complications). Number of cases and particular groups at risk among those identified for resettlement to Canada (clients). How soon the above group will be traveling to Canada.

c. Ongoing action (capacity)

Provide brief description of the current response and capacity, including investigation done and control measures taken (human, medical, etc.)

 d. Proposed response:

What should be done to control this outbreak? Describe proposed control activities and supplies needed (medicines, materials) and expected cost per client, including:

  • Treatment of cases and carriers.
  • Isolation of cases
  • Surveillance of suspects
  • Immunisations. Obtain all immunisation records (consult IFHP Immunization documentation worksheet, if available). Identify required vaccine(s) and number of doses. Confirm vaccine cost per doses including the administration costs.
  • Chemoprophylaxis
  • Personal protection
  • Environmental hygiene
  • Personal hygiene
  • Disinfection and sterilization
  • Pre-departure screening
  • Other

For claims related instructions please consult the provider handbook available at http://provider.medavie.bluecross.ca

Verifying IFHP eligibility

For program integrity purposes, it is the provider’s responsibility to confirm client’s eligibility to the IFHP.

Non-IOM affiliated providers must reference one of the following procedures:

  • Confirm the client has an Interim Federal health Certificate (IFHC)
  • Confirm the IMM-1017 type and the application number: Eligibility for IFHP is confirmed if IMM type = “Ref-Overseas” and application number starts with the letter “G”.

IOM-affiliated providers must follow the following procedures to confirm client eligibility:

  • Confirm that the client’s name appears on the refugee client’s list received from IRCC visa offices;
  • Confirm the IMM-1017 type and the application number: Eligibility for IFHP is confirmed if IMM type = “Ref-Overseas” and application no. starts with “G”.

It is important to note that the PP is to verify the information on the immigration type, client name and eligibility to the IFHP prior to rendering services. In the event that the information is not clear or not complete, the PP should contact Medavie Blue Cross to confirm client’s eligibility at the following email address: CIC_Inquiry@medavie.bluecross.ca, indicating the client’s UCI and benefit code.

Appendix I: Contact Information

In Canada

Operations Directorate

Mail

Senior Director, Integrated Medical Processing Network Division
Migration Health Branch
Immigration, Refugees, Citizenship Canada
300 Slater Street, 7th Floor
Ottawa, ON K1A 1L1

Interim Federal Health Program (IFHP)

Mail

Assistant Director, IFHP
Migration Health Branch
Immigration, Refugees, Citizenship Canada
300 Slater Street, 7th Floor
Ottawa, ON K1A 1L1

Email: IRCC.IFHP-PFSI.IRCC@cic.gc.ca

IFHP Medavie Blue Cross™

Mail

644 Main St., P.O. Box 6000
Moncton, NB E1C 0P9

Provider website: https://www.medaviebc.ca

Customer Service Centre: 1-888-614-1880

Email: CIC_Inquiry@medavie.bluecross.ca

Fax for inquiries: 506-867-4651

Fax for claims submission: 506-867-3841

Panel Physicians Program

Mail

Manager, Global Panel Network Management Unit (GPNMU)
Health Program Integrity and Control Division
Migration Health Branch
Immigration, Refugees, Citizenship Canada
300 Slater Street, 7th Floor
Ottawa, ON K1A 1L1

Email: IRCC.MHBGPNMU-UGRMPDDGMS.IRCC@cic.gc.ca

eMedical Systems Support

For system support

For service in English

Contact the Australian Department of Home Affairs via the “Contact Us” tab in the eMedical system.

For service in French

Contact IRCC at the following:

Email: IRCC.MHBeMedical-eMedicalDGMS.IRCC@cic.gc.ca

Note: This email is monitored from 8:00 a.m. to 4:00 p.m., Canadian EST, Monday to Friday, excluding statutory holidays.

For critical incidents

Contact IT support immediately:

Critical incidents include the following:

  • total loss of the eMedical system (unexpected outages)
  • loss of core functions (cases cannot be submitted; attachments cannot be uploaded)

Note: This service is provided by the Australian Department of Home Affairs 24 hours a day, 7 days a week in English only.

For enquiries regarding medical clinical issues

Panel members should continue to direct all immigration medical exam-related enquiries to their Regional Medical Office.

Regional Medical Offices

London

Mail

Overseas Regional Medical Office
Canadian High Commission
Canada House – Trafalgar Square
London SW1Y 5BJ
United Kingdom

Email: London.pp@international.gc.ca

Manila

Mail

Overseas Regional Medical Office
Canadian Embassy
Level 7, Tower 2, RCBC Plaza
6819 Ayala Avenue
Makati City 0707
Philippines

Fax: +632-843-1103

Email:
Manil.mc-im@international.gc.ca
Manil.mc@international.gc.ca

New Delhi

Mail

Overseas Regional Medical Office
High Commission of Canada
7/8 Shantipath, Chanakyapuri
New Delhi 110021
India

Fax: +91-11-41782020

Email: Delhi-mc@international.gc.ca

Americas

Mail

Ottawa Regional Medical Office
Migration Health Branch
Immigration, Refugees, Citizenship Canada
300 Slater Street, 7th Floor
Ottawa, ON Canada K1A 1L1

Fax: +1-613-954-6211

Email: IRCC.MHBPMInquiries-RenseignementsMPDGMS.IRCC@cic.gc.ca

Appendix II: Client Consent and Declaration

Sample of Client Consent and Declaration

Appendix III: Forms

IMM 1017: Medical Report – Client Biodata and Summary

Sample of IMM 1017: Medical Report – Client Biodata and Summary

IMM 1017B Upfront: Upfront Medical Report – Client Biodata and Summary

Sample of IMM 1017B UPFRONT: Upfront Medical Report – Client Biodata and Summary page 1
Sample of IMM 1017B UPFRONT: Upfront Medical Report – Client Biodata and Summary page 2

IMM 5419 Medical Report

Sample of IMM 5419 Medical Report page 1
Sample of IMM 5419 Medical Report page 2
Sample of IMM 5419 Medical Report page 3
Sample of IMM 5419 Medical Report page 4
Sample of IMM 5419 Medical Report page 5
Sample of IMM 5419 Medical Report page 6

IMM 5544: Resettlement Needs Assessment Form

Sample of IMM 5544: Resettlement Needs Assessment Form page 1
Sample of IMM 5544: Resettlement Needs Assessment Form page 2

IMM 5725: Activities of Daily Living (ADL)

Sample of IMM 5725: Activities of Daily Living (ADL)

IMM 5727: Global Assessment of Functioning (GAF)

Sample of IMM 5727: Global Assessment of Functioning (GAF)

IMM 5728: Acknowledgment of HIV Post-Testing Counselling

Sample of IMM 5728: Acknowledgment of HIV Post-Testing Counselling

IMM 5733: Instructions for Pregnant Client − X-Ray Deferred

Sample of IMM 5733: Instructions for Pregnant Client − X-Ray Deferred

IMM 5734: Specialist’s Referral Form

Sample of IMM 5734: Specialist’s Referral Form

IMM 5738: Chart of Early Childhood Development (CECD)

Sample of IMM 5738: Chart of Early Childhood Development (CECD) page 1
Sample of IMM 5738: Chart of Early Childhood Development (CECD) page 2
Sample of IMM 5738: Chart of Early Childhood Development (CECD) page 3

Appendix IV: List of Immigration Medical Examination Instructions (IMEIs)

A) IMEIs related to process changes resulting from eMedical implementation

  • Activities of daily living (ADL)

    Subject

    Instructions for completing the Activities of Daily Living (ADL) form in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with a possible diminished ADL capacity
    • Completion of the ADL form
    • Completion and grading of an IME for a client with diminished ADL functions

    Instructions

    The ADL assessment provides information about which activities of daily living are impacted by disability due to mental or physical conditions/illnesses. PPs must evaluate clients’ activities of daily living and rate them accordingly. Scoring is based on their level of function, how independently a task can be performed, and whether supervision or assistance is needed in performing the task.

    An ADL assessment is mandatory for all clients who:

    • are 75 years of age or older
    • have abnormal findings on physical examination of the musculoskeletal system
    • have abnormal findings on physical examination of the nervous system
    • have abnormal findings on physical examination suggestive of cognitive impairment or intellectual disability; and /or
    • have an ongoing physical or mental health condition that might prevent them from attending a regular school program, obtaining full-time employment, or living independently
    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    IMEs for clients with an abnormal ADL assessment must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI ADL (Activities of Daily Living) described below
    Text version: TI ADL (Activities of Daily Living)

    TI ADL (Activities of Daily Living)

    IME should be graded B if any abnormalities in the ADL assessment are found.

    Q1: Is the client 75 years old or older?

    No: No need for an ADL assessment

    Yes: ADL assessment is mandatory

    Q2: Is there abnormal findings on physical examination of the musculoskeletal system?

    No: No need for an ADL assessment

    Yes: ADL assessment is mandatory

    Q3: Is there abnormal findings on physical examination of the nervous system?

    No: No need for an ADL assessment

    Yes: ADL assessment is mandatory

    Q4: Is there abnormal findings on physical examination suggestive of cognitive impairment or intellectual disability?

    No: No need for an ADL assessment

    Yes: ADL assessment is mandatory

    Q5: Is there an ongoing physical or mental health condition that might prevent the client from attending a regular school program, obtaining full-time employment, or living independently?

    No: No need for an ADL assessment

    Yes: ADL assessment is mandatory

  • Assessment of cognitive functioning

    Subject

    Instructions for assessing cognitive functioning in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with possible diminished cognitive capacity
    • Completion and grading of an IME for a client with diminished cognitive capacity

    Instructions

    There are various tools available for assessing cognitive functioning (Mental State Exam, Montreal Cognitive Assessment). For the purpose of standardizing scores, the raw score of the tool used to assess cognitive functioning must be transposed to a scale of 30. In scoring the client’s cognitive functioning, the PPs may need to take into account mitigating factors such as the client’s educational attainment, literacy and cultural considerations. In certain circumstances, the raw score may be interpreted upon consideration of additional information such as anecdotal information from family members.

    An assessment of cognitive functioning is mandatory for all adult clients who:

    • are 75 years of age or older
    • have abnormal findings on physical examination of the nervous system
    • have abnormal findings on physical examination suggestive of cognitive impairment or intellectual disability; and/or
    • have an ongoing physical or mental health condition that might prevent them from attending a regular school program, obtaining full-time employment, or living independently
    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with a cognitive functioning score of 25/30 or lower must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for cognitive functioning assessment described below
    Text version: TI for cognitive functioning assessment

    TI for cognitive functioning assessment

    IME should be graded B if any abnormalities in the cognitive functioning assessment are found.

    Q1: Is the client 75 years old or older?

    No: No need for a cognitive functioning assessment

    Yes: cognitive functioning assessment is mandatory

    Q2: Is there abnormal findings on physical examination of the nervous system?

    No: No need for a cognitive functioning assessment

    Yes: cognitive functioning assessment is mandatory

    Q3: Is there abnormal findings on physical examination of the musculoskeletal system?

    No: No need for a cognitive functioning assessment

    Yes: cognitive functioning assessment is mandatory

    Q4: Is there abnormal findings on physical examination suggestive of cognitive impairment or intellectual disability?

