International Office - Healthcare Workers

This is a summary of the final regulations for section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRAIRA), published in the Federal Register, July 25, 2003, as they pertain to registered nurses and other health care workers (except physicians). This law is intended to ensure that workers coming to the U.S. for the purpose of practicing in the area of healthcare meet the following standards:

education, training, license, and experience comparable with that required for an American health care worker of the same type; are authentic; and, in the case of a license, unencumbered;
level of competence in oral and written English considered by the Secretary of HHS, in consultation with the Secretary of Education, to be appropriate for health care work of the kind in which the alien will be engaged;

and

if a majority of States licensing the profession in which the alien intends to work recognize a test predicting an applicant's success on the profession's licensing or certification examination, that the alien has passed such a test, or has passed such an examination (e.g., in the case of nursing, either the NCLEX or CGFNS exams).

If, after reading this information, you are still unclear about the necessary procedures or your responsibilities in complying with the final regulations, email us at visahelp@mc.duke.edu to schedule an appointment with an Advisor on the Medical Affairs Team at the International Office. We will try to accommodate your schedule as much as possible. We will try to accommodate your schedule as much as possible. The following is an FAQ developed by U.S. Department of Homeland Security’s Citizenship & Immigration Services with Duke notes attached. Registered nurses should also review the special requirements for nurses.

What is a Health Care Worker Certification?
A health care worker certification identifies and documents that a foreign health care worker has met minimum requirements for training, licensure, and English proficiency in order to be able to fulfill their professional role as a(n):

Licensed practical nurse, licensed vocational nurse, or registered nurse
Occupational therapist
Physical therapist
Speech language pathologist and audiologist
Medical technologist (clinical laboratory scientist)
Physician assistant
Medical technician (clinical laboratory technician)

Duke Note: The list above is only intended to identify the general grouping of health care occupations and is not intended to be a list of actual job titles. DHS reserves the right to make a determination that a Health Care Worker Certification is required based upon the job description or duties outlined. In consultation with the U.S. Department of Health & Human Services, DHS has identified two factors relevant to the consideration of which health care occupations fall under this requirement:

The first factor is whether the health care occupation generally requires a license/certification or predictor exam in a majority of the states (including Washington, D.C.). This factor reflects the states' historical and practical experience in distinguishing between those health care occupations requiring extensive regulation and those occupations that do not. At the advice of HHS, DHS has included the District of Columbia.
The second factor is whether the health care worker has a direct effect on patient care, or, in other words, whether a health care worker in that occupation could reasonably pose a risk to patient health.

Who Must Obtain a Health Care Worker Certification?
Any non-U.S. citizen coming to the United States for employment as a health care worker (other than a physician) cannot be admitted to the U.S. unless he or she presents a certificate from either the Commission on Graduates of Foreign Nursing Schools (CGFNS) or a certificate of equal standing from an organization with equivalent credentials. These requirements apply to both immigrant (a.k.a., "green card" holder, "lawful permanent resident") and nonimmigrant (e.g., TN, H-1B, etc) applicants. Any non-immigrants coming to receive training in a health care occupation will not be required to obtain certification (F-1 students, J-1’s, H-3’s, etc.).

Are Non-immigrants Subject to the Health Care Worker Certification Requirements?
Yes, as of July 26, 2004, if a nonimmigrant is seeking to be admitted to the United States, is changing status, and/or is requesting an extension of stay, he or she must provide evidence of health care worker certification if the primary purpose for coming to or remaining in the United States is employment in one of the affected health care occupations. Previously, under section 212(d)(3) of the Act, the CIS and the Department of State waived Health Care Worker certification requirements for non-immigrants, while requiring it for immigrants. After careful consideration of the statute and legislative history, it has been determined by DHS that non-immigrants are also subject to the certification requirements.

Which Organizations Are Currently Authorized to Issue Health Care Worker Certificates?

The following organizations are authorized to issue certificates for the following health care occupations:

The Commission on Graduates of Foreign Nursing Schools (CGFNS) is authorized to issue certificates to all 7 health care occupations.
The National Board for Certification in Occupational Therapy is authorized to issue certificates for occupational therapists.
The Foreign Credentialing Commission on Physical Therapy is authorized to issue certificates for physical therapists.