    No: No need for a cognitive functioning assessment

    Yes: cognitive functioning assessment is mandatory

    Q5: An ongoing physical or mental health condition that might prevent the client from attending a regular school program, obtaining full-time employment, or living independently

    No: No need for a cognitive functioning assessment

    Yes: cognitive functioning assessment is mandatory

  • Breast examination

    Subject

    Instructions regarding breast examination of clients as part of the Immigration Medical Examination (IME).

    Instructions

    A screening breast exam is not indicated for an IME. A breast examination, however, may be clinically indicated in the presence of signs or symptoms of breast disease, previous cancer, and patients at high risk for cancer. If a clinical examination of the breasts and axillae is indicated, patients may be referred to their primary care physicians.

    If performed by the Panel Physician, the following are mandatory:

    • Breast exams must always be conducted in the presence of a chaperone
    • Provide the client with an explanation of why and how the examination is being conducted
    • Rationale for a clinical breast examination and the risk factors, must be provided in the comments section of the IME
  • Developmental milestones: Chart of early childhood development

    Subject

    Instructions for evaluating early childhood development and completing the Chart of Early Childhood Development (CECD) section in the context of the Canadian immigration medical examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Assessment of developmental milestones for an infant or child
    • Identification of infants /children with delayed developmental milestones
    • Completion of section 904-CECD and reporting in eMedical
    • Grading of an IME for a client with delayed developmental milestones and an abnormal CECD

    Instructions

    PPs are required to assess the developmental age for all children less than 5 years of age and complete section 904 in eMedical. PPs have to report the developmental age of the child:

    • Observed by the client’s parents /caregivers
    • Observed by himself during the IME

    The CECD will assist PPs in their assessment of the developmental milestones. The CECD is a screening tool used to evaluate a child’s motor /physical, communication /language, social /emotional, and cognitive development from birth to 5 years of age.

    Chart of early childhood development (CECD)
    By 1 month of age
    • Looks at parent /caregiver (focuses gaze)
    • Calms when comforted
    • Startles to loud or sudden noises
    • Sucks well on nipple
    By 2 months of age
    • Follows movement with eyes
    • Makes a variety of sounds (coos, gurgling)
    • Lifts head up while lying on tummy
    • Recognizes and calms to a familiar gentle voice
    • Smiles responsively
    • Has different cries (for example, when tired vs hungry)
    • Holds head up when held at caregiver’s shoulder
    By 4 months of age
    • Follows a moving toy or person with eyes
    • Holds head steady when supported at the chest or waist in a sitting position
    • Responds to parent /caregiver by making sounds, moving limbs
    • Glances from one object to another
    • Holds an object briefly when placed in hand
    • Laughs and smiles responsively
    By 6 months of age
    • Turns head and looks in direction of a new sound
    • Rolls from back to side
    • Uses hands to reach, grasp, bang, and splash
    • Vocalizes pleasure and displeasure
    • Makes sounds while parent /caregiver is talking to him /her
    • Sits with support (for example, pillows)
    • Brings hands or toy to mouth
    By 9 months of age
    • Looks for a hidden toy/object
    • Stands with support when helped into standing position
    • Sits without support for a few minutes
    • Plays social games with parent/caregiver (for example, peak-a-boo)
    • Babbles a series of different sounds
    • Picks up small items using thumb and first finger
    • Makes sounds/gestures to get attention or help
    By 12 months of age
    • Consistently uses 3 or more words (words do not have to be clear)
    • Combines sounds together as though talking
    • Pulls up to stand at furniture
    • Picks up small items using tips of thumb and first finger
    • Responds to own name (looks at person)
    • Understands simple requests (for example “find your shoes”)
    • Walks holding onto furniture or parent /caregiver’s hands
    • Takes things out of containers (for example blocks)
    By 15 months of age
    • Consistently uses 5 or more words (words do not have to be clear)
    • Walks sideways holding onto furniture
    • Stacks 2 blocks
    • Responds to own name when called
    • Imitates a few animal sounds
    • Crawls up a few stairs /steps
    • Tries to squat to pick up a toy from the floor
    • Shows fear of strange people /places
    By 18 months of age
    • Consistently uses 15 or more words (words do not have to be clear)
    • Walks independently
    • Stacks 3 or more blocks
    • Shows affection towards people, pets, or toys
    • Points to what he /she wants or to show parent /caregiver something
    • Walks up a few stairs holding parent /caregiver’s hand
    • Points to at least 3 different body parts when asked
    By 24 months of age
    • Combines 2 or more words
    • Walks backward 2 steps without support
    • Stacks 4 or more blocks
    • Uses toys for pretend play (for example, give doll a drink)
    • Understands 1 and 2 step directions/instructions
    • Tries to run
    • Puts objects into a small container
    By 30 months of age
    • Combines 3 or more words
    • Uses pronouns such as I, you, me, and mine
    • Jumps off the floor with both feet
    • Tries to join in songs and rhymes with parent /caregiver
    • Names most common items (for example, dog, apple, car)
    • Runs without falling most of the time
    • Kicks a ball forward
    By 3 years of age
    • Uses sentences with 5 or more words
    • Understands 2 and 3 step directions /instructions
    • Walks upstairs using handrail
    • Turns pages of a book one at a time
    • Plays with others comfortably
    • Speaks clearly enough to be understood by family all of the time
    • Listens to music or stories for 5-10 minutes
    • Twists lids off jars or turns knobs
    • Plays make-believe games with actions and words (for example, pretending to cook a meal)
    • Shares some of the time
    By 4 years of age
    • Understands 3 step directions/instructions
    • Tells stories with a clear beginning, middle, and end
    • Walks up/down stairs with alternating feet
    • Undoes buttons and zippers
    • Uses toilet/potty during daytime
    • Asks and answers lots of questions
    • Identifies or shows you 4 colours when asked
    • Stands on one foot for 1-3 seconds without support
    • Draws a person with 3 or more body parts
    • Tries to comfort someone who is upset
    By 5 years of age
    • Counts out loud or on fingers to answer “how many are there?”
    • Speaks clearly in adult-like sentences most of the time
    • Stops, starts, and changes direction smoothly when running
    • Throws and catches a ball successfully most of the time
    • Usually plays well in groups
    • Works alone at an activity for 20-30 minutes
    • Knows common shapes and most of the letters of the alphabet
    • Tells long stories about own past experiences
    • Hops on one foot several times
    • Holds a crayon or pencil correctly
    • Shares willingly with others
    • Cooperates with adult requests most of the time
    Reporting

    For children where the observed developmental milestones are not consistent with the chronological age, the PP should provide all relevant information to clarify /confirm a diagnosis, identify medical and/or social services requirements (for example, medical services at home, special education, occupational therapy, speech language therapy, physiotherapy), and establish a prognosis over the next 5-10 years. This will help the medical officer make the determination of current and future (within the next 5-10 years) medical care and social service requirements of the child.

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office (RMO). All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the immigration medical examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with abnormal developmental milestones must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s) submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for Developmental Milestones described below
    Text version: TI for Developmental Milestones

    TI for Developmental Milestones

    IME should be graded B if any developmental milestones are not consistent with the client’s chronological age and developmental delay is suspected. IME should be submitted including any existing test results and specialist reports.

    Q1: Is the client 5 years old or less?

    Yes: Complete an assessment of developmental milestones – Chart of Early Childhood Development

    No: No need to proceed with an assessment of developmental milestones.

    Q2: If an assessment of developmental milestones was performed, is the developmental milestones not consistent with the client’s chronological age and developmental delay is suspected?

    Yes: Provide all relevant information to clarify /confirm a diagnosis, identify medical and/or social services requirements (e.g. medical services at home, special education, occupational therapy, speech language therapy, physiotherapy..), and establish a prognosis over the next 5-10 years.

    Clients should not be referred to specialists unless instructed by the RMO.

    No: Continue the medical examination.

    References

  • Resettlement needs assessment

    Subject

    Instructions for evaluating and reporting the resettlement needs of refugees overseas who have been selected for resettlement in Canada in the context of the Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure panel physicians (PPs) follow a consistent and appropriate process in the:

    • assessment of the resettlement needs of refugees overseas
    • proper completion of the section 948 resettlement needs

    Instructions

    Background

    It is important that refugees with extensive medical and/or social needs are able to 1) travel to Canada efficiently and safely and 2) be able to settle into Canada with their medical and social needs being recognized and attended to quickly and effectively.

    The section 948 in eMedical; resettlement needs has been created in order to capture vital information in support of proper resettlement from a medical perspective. For all overseas refugees selected for resettlement in Canada, section 948 in eMedical is mandatory. In countries where eMedical is not implemented, the Visa Office will issue the IMM 5544 form “Resettlement needs Assessment Form” together with the medical instructions. (IMM 1017 Medical report: client biodata and summary).

    The table below provides information for the PP regarding eMedical and paper-based submission of the IMM 5544.

    eMedical-enabled panel clinics
    • Visa Office (VO) issues IMM 1017 with IMM category of refugee-overseas
    • Section 948 is required to be filled out in eMedical and submitted along with the health case
    • IMM 5544
    Paper-based panel clinics
    • Visa Office (VO) issues IMM 1017 with IMM category of refugee-overseas
    • IMM 5544 is included in medical instructions sent to client by VO as part of the IME
    • Panel physician will complete the IMM 5544 and submit it along with the paper-based IME

    The resettlement needs section is used to provide additional information for three important purposes:

    • to facilitate safe and efficient travel to Canada
    • to maximize post-arrival settlement arrangements on arrival to Canada
    • and to help in determining the destination city in Canada where the medical and social services required for the refugee are available
    Completing the resettlement needs section

    The Resettlement needs section is to be completed for every overseas refugee, even those without medical conditions or concern. Even a negative answer is important. When a refugee has no special travel requirements or settlement issues, the PPs must check the box following the statement “There are no special travel requirements or resettlement needs” (see figure below):

    Box described below
    Text version

    There are no special travel requirements or settlement issues.

    If there are special travel or resettlement issues the PPs will complete, as appropriate, sections 1, 2, 3, 4 and 5.

    The list below (indicative but not exhaustive) highlights some commonly encountered medical conditions which do not warrant the detailed filling in of the resettlement needs section:

    • Hypertension, well controlled with medication
    • Asthma, well controlled with medication
    • Inactive pulmonary tuberculosis
    • Syphilis, treated
    • Epilepsy under good control
    • Diabetes under good control without end organ complications
    • Skin conditions/infections (psoriasis, fungal infections)
    • Visual acuity deficit of equal or better than 6/15 when corrected
    • Radiographic cardiomegaly without clinical manifestations or impairment

    In order to preserve medical confidentiality, no personal medical information is to be placed on the resettlement needs section. Thus, the PPs must attempt to get across the basis of the medical problem and the special needs of the refugee without referring to a specific medical diagnosis. This applies as well for psychological assessment of the refugee client which is an important aspect in the evaluation of resettlement needs. This is very important to remember since the information on the resettlement needs section will be made available to people who are not medical professionals.

    These 5 sections of the resettlement needs section are:

    • Functional Assessment (physical and psychological),
    • Special Travel Requirements,
    • Post-arrival Service Requirements,
    • Housing and Daily Activities or Assistance requirements, and
    • Other Resettlement needs.
    Section 1: Functional assessment

    The functional assessment on the resettlement needs section is clear in identifying major problems that can impact on resettlement of the refugee in Canada (see figure below):

    Section 1: Functional assessment described below
    Text version: Section 1: Functional assessment
    1. Functional assessment: Indicate Yes or No for every listed impairments: Hearing impairment (Partial or Complete); Vision impairment (Partial or Complete); Speech impairment (Partial or Complete); Cognitive impairment (Mild or Moderate or Severe); Mobility impairment (indicate the current mobility aid and the mobility aid required); Other impairment (provide details). Activity of daily living (Independent or Partial care or Total care; provide details).

    If any of the above noted impairments is present the PPs must indicate “yes”. If they are not present the PPs must check “No”. Even when only one impairment is present, all other answers must be completed with a “No” response.

    When there is a positive response to any of these functional assessment questions, the PPs must provide additional information about the impairment (That is, degree of impairment, use of/requirement for a mobility aid). The PPs must also indicate what level of Activities of Daily Living (ADL) the refugee is functioning at and must also add any details that would assist in understanding the degree to which a refugee might be dependent on others for care (for example: the requirement for assistance with feeding, bathing or toileting).

    When “Other” functional impairment is marked, remarks are required from the PPs in order to provide information regarding what the problem is, without stating a medical diagnosis.

    If the refugee is currently using, or requires, a mobility aid, the nature of that aid must be noted in the space “Current mobility aid” and if the refugee needs a different aid, this must be stated in the option marked: “Mobility aid required”. The most commonly used mobility aids are canes, walkers and wheelchairs.

    Finally, if a person is using or would benefit from a mobility aid, the PPs must take this into account when completing section 4, “Housing Requirements” by adding a notation regarding the need for a single level dwelling and/or elevator access.

    Section 2: Special travel requirements

    The special travel requirements for the refugee to get to their final destination in Canada are listed on the Resettlement needs section (see figure below):

    Section 2: Special travel requirements described below
    Text version: Section 2: Special travel requirements
    1. Special Travel Requirements: In the “Special travel requirements” section, select the applicable ones: None, Wheelchair, Stretcher, Medical escort required, Other. Provide details if necessary.

    A “Wheelchair” must be indicated whenever the refugee is using or requires a mobility aid. An indication of the size/type of wheelchair required would be helpful. A wheelchair should also be indicated for persons with any medical condition limiting their ability to move quickly or safely when transferring between terminals at an airport. Often this would be the case for persons with mobility problems associated with osteoarthritis, amputation, or cerebral palsy. It should also be considered for persons with cardio-respiratory disorders such as angina, congestive heart failure, valvular heart disease, or chronic obstructive pulmonary disease (COPD).

    Please note that request for a “Medical Escort” will be vetted by the Regional Medical Office (RMO) responsible for the refugee’s IME and by IRCC in Ottawa.

    If the “Other” option is used, the PPs must provide the specific information in the “Details” section below the responses. Most commonly the option of “Other” will be used when the refugee should be accompanied by an adult family member or might need assistance in undertaking immigration formalities at the Port of Entry in Canada.

    It is possible for more than one box to be completed in this section. For example a refugee with severe congestive heart failure might need both a wheelchair during the travel period as well as a medical escort.

    Section 3: Post-arrival services required

    This section of the resettlement needs Assessment is important as it indicates the actual social and/or medical services that the refugee will require in Canada. Please keep in mind that all refugees will be seen by general practitioners (GPs) in Canada within weeks of their arrival. We are asking PPs to note in this section any requirement for services that would be outside of the services provided by GPs. For example, common diabetes or hypertension are handled by GPs in Canada. Follow up for diabetes would therefore not represent a post-arrival service worth noting.

    Social services available in Canada range from special education, speech therapy, occupational therapy, physiotherapy to vocational rehabilitation, attendant care. Social services can also include specialized housing services such as home care and long term care (these housing and care services would require an application to be made and would usually require an assessment by a health professional regarding the need and eligibility for the service). Medical services available in Canada run the full range of specialties and include operative and non-operative care for such medical conditions as cancer, renal failure, coronary artery disease, osteoarthritis, hepatitis and the human immunodeficiency virus (HIV).

    In filling in the resettlement needs section, the post-arrival services requirements are either “no services required” or “Consultation with a health care professional required” (see figure below):

    Section 3: Post-arrival services required described below
    Text version: Section 3: Post-arrival services required
    1. Post-arrival services required. In the “Post-arrival services required” section of the Resettlement Needs section, the requirements are either “no services required” or “Consultation with a health care professional required”. If “Consultation with a health care professional required” is checked, indicate if it is Urgent (72 hrs); Specialized services, Within X weeks, Long term services or As required. Provide details if necessary.

    When a consultation is required, the PPs must indicate how quickly that should take place (as shown in the figure above). Again, please keep in mind that post-arrival services worth noting are those provided outside the scope of what GPs would provide.

    In deciding on the number of weeks that would be reasonable before the refugee should be seen by a specialist consultant, the PPs must keep in mind that a consultation with a specialist in Canada, can take several weeks and even months to set up. Thus, for a chronic, well controlled, medical condition, one should indicate “as required”.

    Long standing conditions that require assessment for a special education class, vocational training, or rehabilitation can also usually be marked “as required”.

    Conditions that might benefit from being seen by a specialist in a shorter period of time would be unstable angina or congestive heart failure, or newly diagnosed diabetes needing training of the use of insulin.

    In general, almost any refugee requiring a medical escort to accompany them safely to Canada will require an “urgent” specialist assessment. This might include a case of severe COPD requiring oxygen for travel or for everyday use, or a case of severe valvular heart disease requiring stabilisation of secondary heart failure and an “urgent” assessment for consideration of valve replacement surgery. Individuals requiring an assessment for home care or long term residential care must also be marked “urgent”.

    If there is any uncertainty with respect to the urgency or time-frame for an Applicant to be assessed by a medical specialist upon arrival to Canada, please contact your Regional Medical Office.

    If the refugee’s visual impairment appears to be, or is most likely due to a simple refractive error (most often with younger clients) the best option would be recommendation to see an optometrist. If on the other hand, the visual problem could reasonably be due to cataracts or glaucoma (based on clinical findings or the age of the client) the best option would be referral to an ophthalmologist.

    As stated earlier, the “Specialised Services” noted under “Consultation with a health care professional” can refer to needs for such varied social and medical services as:

    • special education
    • occupational therapy
    • physiotherapy
    • speech therapy
    • vocational training
    • lip reading or sign language training
    • training for a blind person in navigating his home and community

    Long term services can refer to such services as placement of the refugee in a long term care centre for someone who has had a stroke and is not (and will never be) independent in their activities of daily living

    Section 4: Housing and daily activities/assistance requirements

    The housing and daily activities/assistance requirements section offers the PPs four options for completion (see figure below):

    Section 4: Housing and daily activities/assistance requirements described below
    Text version: Section 4: Housing and daily activities/assistance requirements
    1. Housing and daily activities/assistance requirements. The “housing and daily activities/assistance requirements” section offers the PPs four options for completion: Fully independent, no assistance required; Wheelchair access required; Home care/support services required (Periodically or Permanently); Specialized services required to accommodation functional impairments. Please specify the specialized services required.

    The first two options are more or less self-explanatory. The PPs shall keep in mind that someone who does not currently use a wheelchair but who would benefit from one must have the “Wheelchair access required” response checked. This must correspond with a previous positive response regarding “Mobility impairment” in Section 1 of this form.

    If the PPs consider that “Home care/support services” are required for a refugee to carry out daily activities in their own home, this must be checked as well as the anticipated frequency of that service. For example, attendant care (for example, nursing care) might be considered necessary for an elderly person who is not able to see well enough to count out daily medications or to give an insulin injection. This would be required daily and permanently. For someone requiring assistance with bathing, the visits by a home care nurse might only be once a week, in which case “periodic” must be checked.

    Types of home care services available in Canada are “periodic” and “permanent” (see figure above).

    The last option for the PP to consider under Housing and Daily Activities is “Specialized services required to accommodate functional impairments”. This could include long term care in a residential facility with 24-hour nurse staff. Normally this expensive form of residential care is limited to persons who cannot safely function with the more limited nursing services available through home care. Another specialized service might be home oxygen for a refugee with severe COPD.

    Section 5: Other comments related to resettlement needs

    This section must only be used when relevant details are needed and cannot be written in any of the above sections. Again under no circumstances should a medical diagnosis or information that leads to a medical diagnosis appear on the Resettlement needs section. The PPs must attempt to get across the basis of the medical problem and needs without referring to a specific medical diagnosis.

    Once the Resettlement needs section is completed, PPs will submit the completed document electronically. PPs who works on paper IME will date and sign at the bottom of the form indicating their P number and the place where the form was completed.

    Example: Section 948 Resettlement needs in eMedical

    Section 948 Resettlement needs in eMedical described below
    Text version: Section 948 Resettlement needs in eMedical

    In eMedical, Section 948 Resettlement Needs, in the Record results section:

    Select the exam date.

    • Q1: Does the client have any resettlement/special needs? Select Yes and provide details.
    • Q2: Functional assessment
      • Q2.1 Hearing impairment (Partial or Complete)
      • Q2.2 Vision impairment (Partial or Complete)
      • Q2.3 Speech impairment (Partial or Complete)a
      • Q2.4 Cognitive impairment (Mild or Moderate or Severe)
      • Q2.5 Mobility impairment (indicate the current mobility aid and the mobility aid required)
      • Q2.6 Other impairment (provide details).
      • Q2.7 Activity of daily living (Independent or Partial care or Total care).
    • Q3: Special travel requirements: Select the applicable one: None, Wheelchair, Stretcher, Medical escort required, Other.
    • Q4: In the “Post-arrival services required” section, the requirements are either “No services required” or “Consultation with a health care professional required”. If “Consultation with a health care professional required” is checked, indicate if it is: Urgent (72 hrs); Specialized services, Within X weeks, Long term services or As required. Provide details if necessary. Indicate in how many weeks the consultation is required.
    • Q5: In the “housing and daily activities/assistance requirements” section offers the PPs four options for completion: Fully independent, no assistance required; Wheelchair access required; Home care/support services required (Periodically or Permanently); Specialized services required to accommodation functional impairments.
    • Q6: Do you have any other comment you would like to make in relation to this person’s resettlement needs? Select Yes or No.

    Resettlement needs assessment form

    Resettlement needs assessment form IMM 5544 (PDF, 2.3 MB)

B) IMEIs related to conditions of significance

  • Cancer or Malignancy

    Cancer or Malignancy (PDF, 279.21 KB)
  • Cognitive impairment in adults

    Subject

    Instructions for screening clients with possible impaired cognitive functioning in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with possible impaired cognitive functioning (for example, senile dementia)
    • Completion and grading of an IME for a client with impaired cognitive functioning

    Instructions

    Screening and testing

    It is important identify clients with cognitive impairment, as well as their specific medical care and social service needs. Such conditions may represent a significant burden and excessive demand on Canadian health services, especially when supportive home care, respite care for family members, and /or placement in a long term care facility is required or anticipated.