Which English Language Testing Organizations Are Approved for Purposes of Health Care Worker Certification?
Every alien must meet certain English language requirements in order to obtain a certificate unless otherwise exempted. The following testing services had been approved:

Educational Testing Service (ETS)
Test of English in International Communication (TOEIC)
International English Language Testing System (IELTS)

What are the Acceptable English Language Test Scores for Health Care Worker Certification?
The statute vests the Secretary of Health and Human Services with the sole discretion to determine the minimum scores required for a Health Care Worker Certification.

Occupational and physical therapists. An alien seeking to perform labor in the United States as an occupational or physical therapist must obtain the following scores on the English tests:
ETS: Test Of English as a Foreign Language (TOEFL): Paper-Based 560, Computer-Based 220; Test of Written English (TWE): 4.5; Test of Spoken English (TSE): 50.
Important: The certifying organizations shall not accept the results of the TOEIC, or the IELTS for the occupations of occupational therapy or physical therapy.
Registered nurses and other health care workers requiring the attainment of a baccalaureate degree. An alien coming to the United States to perform labor as a registered nurse (other than a nurse presenting a certified statement under section 212(r) of the Act) or to perform labor in another health care occupation requiring a baccalaureate degree (other than occupational or physical therapy) must obtain one of the following combinations of scores to obtain a certificate:
ETS: TOEFL: Paper-Based 540, Computer-Based 207; TWE: 4.0; TSE: 50;
TOEIC Service International: TOEIC: 725; plus TWE: 4.0 and TSE: 50; or
IELTS: 6.5 overall with a spoken band score of 7.0. This would require the Academic module.
Occupations requiring less than a baccalaureate degree. An alien coming to the United States to perform labor in a health care occupation that does not require a baccalaureate degree must obtain one of the following combinations of scores to obtain a certificate:
ETS: TOEFL: Paper-Based 530, Computer-Based 197; TWE: 4.0; TSE: 50;
TOEIC Service International: TOEIC: 700; plus TWE 4.0 and TSE: 50; or
IELTS: 6.0 overall with a spoken band score of 7.0. This would allow either the Academic or the General module.

Questions and Answers about Exemptions for Certain Health Care Workers
Q: Are foreign health care workers - trained in the United States or in possession of a valid state license - subject to the health care certification requirement?
A: Yes. While Congress provided certain nurses with a less rigorous, alternative certification process, it did not provide a less rigorous alternative certification option to state-licensed foreign health care workers. Possession of a state license does not exempt a foreign health care worker from compliance with the certification requirement. Similarly, health care workers who have been trained in the United States are not exempt from the certification requirement.

Q: Are there any accommodations for foreign health care workers who have been trained in the United States?
A: Yes. Foreign health care workers may be automatically deemed to have met the English language and/or educational comparability requirements if they have graduated from certain programs or from programs in certain countries. The following groups may be deemed to have met the English language requirements:

Graduates of health professional programs in Australia, Canada (except Quebec), Ireland, New Zealand, the United Kingdom, and the United States.
Alien nurses who are presenting the alternate certified statement under section 212(r) of the Act.
For nurses, graduation from an entry-level program accredited by the National League for Nursing Accreditation Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE);
For occupational therapists, graduation from a program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association (AOTA);
For physical therapists, graduation from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association (APTA); and
For speech language pathologists and audiologists, graduation from a program accredited by the Council on Academic Accreditation in Audiology and Speech Language Pathology (CAA) of the American Speech-Language-Hearing Association (ASHA).

The following groups may be deemed to have met the educational comparability requirements:

For nurses, graduation from an entry-level program accredited by the National League for Nursing Accreditation Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE);
For occupational therapists, graduation from a program accredited by the Accreditation Council for Occupational Therapy Education (ACOTE) of the American Occupational Therapy Association (AOTA);
For physical therapists, graduation from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association (APTA); and
For speech language pathologists and audiologists, graduation from a program accredited by the Council on Academic Accreditation in Audiology and Speech Language Pathology (CAA) of the American Speech-Language-Hearing Association (ASHA).

Q: Are dependents subject to the health care worker certification requirement?
A: No. For example, if you are here as an L-2 nonimmigrant, your primary purpose for entering the United States is to join your spouse. Since an L-2 nonimmigrant spouse is authorized employment, you may engage in employment as a health care worker without obtaining the certification. This will also apply to other dependents who are accompanying a principal alien and who are employment authorized within their dependent status.

Healthcare Workers Acknowledgement Form