    During the medical history-taking and physical examination, the PPs must be vigilant for the presence of possible cognitive impairment.

    The following information will assist the Regional Medical Office (RMO) in its assessment of the IME:

    • Diagnosis/differential diagnosis, and etiology if known
    • Duration, stability, and/or progression of symptoms
    • Ability to complete activities of daily living and live independently
    • Recent medical/health care received (for example, hospitalization, specialist consultations)
    • Current and anticipated (over the next 5-10 years) medical care and social service needs (home care, nursing/attendant care, respite care for family members, and/or placement in a long term care facility
    • Co-morbidities, such as vascular disease (multi-infarct dementia), electrolyte imbalance, other organic causes of cognitive impairment
    • History of neurological problems or associated conditions (e.g. Parkinson’s, Alzheimer etc.)
    • Medications: regimen, recent changes
    • Drug or alcohol abuse
    Additional investigation

    An assessment of cognitive functioning and activities of daily living (ADL) is mandatory for all clients aged 75 years and older. For clients with abnormal findings suggestive of cognitive impairment, regardless of age, assessments of ADL and cognitive function must be included.

    Reporting

    All additional assessment information, including assessments of ADL and cognitive functioning, must be attached to the IME report.

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    Any behaviour suggesting the client may present a danger to self or others must be reported.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IME’s for clients with abnormal cognitive functioning must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating medical information pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI Cognitive impairment in adult described below
    Text version: TI Cognitive impairment in adult

    TI Cognitive impairment in adult

    IME should be graded B if any abnormalities on medical history and/or physical examination suggestive of cognitive impairment are found.

    Q1: Is the client 75 years old or older?

    No: Is there any abnormalities on medical history and/or physical examination suggestive of cognitive impairment? If Yes, an ADL and a Screening test for cognitive functioning are mandatory. If No, grade B and submit IME including any existing test results and specialist reports.

    Yes: An ADL and a screening test for cognitive functioning are mandatory.

    Q2: If the client is ≤ 75 years of age, is there any abnormalities on medical history and/or physical examination suggestive of cognitive impairment?

    No: No need for a Screening test for cognitive functioning. Grade B and submit IME including any existing test results and specialist reports.

    Yes: An ADL and a Screening test for cognitive functioning are mandatory.

  • Diabetes, hypertension, chronic renal or cardiac diseases

    Subject

    Instructions for screening of clients with diabetes, hypertension or chronic renal/cardiac diseases in the context of the Canadian immigration medical examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of end-organ damage/renal function impairment in clients with diabetes, hypertension or chronic renal/cardiac diseases
    • Investigation of clients with end-organ damage/renal function impairment to help determine their need for medical and /or social services
    • Completion and grading of an IME for a client with end-organ damage/renal function impairment

    Instructions

    Rationale

    Long standing diseases such as diabetes, hypertension and chronic renal or cardiac conditions are responsible for end-organ damages and gradual loss of kidney function over time. Chronic renal disease is responsible for a high burden of disease in Canada and lifesaving renal replacement therapies (dialysis and/or kidney transplantation) remain expensive and in short supply.

    Screening and testing

    During the IME, the PPs must be vigilant in assessing clients with diabetes, hypertension or chronic renal or cardiac diseases for the presence of possible end-organ damage and long term complications, especially renal function impairment. Signs associated with end-organ damage include:

    • retinopathy
    • neuropathy: check for symptoms or findings such as peripheral neuropathy or pain, autonomic neuropathy (for example, erectile dysfunction, gastrointestinal disturbance, orthostatic hypotension), PPs should include screening via monofilament during foot exam
    • Cardiopathy: chest auscultation and radiography is necessary to assess cardiomegaly and cardiopathy
    • Nephropathy: special attention should be brought during the IME to blood pressure measure as well as to urinalysis and creatinine results (refer to TIs on urinalysis and serum creatinine)

    The identification of clients with end-organ damage and renal function impairment is based on the completion of an appropriate medical history, careful review of risk factors and commonly associated co-morbid conditions, physical examination, and screening investigations.

    If an established history of diabetes, hypertension or renal/cardiovascular disease (for example, ischemic heart disease/coronary artery disease, valvular heart disease, cardiomyopathy, cerebrovascular disease [transient ischemic attack, stroke], peripheral artery disease, and /or congenital heart disease) is identified during the IME, the following information will help determine the client’s need for specialized medical care and/or social services.

    • Diagnosis
    • Duration and progression of symptoms
    • New York Heart Association [NYHA] Functional Classification
    • Impact on activities of daily living (ADLs)
    • Past investigations and treatment /intervention, including hospitalization, surgery, need for renal replacement therapy
    • Available specialist reports from past consultations
    • Current medications
    • Anticipated treatment needed (surgery, dialysis, etc)
    Assessment of renal function

    Urinalysis is required for all clients ≥ 5 years of age. A urinalysis is also required for clients less than 5 years of age if there is a past history of diabetes, hypertension or kidney disease or if renal function impairment is suspected

    A serum creatinine level is required for all clients ≥ 15 years of age. A serum creatinine is also required for clients less than 15 years of age if there is a past history of diabetes, hypertension or kidney disease or if renal function impairment is suspected.

    Calculation of the estimated glomerular filtration rate (eGFR) is required when serum creatinine is abnormal. (eGFR calculator)

    Additional investigation

    Clients identified to have impaired renal function (eGFR < 30 mL /min /1.73m2), require the following:

    • Urine albumin-to-creatinine ratio (ACR)

    Clients with advanced chronic renal failure or end-stage kidney disease (eGFR of <30ml/min at any time during the IME) have been identified in the latest Canadian TB standards as a high risk group for Latent TB reactivation. These clients should therefore be screened with IGRA (or TST if IGRA is not available).

    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the immigration medical examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with renal function impairment must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s) submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for screening of clients with diabetes, hypertension or chronic renal/cardiac diseases described below
    Text version: TI for screening of clients with diabetes, hypertension or chronic renal/cardiac diseases

    TI for screening of clients with diabetes, hypertension or chronic renal/cardiac diseases

    Q1: Is the client have history or suffer from long standing diseases such as diabetes, hypertension and chronic renal or cardiac conditions?

    Yes: An assessment of renal Function is mandatory. A urinalysis and a serum creatinine is required for ALL clients regardless of their age. Continue with Q2.

    No: A urinalysis is required for all clients greater (≥) than 5 years of age and a serum creatinine is required for all clients ≥ 15 years of age.

    Q2: Is initial urinalysis dipstick shows 1+ for protein or microscopy is normal with protein < 0.30 mg/L and serum creatinine level normal?

    Yes: Grade the exam B and submit IME including all additional test results and specialist reports.

    No: Repeat urinalysis. If dipstick shows 2+ or 3+ for protein or microscopy is abnormal with protein > 0.30 mg/L. Grade the exam B and submit IME including all additional test results and specialist reports.

    Q3: Is serum creatinine level normal?

    No: Calculate eGFR. If results are <30 mL/min /1.73 m2, calculate albumin-to-creatinine ratio (ACR) and screened for LTBI with IGRA (or TST if IGRA is not available).

    Yes: Grade the exam B and submit IME including all additional test results and specialist reports.

    References

  • Debilitating conditions

    Subject

    Technical Instructions (TI) for screening clients with debilitating conditions in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with a debilitating condition
    • Completion and grading of an IME for a client with a debilitating condition

    Instructions

    Screening and testing

    It is important to identify clients with debilitating conditions, as well as their specific medical care and social service needs. Such conditions may represent a significant burden and excessive demand on Canadian health services, especially when supportive home care, respite care for family members, and/or placement in a long term care facility is required or anticipated.

    A wide range of chronic diseases may lead to a debilitated state, including the following:

    • Neurological diseases: multiple sclerosis, amyotrophic lateral sclerosis (ALS), Parkinson’s, cerebrovascular disease/stroke
    • Musculoskeletal and autoimmune diseases: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), fibromyalgia, other chronic pain conditions /syndromes
    • Cardiovascular diseases: peripheral vascular disease +/- amputation, cerebrovascular disease/stroke
    • Respiratory diseases: chronic obstructive pulmonary disease, pulmonary fibrosis, oxygen therapy at home
    • Some psychiatric conditions: schizophrenia, schizoaffective disorder, bipolar disorder
    • Others: advanced cancers; any medical condition with a history of an aggressive course, significant functional impairments, and /or treatment with disease-modifying or biologic therapies

    During the medical history-taking and physical examination, the PPs must be vigilant for the presence of debilitating conditions. The identification of clients with debilitating conditions is based on a directed medical history and physical examination. Populations at increased risk include the elderly, patients with long standing chronic diseases (for example, diabetes, hypertension, chronic obstructive pulmonary disease), and/or a family history of cardiac or neurological diseases.

    The following information will assist the Regional Medical Office (RMO) in its assessment of the IME:

    • Diagnosis/differential diagnosis, and etiology if known
    • Duration, stability, and/or progression of symptoms
    • Ability to complete activities of daily living and live independently
    • Recent medical/health care received (for example, hospitalization, specialist consultations)
    • Current and anticipated (over the next 5-10 years) medical care and social service needs (medical treatment, physiotherapy, home care, nursing /attendant care, respite care for family members, and /or placement in a long term care facility
    • Medications: regimen, disease modifying and /or biologic therapies
    Additional investigation

    An assessment of cognitive functioning and activities of daily living (ADL) is mandatory for all clients aged 75 years and older. For clients with abnormal findings suggestive of a debilitating condition, regardless of age, assessments of ADL and cognitive function must be included.

    Reporting

    All additional assessment information, including assessments of ADL and cognitive functioning, must be attached to the IME report.

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with a debilitating condition must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for Debilitating condition described below
    Text version: TI for Debilitating condition

    TI for Debilitating condition

    IME should be graded B if any abnormal findings on medical history and /or physical examination suggestive of the presence of a debilitating condition are found.

    Q1: Regardless of the age of the client, is there any abnormal findings on medical history and /or physical examination suggestive of the presence of a debilitating condition?

    Yes: An ADL and screening test for cognitive functioning is mandatory. Grade B and submit IME including any existing test results and specialist reports.

    No: No need to proceed with ADL and screening test for cognitive functioning. Grade B and submit IME including any existing test results and specialist reports.

  • Genital, gynecological and rectal examination

    Subject

    Instructions regarding examination of genitals, gynecological and rectal examinations of clients as part of the Canadian Immigration Medical Examination (IME).

    Instructions

    Genital, gynecological and rectal examinations are never indicated in the context of the IME. Panel Physicians are not to conduct these examinations during the IME. If there is a history or a clinical suspicion of genital, gynecological or colorectal malignancy, please make note of it in the medical history portion of the IME.

  • Developmental delay in children

    Subject

    Instructions for screening children with a possible developmental delay in the context of the Canadian immigration medical examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with possible developmental delay
    • Completion and grading of an IME for a child with developmental delay

    Instructions

    Screening and testing

    Developmental delay refers to a significant delay in the process of development and does not refer to a condition where a child is slightly or momentarily lagging in development. The presence of developmental delay is an indication that, without special intervention, the child’s ability to attain normal developmental milestones and educational performance at school is in jeopardy. PPs must be vigilant in their assessment of all paediatric age groups for the presence of possible delays in development, including cognitive, social, speech and language, neurological and behavioural function in children (for example, cerebral palsy, autism, etc.).

    The following information should be collected as it will assist medical officers make the determination of current and future (within the next 5-10 years) medical care and social service needs.

    • Is there anything in the child’s medical history that would suggest increased risk for developmental delay (that is, complications during pregnancy or delivery, premature delivery, illness, etc.) Please provide details
    • Duration, severity, stability, and/or progression of the apparent developmental impairment(s)
    • Whether the developmental delay is expected to improve with time, get worse, or stay the same
    • Current and future living arrangements (for example, with family or in institutional care facility; who is paying?)
    • Need for specialized services (for example, speech and language therapy, occupational therapy, physiotherapy, or supportive home care services) currently or anticipated over the next 5-10 years
    • For children ≤ 5 years of age, completion of the Chart of Early Childhood Development (CEDC) is mandatory; please pay particular attention when assessing children known to be at increased risk for developmental issues (that is: premature or difficult birth; illness; trisomy 21, etc.)
    • Special education requirements (for example, individualized special education plan, recommended student-to-teacher ratio, or need for an educational assistant)
    Additional investigation

    When a PP identifies clients with suspected learning disabilities and/or developmental delay, he should provide all relevant information to clarify /confirm the diagnosis, distinguish between medical and social services requirements (for example, medical services at home, special education, occupational therapy, speech language therapy, physiotherapy), and establish a prognosis over the next 5-10 years. This will help the medical officer make the determination of current and future (within the next 5-10 years) medical care and social service requirements of the child.

    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office (RMO). All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME

    In parallel to the immigration medical examination process, PP are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IME’s for clients with developmental delay must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit file with a note indicating medical information pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for Developmental Delay in Children described below
    Text version: TI for Developmental Delay in Children

    TI for Developmental Delay in Children

    IME should be graded B if any abnormalities on medical history and /or physical examination suggestive of developmental delay are found. IME should be submitted including any existing test results and specialist reports.

    Q1: Is there any abnormalities on medical history and /or physical examination suggestive of developmental delay?

    Yes: Provide all relevant information to clarify /confirm the diagnosis, distinguish between medical and social services requirements (e.g. medical services at home, special education, occupational therapy, speech language therapy, physiotherapy..), and establish a prognosis over the next 5-10 years.

    Do not refer client to specialist unless instructed by the RMO.

    No: Continue the medical examination.

    References

  • Hearing impairment or deafness

    Subject

    Instructions for screening clients who may be deaf or have a significant hearing impairment in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with deafness or hearing impairment
    • Investigation of clients with significant hearing impairment to help determine their need for medical and /or social services
    • Completion and grading of an IME of a client with deafness or hearing impairment

    Instructions

    Rationale

    The PPs must screen all clients for deafness or hearing impairment and provide additional details of any abnormalities that are identified. This screening is particularly important for children as they may be offered medical /surgical interventions and could require specialized medical and /or social services.

    During the medical questionnaire, PPs must be vigilant for the presence of hearing impairment in clients who have the following risk factors:

    • Family history of permanent childhood hearing loss (because most hereditary hearing loss is autosomal recessive, many children with hereditary hearing loss may not have affected relatives)
    • Admission to a neonatal intensive care unit (NICU) for > 5 days
    • NICU stay, regardless of duration, requiring extracorporeal membrane oxygenation, assisted ventilation, exchange transfusion for hyperbilirubinemia, or loop diuretics.
    • Congenital or central nervous system infections
    • Ototoxic drug exposure, including chemotherapy
    • Congenital head and neck deformities (for example, anomalies of the pinna or temporal bone, ear canal, ear tags, ear pits) and /or trauma (particularly basal skull and temporal bone fractures)
    • Neurodegenerative disorders
    • Genetic syndromes associated with hearing loss (for example, Marfan or Ehlers-Danlos syndromes)
    • Chronic or recurrent otitis media with effusion
    • Anatomic deformities and other disorders that affect eustachian tube function

    During the physical examination, PPs must pay special attention to signs of hearing loss in children, including:

    • “Baby talk” is not progressing or speech /language development is delayed or difficult
    • Difficulty locating sounds
    • Speaks too softly or too loudly
    • Turns up the TV volume to an excessively high level
    • Behavioural or academic problems; is often classified as being inattentive or disruptive, especially during listening activities
    • Often asks, “What?”
    • Speech sounds different or child does not speak clearly
    • Language is characterized by a reduced vocabulary where words are often missing endings

    Several methods can be used in a clinical context to test hearing, depending on a child’s age, development, and health status. Behavioural tests involve careful observation of a child’s behavioural response to sounds such as calibrated speech and tones. The behavioural response might be an infant’s eye movements, a head-turn by a toddler, placement of a game piece by a preschooler, or a hand-raise by a grade-schooler. Speech responses may involve picture identification of a word or repeating words at soft or comfortable levels. Very young children are capable of a number of behavioural tests.

    The following questions can be used to identify older children and adolescents for whom a hearing screen may be necessary:

    • Do you have a problem hearing over the telephone?
    • Do you have trouble following the conversation when two or more people are talking at the same time?
    • Do others complain that you turn the television volume too high?
    • Do you have to strain to understand conversation?
    • Do you have trouble hearing in a noisy background?
    • Do you find yourself asking other people to repeat themselves?
    • Do many people you talk to seem to mumble (or not speak clearly)?
    • Do you misunderstand what others are saying and respond inappropriately?
    • Do you have trouble understanding the speech of women and children?
    • Do people get annoyed because you misunderstand what they say?
    Additional investigation

    For children or adults with significant and incapacitating hearing impairment, the PPs must include the following additional information that will assist the Regional Medical Office in its assessment:

    • Communication skills used by the hearing impaired client such as lip-reading, signing, reading or writing
    • Interpretation of formal audiological testing; and any existing reports from a specialist that details the client’s abilities and specialized service needs (for example, speech and language therapy, hearing aids and /or surgery (cochlear implant)
    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs with significant abnormal findings on the hearing examination must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI Hearing Impairment or Deafness described below
    Text version: TI Hearing Impairment or Deafness

    TI Hearing Impairment or Deafness

    IME should be graded B if abnormal findings on medical history and /or physical examination are suggestive of hearing impairment.

    Q1: Is there any abnormal findings on medical history and /or physical examination suggestive of hearing impairment?

    Yes: Provide details on communication skills and provide interpretation of formal audiological assessment.

    No: Continue with the medical examination.

    References

  • Hepatitis/Liver Disease

    Hepatitis/Liver Disease (PDF, 420.66 KB)
  • HIV

    Subject

    Instructions for Human Immunodeficiency Virus (HIV) screening in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with HIV infection
    • Completion and grading of an IME for a client with positive HIV testing

    Instructions

    Screening and testing

    HIV screening is required for all clients 15 years of age and older undergoing an IME. PPs must also request HIV screening for clients below the age of 15 with any of the following risk factors:

    • Signs and/or symptoms compatible with HIV diagnosis
    • History of being sexually active
    • History of another sexually transmitted infection such as syphilis, herpes, chlamydia, gonorrhea
    • History of sharing contaminated needles, syringes and other infected equipment and drug solutions for injection drug use
    • History of receiving unsafe injections, blood product transfusions or medical procedures that involve unsterile cutting or piercing
    • Accidental needle stick injuries, including among health workers
    • Suspected active Tuberculosis (TB), Hepatitis B, Hepatitis C
    • Tattoos, body piercing, or acupuncture not thought to be done with aseptic technique
    • History of being born to an HIV positive mother; or
    • Any child showing failure to thrive
    Counselling and consent

    Culturally sensitive, age and gender appropriate pre- and post-test counselling should be provided with consideration given to relevant legal, ethical, social and human rights issues. If an interpreter is used, PPs must select and ensure that the interpreter is unbiased and has no connection to the client. Family members or friends cannot act as interpreters for clients. The use of a professional interpreter is at the client’s expense.

    Detailed information on pre- and post-test counselling parameters can be found in the International Organization for Migration (IOM) Guide for HIV Counsellors: IOM HIV Counselling in the Context of Migration Health Assessment.

    PPs should provide pre-test counselling (see the example in Annex 1 below; Ontario Public Health form for an example of an HIV requisition ) that includes information on the following:

    • Means of HIV transmission and prevention
    • Description of testing procedure
    • Confidentiality of HIV testing, reporting, and record handling
    • Meaning of HIV screening test results, including the possibility of false positive or false negative results
    • Need to inform anyone at risk of infection if the test is positive
    • Client’s consent to undergo testing

    For all clients with positive HIV testing, PPs must provide a completed (signed and dated) Acknowledgement of Post-test Counselling form (Annex 2). Only the post-test counselling form must be documented on the IME.

    Testing

    Only laboratories trained and equipped for HIV testing, including those using validated laboratory tests recommended by Health Canada or the World Health Organization (WHO) should be used.

    Further details on rapid HIV serological tests are available.

    Results and reporting

    An indeterminate or reactive (that is, positive) test result should be repeated automatically by the laboratory using a different assay on the same blood specimen prior to reporting the initial result.

    For results that are discordant (that is, first test is reactive, and the second assay is non-reactive) the same blood specimen should be tested by means of a third assay (different from the first and second assays using the same specimen). A positive result at this point would confirm HIV seropositivity.

    If the final test result on the first blood specimen remains indeterminate, then a repeat HIV test (second blood specimen) is mandatory. If the final test result of the repeat specimen is indeterminate (that is, two indeterminate final results), the reports should be submitted with the IME.

    The post-test counselling form must be completed by the PP. IME results must be forwarded directly to IRCC with all laboratory test results attached.

    Post-Test Counselling for Negative Results

    A single negative result does not preclude the possibility of HIV infection, but is acceptable as an initial test for IME purposes. Post-test counselling after a negative HIV test result is recommended, but not mandatory for IRCC purposes. This would include providing information on the importance of risk reduction. PPs should indicate whether they believe that there may be a high risk of a false-negative result.

    Post-Test Counselling for Positive Results

    Post-test counselling for a positive result should occur after the lab has reported a confirmed positive HIV result. A referral to an HIV specialist (or a physician with a special interest and knowledge of HIV treatment), including additional HIV-related testing (CD4 count, viral load), must be requested for all clients with confirmed positive HIV testing. All IME submissions for clients with HIV-positive serology results must include a completed (signed and dated) Acknowledgement of HIV Post Test Counselling form (in Annex 2) even if the applicant is already aware that they are HIV (+). Any available documentation from previous consultations and treatment should be attached to the IME report.

    Screen for TB and Hepatitis B/C in HIV (+) Clients

    According to The Canadian Tuberculosis Standards, Chapter 10, page 247, all patients with newly diagnosed HIV infection should be assessed for the presence of active TB. HIV positive individuals are also at high risk of reactivation of latent TB and thus should be screened for LTBI. TB risk is increased regardless of CD4 count in HIV-infected persons and typical clinical or radiologic features may be absent. Hepatitis B and C screening must also be done for all HIV-infected persons as they are important conditions of co-morbidity.

    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with abnormal HIV serology must be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for HIV described below
    Text version: TI for HIV

    TI for HIV

    Q1: Is the client 15 years or older?

    Yes: Performed an initial screening for HIV with an ELISA test

    No: Performed an initial screening for HIV only if client present signs and /or symptoms of or risk factors for HIV (refer to list under ‘Screening and Testing’).

    Q2: Is the initial HIV results negatives

    Yes: Submit IME and all laboratory reports

    No: Continue with Q3 if results are positives or Q4 if results are indeterminate.

    Q3: Is the initial HIV results are confirmed positive?

    Yes:

    • Screen for Hepatitis B and C, Syphilis and CXR (PA for adult and AP + lateral if < 11yo) if not already done.
    • Screen for LTBI: request IGRA or TST if IGRA not available
    • Grade B and include signed Post-test counselling form

    No: If results are negatives, submit IME or continue with Q4 if results are indeterminate

    Q4: Is the initial HIV results are indeterminate?

    Yes: Repeat test on a new blood specimen required by ELISA or Western Blot

    No: Refer to Q2 or Q3

    Q5: Is the results of the repeated HIV tests confirmed positive?

    Yes:

    • Screen for Hepatitis B and C, Syphilis and CXR (PA for adult and AP + lateral if < 11yo) if not already done.
    • Screen for LTBI: request IGRA or TST if IGRA not available
    • Grade B and include signed Post-test counselling form

    No: Submit IME and all laboratory reports

    References

    Annex 1: Pre-test counselling

    Pre-test counselling (PDF, 731.31 KB)

    Click on HIV Serology Requisition Form (PDF, 731 KB) - new (as of Feb 5, 2018)

    Annex 2: Post-test counselling form

    Acknowledgement of HIV post-test counselling (IMM 5728) (PDF, 1.54 MB)

  • Psychiatric conditions

    Subject

    Instructions for screening immigration clients with psychiatric conditions in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with psychiatric illness
    • Assessment of clients with a suspected or confirmed specific psychiatric conditions such as depressive disorder, psychotic disorder, substance use disorder, and /or antisocial behaviour in order to determine their risk to public safety and their potential need for medical and /or social services
    • Completion and grading of an IME for a client with a psychiatric condition

    Instructions

    Screening and testing

    During the IME, PPs must assess all clients for mental health. The identification of psychiatric illness is important in order to provide the information required for the medical officer to assess the client’s potential risk to Canadian public safety, and demand on Canadian medical /social services.

    Diagnostic criteria for individual psychiatric conditions can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

    • Anxiety disorders, personality troubles or mild mood disorders requiring no or minimal follow up and that have no impact on public safety are quite common. These conditions do not represent a demand on Canadian medical/social services and as such, should be noted by the PP on the IME in the 501-Medical Examination: Detailed Questions; Mental and Cognitive state. No additional investigation is required
    • Depression is the most common psychiatric disorder in the general population. Again, the PP should assess the depressive disorder in terms of risk to public safety and the level of services required by the client. A variety of screening instruments are available, but their reliability can be affected by the client’s interpretation of mental health terms and their cultural conception of symptomatology. An awareness of the terms used by a particular population to describe emotional issues, as well as the relevancy of particular questions in determining an individual’s mental state, could facilitate the identification of depression in such groups. Despite some of their limitations, depression screening tools remain valuable in the identification of immigration applicants possibly suffering from a depressive disorder. A commonly used short screening tool for depression is the PHQ-9 (Patient Health Questionnaire)
    • Psychosis, broadly defined as the loss of contact with reality, can be accompanied by delusions and /or hallucinations and is associated with an increased risk of the individual harming themselves or others. PPs must provide information concerning whether the applicant is likely to mount a harmful action in response to a psychotic disturbance
    • Substance use disorders are important to identify due to their association with antisocial and criminal behaviours, as well as their ability to induce mood disturbances and psychosis. Substances of abuse include, but are not limited to: alcohol, marijuana, opioids, cocaine, methamphetamine, benzodiazepines, caffeine, tobacco, and prescription /over-the-counter medications. If a substance use disorder is identified, it is important to document the route of use, frequency of use, amount per use, last use, and whether any rehabilitation treatment has already been required and/or is anticipated. Include any past history and potential further risk for impaired driving
    Screen for conditions of public safety concern

    A condition of public safety concern refers to a mental health condition in an individual, for which the examining physician is of the opinion that the person is likely to cause harm to others. Screening for psychiatric conditions of public safety concern in a diverse population is challenging. It is important to identify clients with mental health disorders to determine whether they are likely to pose a danger to Canadian public safety.

    To further aid PPs, a current or past history of any of the following characteristics might suggest that the individual could pose a danger to Canadian public safety:

    • Delusional behaviour, or a diagnosis of schizophrenia or schizoaffective disorder
    • Antisocial, violent, or impulsive behaviour (including impaired driving)
    • Paranoid ideas or odd beliefs
    • Homicidal or suicidal thoughts
    • Substance use disorder
    • Memory disturbance
    • Psychological or physical trauma, including post-traumatic stress disorder (PTSD)
    • Aberrant sexual disorders, such as pedophilia
    Screen for demand on social and/or medical services

    PPs must screen clients for conditions that might result in an increased need for social and /or medical services (excessive demand). Psychiatric conditions, sometimes regardless of treatment, can significantly impair an individual’s social, academic, and /or occupational functioning. In such cases, the individual might require extended medical rehabilitation and access to a variety of supportive social services. Therefore, it is important for PPs to provide information that could help clarify the applicant’s ability to live independently and maintain employment. In cases of established psychiatric illness, PPs must comment on whether the applicant has been assessed by a psychiatrist, whether they are followed by a treating physician (for example, psychiatrist or family doctor), whether hospitalization has been required for the condition (if so, when and how often?), and whether the condition is likely to remain stable, improve, or worsen. It should also include a description of investigations, treatments and services that will likely be required in the future (for example, medication, hospitalization, detoxification treatment, long term care facility admission, special programs etc.)

    Reporting

    PP’s must not refer clients to specialists unless instructed by the Regional Medical Office. All existing lab results and/or any specialist reports from previous specialist consultations must be attached to the IME.

    Medication prescribed for psychiatric conditions (for example, SSRIs and other antipsychotics should all be noted in the 501 Medical Examination: Medical History.

    Anxiety disorders, personality troubles or mild mood disorders requiring no or minimal follow up and that have no impact on public safety should be noted on the IME in the 501-Medical Examination: Detailed Questions; Mental and cognitive state. No additional investigation is required.

    In cases where a mental health condition is identified and possible risk to public safety and /or increased need for social/medical services is suspected, the PP should provide all available reports (psychiatry, psychology /psychotherapy, treating family doctor, social worker, etc.). PP should also note in the IME his own assessment of the condition; this should include history of the mental condition, a full description of current symptoms, expected investigations and treatment (including medication, hospital admissions, out-patient visits etc.) as well as an evaluation of any behaviour that could potentially be harmful to self or others.

    PP should indicate if an evaluation in psychiatry is suggested to further evaluate the client. PP’s must not refer clients to specialists unless instructed by the Regional Medical Office.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with evidence of mental health disorders must be graded B.

    All files are to be submitted within the 10-day client service standard. In cases where report(s) are pending, submit the IME with a note indicating that additional medical information is pending. The Regional Medical Office will create a ‘furtherance request’ for the pending information.

    Algorithm

    TI for Psychiatric Conditions described below
    Text version: TI for Psychiatric Conditions

    TI for Psychiatric Conditions

    IME should be graded B if abnormal findings on medical history and /or physical examination suggests a mental health condition associated with potential risk to Canadian public safety or potential increased need for social/medical services.

    Q1: Is there abnormal findings on medical history and /or physical examination suggests a mental health condition associated with potential risk to Canadian public safety or potential increased need for social/medical services?

    Yes: Provide full assessment and include history of the mental condition, a full description of current symptoms, expected investigations and treatment (including medication, hospital admissions, out-patient visits etc) as well as an evaluation of any behaviour that could potentially be harmful to self or others.

    Provide any available reports (psychiatry, psychology /psychotherapy, treating family doctor, social worker, etc.).

    Indicate if an evaluation in psychiatry is suggested to further evaluate the client. PP’s must not refer clients to specialists unless instructed by the Regional Medical Office.

    Grade B and submit IME including any additional test results and specialist reports

    No: Complete the IME following the normal process.

    References

  • Syphilis

    Subject

    Instructions for syphilis screening in the context of the Canadian Immigration Medical Examination (IME).

    Goal/objective

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with syphilis infection
    • Further investigation of clients with positive syphilis testing to ensure that appropriate treatment has been completed prior to entry into Canada
    • Completion and grading of an IME for a client with positive syphilis testing

    Instructions

    Screening

    Syphilis screening is required for all clients 15 years of age and older undergoing an IME. PPs must also request syphilis testing for clients below the age of 15 with any of the following risk factors:

    • Signs and /or symptoms compatible with syphilis infection (see table below)
    • High risk sexually activity (for example, unprotected anal or vaginal sex, multiple sexual partners)
    • History of another sexually transmitted infection such as HIV, herpes, chlamydia, gonorrhoea
    • History of being born to a mother diagnosed with syphilis
    • History of sexual contact with a known case of syphilis
    • History of pregnancy
    • Men having sex with men
    • Sex workers
    • Injection drug users

    The evaluation consists of a medical history, physical examination and laboratory tests. Panel physicians are required to report signs and symptoms related to syphilis, previous syphilis diagnosis and evidence of recent or previous treatment. Symptoms are non-specific and it is entirely possible to go through the early stages of the infection without knowing about it.

    Syphilis, signs & symptoms
    Stages Signs and symptoms
    Primary Chancre, usually at the site of inoculation (for example, genitals, anus, mouth) after a mean incubation period of 21 days.
    Secondary Mucocutaneous lesions, rash affecting palms and soles, condylomata lata, non-specific constitutional symptoms such as malaise, fever and lymphadenopathy.
    Latent Asymptomatic, positive syphilis serology with no clinical signs and symptoms.
    Tertiary: Neurosyphilis, Cardiovascular syphilis and Gummatous lesions (gumma)

    Acute changes in mental status, meningitis, stroke, cranial nerve dysfunction and auditory or ophthalmic and ocular abnormalities. Late neurosyphilis occurs 10–30 years or more after infection characterized by tabes dorsalis and general paresis

    Aortic aneurysm, aortic regurgitation, coronary artery ostial stenosis

    Tissue destruction of any organ; manifestations depend on the affected site

    Congenital Syphilis

    Signs of early congenital syphilis include bullous rash, rhinitis, laryngitis, lymphadenopathy, hepatosplenomegaly, osteochrondritis, periostitis, meningitis and chorioretinitis

    The signs of late congenital syphilis infection in children over the age of 2 years include inflammatory manifestations affecting the eyes, ears and joints, as well as skeletal malformations and stigmata resulting from developmental damage during the early stages of syphilis.

    Testing

    Several tests are available to screen for Treponema pallidum, the bacteria that causes syphilis. There are 2 categories of serologic tests to detect syphilis: Non-treponemal tests and Treponemal-specific tests.

    Non-treponemal tests detect antibodies often associated with, but not specific to, syphilis infection. These tests provide semi-quantitative results, which can be used to assess response to treatment. Non-treponemal tests include: rapid plasma reagin (RPR); venereal disease research laboratory (VDRL), and toluidine red unheated serum test (TRUST).

    Treponemal tests detect antibodies specific to T. pallidum. These antibodies can remain after treatment. Treponemal tests include: T. pallidum enzyme immunoassay (EIA), T. pallidum chemiluminescence immunoassay (CIA), T. pallidum particle agglutination assay (TPPA), fluorescent treponemal antibody absorption (FTA-ABS), and microhemagglutination test for antibodies for T. pallidum (MHA-TP). Unlike most Non-treponemal tests, Treponemal tests are often automated and are now frequently being used in the initial screening tests for syphilis.

    Results

    Historically, a Non-treponemal or a Treponemal test could be used for initial syphilis screening and the type of test used is dictated by the clinical laboratory. A majority of the Canadian provincial public health laboratories now utilize one of the following Treponemal assays as an initial syphilis antibody screening test: EIA) or CIA. If this initial antibody screen is non-reactive (negative), then no further testing is required. If the antibody screen is reactive (positive), confirmatory testing with both the RPR and TPPA must be performed on the same blood sample. This is the preferred syphilis testing algorithm. The RPR is particularly helpful in differentiating acute from latent or remote syphilis infection and can be used to identify reinfection and monitor response to treatment.

    If neither of the EIA or CIA syphilis antibody tests are available in the PPs jurisdiction, the panel can opt to request non-Treponemal tests as the initial syphilis screening test. If the initial screening is reactive, confirmatory testing on the same blood sample with TPPA (or FTA-ABS) must be performed. If the initial screening is non-reactive, then no further testing is required unless there is clinical suspicion of early syphilis. If clinical suspicion of early syphilis is present, repeat syphilis testing RPR (or VDRL) with TPPA (or FTA-ABS) on a new blood sample 4 weeks after initial screening test.

    Indeterminate or discordant results (initial test reactive and second test non-reactive) are to be repeated on a new blood sample 4 weeks after the initial screening test. In these situations, the IME should be submitted within 10 days of the initial exam with a note indicating further results will be provided once available.

    Treatment

    Syphilis is completely curable with antibiotics. If untreated, it is a public health risk mainly due to sexual transmission during the early stages of infection or through transmission of infection from mother to fetus (congenital syphilis). In some untreated individuals, long term serious complications can occur.

    For the purpose of the IME, all cases of syphilis infection must be adequately treated and proof of this treatment is required (Form IMM 5965 E — Appendix A). Local health authorities should be involved in the treatment of all syphilis positive cases and treatment must be consistent with accepted syphilis treatment guidelines (World Health Organization, Canadian Guidelines on Sexually Transmitted Infections).

    The appropriate treatment regimen will depend on the client’s stage of syphilis infection. In asymptomatic seropositive individuals who lack a clear history of prior syphilis infection or treatment, the diagnosis is late latent syphilis or latent syphilis of unknown duration. The treatment for late latent syphilis and latent syphilis of unknown duration is the same and acceptable regimens are:

    • Benzathine penicillin G 2.4 million units IM weekly for 3 consecutive weeks; or
    • Doxycycline 100 mg PO bid for 28 days; or
    • Ceftriaxone 1 g IV or IM daily for 10 days (only in exceptional circumstances)

    If a client testing positive for syphilis indicates a previous history of syphilis treatment, the client should be referred to the local public health authority to determine if the testing result is compatible with a new infection (reinfection) and if a new course of treatment is required. IRCC requires: regimen, dosage, and dates of administration.

    Proof of treatment information should be noted in the General Supporting comments of the 712 - Syphilis test section or a report may be attached to the IME.

    Reporting

    All additional lab result reports must be attached to the IM. Any specialist reports from previous consultations must also be attached.

    For cases with negative screening: submit and include copy of test results if performed in laboratory.

    For cases with positive screening: submit with copy of tests results and proof of treatment (also add a note in the General Supporting comments of the 712 - Syphilis test section)

    For cases with indeterminate or discordant results (initial test reactive and second test non-reactive), submit the file indicating “Indeterminate (or discordant) results, Syphilis testing will be repeated in 4 weeks. Please create Furtherance”.

    If not already done, Hepatitis B and C testing is required for all clients who screened positive for syphilis.

    In parallel to the Immigration Medical Examination process, PPs are to provide appropriate and timely advice to the client when they discover a serious medical condition not known to the client. In doing so, they are to uphold professional and ethical standards by referring the client back to their usual treating physician or to an appropriate specialist upon request.

    Grading and submission of files

    All IMEs for clients with abnormal syphilis serology should be graded B.

    All files are to be submitted within the 10 day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    TI for Syphilis described below
    Text version: TI for Syphilis

    TI for Syphilis

    All IMEs for clients with abnormal syphilis serology should be graded B.

    Preferred Testing Algorithm

    Q1: What is the result of the treponemal test Antibody screening with either EIA or CIA?

    If non-reactive: Submit the IME including all available test results and specialist reports

    If reactive: Proceed to a confirmatory testing on the same blood sample with RPR and TPPA.

    Q2: What is the result of the confirmatory testing on the same blood sample with RPR and TPPA?

    If indeterminate /Discordant Results: Repeat syphilis testing: EIA or CIA with RPR and TPPA on a new blood sample 4 weeks after the initial screening test. Continue with Q3.

    If reactive: Provide a proof of appropriate syphilis treatment, serology for HIV, Hepatitis B and C serology (if not already completed). Submit the IME including all available test results and specialist reports.

    Q3: What is the result of the repeated syphilis testing 4 weeks after the initial screening test?

    If reactive: Provide a proof of appropriate syphilis treatment, serology for HIV, Hepatitis B and C serology (if not already completed). Submit the IME including all available test results and specialist reports.

    If indeterminate /Discordant Results: Submit the IME including all available test results and specialist reports.

    Alternative Testing Algorithm

    Q1: What is the result of the Non-Treponemal test: RPR (or VDLR)?

    If non-reactive: Do you have clinical suspicion of early syphilis infection? If No, submit the IME including all available test results and specialist reports. If Yes, repeat syphilis testing: RPR (or VDRL) with TPPA (or FTA-ABS) on a new blood sample 4 weeks after initial screening test and continue with Q3.

    If reactive: Proceed with a confirmatory testing on the same blood sample with TPPA (or FTA-ABS)

    Q2: What is the result of the confirmatory testing on the same blood sample with TPPA (or FTA-ABS)?

    If indeterminate /Discordant Results: Repeat syphilis testing: RPR (or VDRL) with TPPA (or FTA-ABS) on a new blood sample 4 weeks after initial screening test. Continue with Q3.

    If reactive: If confirmed reactive, provide proof of appropriate syphilis treatment, serology for HIV, Hepatitis B and C serology (if not already completed). Submit the IME including all available test results and specialist reports.

    Q3: What is the result of the repeated syphilis testing 4 weeks after initial screening test?

    If reactive: Provide proof of appropriate syphilis treatment, serology for HIV, Hepatitis B and C serology (if not already completed). Submit the IME including all available test results and specialist reports.

    If indeterminate /Discordant Results: Submit the IME including all available test results and specialist reports.

    References

  • Tuberculosis

    Subject

    Instructions for screening clients to detect active or latent pulmonary tuberculosis infection (LTBI) in the context of the Canadian Immigration Medical Examination (IME).

    Goal/Objective

    This document provides guidelines, instructions and algorithms for the screening and diagnosis of active and latent TB according to the latest Canadian Tuberculosis Standards2 and World Health Organisation (WHO) guidelines on TB.3

    These instructions are provided to ensure that panel physicians (PPs) follow a consistent and appropriate process for the following:

    • Identification of clients with active TB or LTBI
    • Investigation of clients where there is clinical suspicion of active TB or LTBI
    • Investigation of clients who are close contacts of an individual with active TB
    • Identification and investigation of high risk clients for TB
    • Referral to a specialist for further investigation and treatment of suspected active or latent TB
    • Completion and grading of an IME of a client with active TB or latent LTBI

    Instructions

    Particular attention must be paid to signs, symptoms and risk factors suggestive of active tuberculosis. Some of the strongest predictors of active TB include the country of origin, living conditions, recent contact with active TB and medical comorbidities (Appendix A)4. The following instructions apply to all clients who require an IME.

    1. Screen all clients for tuberculosis during the review of medical history and physical examination.
    2. Require a postero-anterior chest x-ray (CXR) for all clients ≥ 11 years of age.
    3. Require an antero-posterior and lateral CXR for all clients < 11 years of age with a previous history of TB infection/treatment or recent close TB contacts.
    4. Perform the tuberculosis screening algorithm for clients with active TB.
    5. Require IGRA/TST testing for clients who are in the following five high risk groups LTBI:
      1. Clients who have been in close contact with an active TB case within the previous 5 years (Appendix A)
      2. Clients with HIV positive serology
      3. Clients with a history of cancers originating in the head/neck within the last 5 years (i.e. cancer of the oral cavity, salivary glands, larynx, pharynx, nasal cavity or paranasal sinuses). Note: thyroid cancers are not considered high risk
      4. Clients with advanced chronic renal failure or end-stage kidney disease (eGFR of <30 ml/min at any time during the IME)
      5. Clients with a solid organ or bone marrow transplant on immunosuppressant therapy. Note: immunosuppressant therapy without transplant is not to be included in this risk group at the moment

    For Canadian immigration purposes, LTBI screening is strictly limited to the 5 above-mentioned high risk groups.

    950 – IGRA/TST testing

    For clients ≥ 2 years of age, Interferon Gamma Release Assay (IGRA) testing is required, using one of the two following tests: QIAGEN QuantiFERON® for TB (or any iteration such as QuantiFERON-Plus) or OXFORD IMMUNOTEC T-SPOT®.TB. For immigration purposes, an indeterminate, borderline, or weakly positive IGRA results should be reported as negative.

    The tuberculin skin test (TST) can be used in place of IGRA only if both of the above mentioned two IGRA products are not licensed in the country of practice.

    For clients < 2 years of age a tuberculin skin test (TST) should be performed, using purified protein derivative (PPD) administered intradermally by the Mantoux method. Preparations used should be equivalent to 5TU.

    For clients that do not have any of the high risk conditions, an induration ≥ 10 mm is clinically used for positive results. For LTBI screening guidelines, a TST positive result is a measured induration ≥ 5mm read 48 to 72 hours after planting the PPD. Clients with documented positive PPD results should be reported as positive and Panel Physicians should proceed with the algorithm.

    502 - CXR

    A PA CXR will have already been completed for clients > 11 years of age.

    For clients < 11 years old, complete a 502-AP CXR and a 510-Lateral. AP CXR instructions do not currently exist in eMedical so PP’s will need to specifically request an antero-posterior view from the radiologist rather than a postero-anterior view.

    Clients who test positive for LTBI screening and/or have CXR lesions ≥ 4.0 and/or have symptoms of active TB must undergo further investigation for the following to rule out active TB disease:

    • 601 - Sputum smear & culture (x3) and if licensed, GeneXpert of a positive smear or on first sputum if all smears negative (Appendix B)
    • 602 - TB specialist report
    • 707 - HIV screening, if not already done

    602 TB specialist report

    A TB specialist is defined as a physician with experience or expertise sufficient to evaluate and treat tuberculosis. The TB specialist report must contain the following information:

    • a report clarifying /confirming the applicant’s diagnosis and management /treatment needs
    • results of sputum testing (three sputum samples [induced, if necessary]) for AFB microscopy and Mycobacterial culture)
    • follow-up PA chest x-ray image
    • If active pulmonary TB is confirmed, provide treatment details (drug regimen, start date, and expected duration)
    • all follow-up investigations (repeat sputum testing to confirm conversion to negative, repeat PA chest x-ray images)

    If the client is already managed by a specialist at the time of the TB investigation or has a previous report available, do not re-refer clients. Submit all pertinent reports with the IME. If a previous report is not adequate or sufficiently current, the case will be furthered at the discretion of IRCC for additional follow-up with a TB specialist.

    Contact Tracing

    If a person infected with pulmonary tuberculosis is identified during the course of the IME, it is imperative to conduct contact tracing. Any client that meets the definition of close contact (Appendix A) and requires an IME should be considered part of the high risk groups and must undergo screening as outlined in the instructions.

    Panel Physicians should notify the RMO as soon as possible if IME’s have already been completed and submitted for family members who require contact tracing.

    Results and Reporting

    All IMEs for clients with active, latent or suspicions of pulmonary TB must be graded B. All results and specialist reports must be attached to the file. General comments should be entered as per the algorithm.

    When indicated, Tuberculosis screening with sputum testing should be requested. If not possible to obtain sputum or procedure requires a specialist referral, submit file with a note indicating: “Applicant unable to produce sputum” or “Specialist referral required”. The Regional Medical Office will provide further instructions.

    Any previous chest x-rays or specialist reports available should be submitted with IME.

    For results and reporting for contact tracing, go directly to the contact tracing algorithm below.

    HIV and TB are often comorbid conditions and their screenings should be done hand in hand. All patients with HIV infection are at high risk of reactivation of latent TB and should be assessed for the presence of ATB. TB risk is increased regardless of CD4 count in HIV-infected persons and typical clinical or radiologic features may be absent.

    Following the same logic, all clients testing positive for ATB or LTBI should be screened for HIV regardless of age.

    Applicants diagnosed with Active Tuberculosis must be treated according to recognized guidelines such as the Canadian Tuberculosis Standards2, the Communicable Disease Network Australia (CDNA) 8, UK NICE 9, the USA Centers for Disease Control and Prevention (CDC) 10 or the World Health Organization (WHO).11, 12 Although Directly Observed Therapy is not mandatory, applicants should be informed that it is highly recommended.

    Grading and submission of files

    All IMEs for clients with active, latent or suspicions of pulmonary TB must be graded B. All results and specialist reports must be attached to the file. General comments should be entered as per the algorithm.

    All files are to be submitted within the 10-day client service standard. For cases with pending report(s), submit the IME with a note indicating additional medical information is pending. The RMO will create a furtherance request for the outstanding information.

    Algorithm

    Pulmonary Tuberculosis and Latent TB Screening described below
    Text version: Pulmonary Tuberculosis and Latent TB Screening

    All clients are screened for TB during medical history taking, physical examination and CXR (≥ 11 years)

    Active TB

    Q1: Is there suspicion of Active TB and/or CXR graded ≥ 4.0?

    Yes: Order 601 Sputum SFB smears and culture X 3. GeneXpert should be done on the first specimen when all AFB smears are negative OR on any specimen with a positive smear.

    No: Grade and Submit the IME.

    Q2: Is the sputum smear or GeneXpert result positive?

    Yes: Attach results. Add a general comment: “Active TB screening, smears positive, cultures pending”. Order 707-HIV test, if not already done. Refer to TB specialist. Initiate contact tracing. Grade B and submit IME.

    No: Attach results. Add general comment: “Active TB screening, smears negative, cultures pending”. Grade B and submit IME.

    Clients with Latent TB High Risk Conditions*

    Q1: Does the client have any of the 5 high risk conditions?

    Yes: Order 950 – IGRA if ≥ 2 years of age or TST if the client is < 2 years AND clients < 11 years of age require a 502-AP CXR and 510-Lateral CXR

    No: Proceed with standard IME screening

    Q2: Are ALL the results negative (IGRA, TST <5mm, CXR < 4.0 and no suspicion of TB)?

    Yes: Attach results. Add general comment: “High risk group, LTBI screen negative, sputum smears/cultures not indicated”. Grade B and submit IME.

    Q3: Are ANY of the results positive (IGRA, TST > 5mm, CXR ≥; 4.0 or a suspicion of TB)?

    Yes: Order 601 Sputum SFB smears and culture X 3. GeneXpert should be done on the first specimen when all AFB smears are negative OR on any specimen with a positive smear AND 602 – TB specialist report AND 707 – HIV test, if not already done.

    Q4: Are the sputum smears and/or GeneXpert positive?

    Yes: Attach results and reports. Add General Comment:” High risk group, LTBI screen positive, sputum smear positive (or negative), cultures pending”. Refer to TB specialist. Initiate contact tracing. Grade B and submit IME.

    No: Attach results and reports. Add general comments: “High risk group, LTBI screen positive, sputum smears negative, cultures pending”. Grade B and submit IME.

    Contact Tracing Algorithm described below
    Text version: Contact Tracing Algorithm

    Clients require 950 – IGRA if ≥ 2 years of age or TST if the client is < 2 years AND clients < 11 years of age require a 502-AP CXR and 510-Lateral CXR.

    Q1: Are ALL the results negative (IGRA, TST <5mm, CXR < 4.0)

    Yes: Attach results. Add general comment: “Contact tracing completed, results negative”. Grade B and submit IME.

    No: If any of the results are positive (IGRA, TST > 5mm, CXR 4.0) proceed with the TB screening algorithm.

    Appendix A

    Predictors of Active Pulmonary Tuberculosis
    Symptoms
    • Persistent cough
    • Fever
    • Night sweats
    • Anorexia
    • Fatigue
    Signs
    • Bronchial breathing, rales or crepitation
    • Weight loss
    • Hemoptysis
    • Fibrotic lesion on chest x-ray
    Risk Factors
    • Country of origin with high TB incidence15
    • Medical conditions affecting Immune System
    • Extra Pulmonary Disease
    • HIV infection4
    • Malnutrition4
    • Work environment with silica exposure13
    Definition of Close Contact16

    A TB close contact is an individual who has shared the same air space for a prolonged period of time with a person with infectious TB. The exact duration of exposure is traditionally at least 8 hours of cumulative exposure.

    Examples of close contacts may include individuals:
    • living in the same household
    • sharing a confined workplace
    • sharing sleeping quarters for at least one night
    • living in residential institutions such as
      • military barracks
      • correctional institutions
      • boarding schools

    Appendix B – Sputum Collection/Induction

    Specimen Comment
    Spontaneous Sputum
    • Adequate specimen and not saliva
    • Minimum 5 ml
    Induced Sputum
    • Can be used as of 3 years old
    • Under medical supervision/approval according to standard procedure.
    • Inhalation 3% hypertonic saline with ultrasonic nebulizer
    • Rate of 5-6 ml per minute
    • Assess every 5 minutes and terminate when sputum obtained or 15 minutes of nebulisation is reached
    Technical Instruction for all Specimen Types14
    • Collection in morning under direct supervision and at least one hour between specimen
    • Distilled or filtered bottle only for rinsing mouth
    • Collection container: Sterile, single use, screw capped 20 to 50 ml centrifuge tube
    • Centrifugation required before preparing smears
    • Identification: Each specimen identified with unique bar code/number, date/time, specimen information
    • Requisition: Clearly mark sputum spontaneous or induced
    • Transport: Same day delivery. If not possible to deliver immediately to laboratory refrigerate (2-8°C) using refrigerator or cooler with ice packs

    Procedures to be performed in designated collection area by trained technician using protective equipment (Adequate respiratory protection with N-95 mask and gloves).

    Initial TB investigation consists of three sputum specimens to undergo microscopy for Acid-fast bacilli (AFB) as well as culture for mycobacteria at the M. tuberculosis complex level for all three specimens. When available, molecular testing based on nucleic acid amplification (GeneXpert MTB/RIF) should be performed on the first specimen when all AFB smears are negative OR on one of any specimen with positive smear2,6. Please note that this test is not accepted as a substitute for tuberculosis cultures, which are required in all cases where sputum is collected.

    The three sputum specimens can be collected on the same day, at least 1 hour apart. Preferably spontaneously produced deep cough sputum should be obtained. When not possible to obtain spontaneous sputum, it is recommended that sputum inductions be performed.2 (Appendix B)

    Concentrated sputum smear microscopy using auramine stain with fluorescence microscopy is preferable but Zielh-Neelsen or Kinyoun staining is acceptable. 2 Solid and liquid medium cultures are required for every specimen sent for smear microscopy.7 Drug susceptibility test (DST) using phenotypic method should be performed for all first positive culture.1

    References

    1. Immigration and Refugee Protection Act (A.C. 2001, c27), Part 1, Division 2.0, Sect 16(1)(2)(b)
    2. Canadian Tuberculosis Standards 7th Edition: 2014
    3. WHO Guidelines on Tuberculosis
    4. WHO: TB comorbidities and risk factors
    5. Canadian Panel Physician’s handbook
    6. Centers for Disease Control (CDC): Updated Guidelines for the Use of Nucleic Acid Amplification Tests in Diagnosis of Tuberculosis. MMWR Morb Mortal Wkly Rep.
    7. ATS/IDSA/CDC and Prevention Clinical Practice Guidelines: Diagnosis of tuberculosis in Adults and Children pg. e3 (PDF, 3.87 MB)
    8. Australia, CDNA National Guidelines for Public Health Units- Management of TB
    9. United Kingdom, NICE guideline for diagnosis and management of tuberculosis
    10. Center for Disease Control and Prevention, Tuberculosis treatment guidelines
    11. WHO guidelines for treatment of drug-susceptible tuberculosis and patient care (2017 update)
    12. WHO treatment guidelines for drug-resistant tuberculosis (2016 update) (PDF, 396 KB)
    13. Systematic screening for active tuberculosis: an operational guide by WHO (2015) (PDF, 6.74 MB)
    14. Mycobacteriology Laboratory Manual (PDF, 2.63 MB)
    15. High burden country list (TB- World Health Organisation) (PDF, 3.86 MB)
    16. WHO: Recommendations for Investigating Contacts of Persons with Infectious Tuberculosis in Low and Middle Income Countries pg. 28, 29 (PDF, 1.01 MB)

Appendix V: Instructions for Submission of Paper-Based IME

This appendix provides the order of the following various documents that are part of the IME:

Include a log sheet with the client’s name and date of birth and the file numbers of all files in the package. The log sheet and tracking numbers are used to trace lost or misplaced records.

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