attachment 2: sample referral1. case intake/referral form iss-usa a-22. port of entry (poe) into us...

UNCLASSIEFIED

Privacy/PII

Action Office: CONS, CONGEN,

CONS_OVERSEAS_CITIZENS_SERVICES_PROTECTED

MRN: 18 SANTO DOMINGO 2018

DATE/DTG: OCT 1, 2018/211802Z OCT 18

FROM: AMEMBASSY SANTO DOMINGO

ACTION: WASHDC, SECSTATE ROUTINE

E.O.: 13526

TAGS: AFIN, CASC, CPAS

Captions: SENSITIVE, OVERSEAS CITIZENS SERVICES-PROTECTED

Pass Line: CGFS/F/AOD/AA/CAA

CA/OCS/ACS/WHA

CA/PPT/S/TO/RS/DO/C

Subject: FIMED: REPATRIATION OF SAMPLE REPATRIATION CABLE

1. (SBU) Name/DPOB: SAMPLE REPATRIATION CABLE; NOVEMBER 13, 1935; NEW YORK CITY, NEW YORK

2. (SBU) PPT: NO. 123456789 ISSUED 9/30/2017

3. (SBU) Source of Funds Contacted: Subject listed two people on the Privacy Act Waiver (DS-5505). ACS

made efforts to contact friends, family and former associates of the subject.

(a) Name, relationship, phone number:

(b) Name, relationship, phone number:

4. Prior Post Action:

5. Privacy Act Waiver: Yes

6. (SBU) Total Assistance Requested:

7. (SBU) Total Expended:

8. (SBU) Travel:

9. (SBU) Subsistence:

10. (SBU) Other Expenses:

11. (SBU) Domestic Billing Cost:

12. (U) Desires to Return to the U.S.: Yes

13. (U) Date Last Departed U.S.: July 11, 2008

14. (SBU) Last Residence in the U.S.:

15. (SBU) Final Destination:

16. (SBU) Federal Benefits/SSN:

17. (SBU)Reason for Destitution:

18. (SBU) Diagnosis:

19. (SBU) Present Location:

20. (U) Attending Physician:

21. (U) Date Able to Travel:

22. (U) Hospitalization Required:

23. (U) Medical Records:

ATTACHMENT 2: SAMPLE REFERRAL

24. (U) Medical Escort:

25. (U) Escort for Final Destination:

26. (U) Special Requirements:

27. (SBU) Final Action:

28. (SBU) Remarks:

Signature:

Drafted By:

Cleared By:

Approved By:

Released By:

Action Post:

Dissemination Rule:

UNCLASSIEFIED

Privacy/PII

Action Office: CONS, CONGEN,

CONS_OVERSEAS_CITIZENS_SERVICES_PROTECTED

MRN: 18 SANTO DOMINGO 2018

DATE/DTG: OCT 1, 2018/211802Z OCT 18

FROM: AMEMBASSY SANTO DOMINGO

ACTION: WASHDC, SECSTATE ROUTINE

E.O.: 13526

TAGS: AFIN, CASC, CPAS

Captions: SENSITIVE, OVERSEAS CITIZENS SERVICES-PROTECTED

Pass Line: CGFS/F/AOD/AA/CAA

CA/OCS/ACS/WHA

CA/PPT/S/TO/RS/DO/C

Subject: FIMED: REPATRIATION OF SAMPLE REPATRIATION CABLE

1. (SBU) Name/DPOB: SAMPLE REPATRIATION CABLE; NOVEMBER 13, 1935; NEW YORK CITY, NEW YORK

2. (SBU) PPT: NO. 123456789 ISSUED 9/30/2017

3. (SBU) Source of Funds Contacted: Subject listed two people on the Privacy Act Waiver (DS-5505). ACS

made efforts to contact friends, family and former associates of the subject.

(a) Name, relationship, phone number:

(b) Name, relationship, phone number:

4. Prior Post Action:

5. Privacy Act Waiver: Yes

6. (SBU) Total Assistance Requested:

7. (SBU) Total Expended:

8. (SBU) Travel:

9. (SBU) Subsistence:

10. (SBU) Other Expenses:

11. (SBU) Domestic Billing Cost:

12. (U) Desires to Return to the U.S.: Yes

13. (U) Date Last Departed U.S.: July 11, 2008

14. (SBU) Last Residence in the U.S.:

15. (SBU) Final Destination:

16. (SBU) Federal Benefits/SSN:

17. (SBU)Reason for Destitution:

18. (SBU) Diagnosis:

19. (SBU) Present Location:

20. (U) Attending Physician:

21. (U) Date Able to Travel:

22. (U) Hospitalization Required:

23. (U) Medical Records:

24. (U) Medical Escort:

25. (U) Escort for Final Destination:

26. (U) Special Requirements:

27. (SBU) Final Action:

28. (SBU) Remarks:

Signature:

Drafted By:

Cleared By:

Approved By:

Released By:

Action Post:

Dissemination Rule:

1. Case Intake/Referral FormISS-USA

Section A. *Referral Information*

A-1. Date Case Opened

__/__/____

A-2. Repatriate's Last US Address

A-3. Last Date Departed USA

__/__/____

A-4. Primary reason for Repatriation

Destitute Emergency Evacuation Health and Safety Exemption

Unaccompanied Minor Certified Mentally Incompetent

Group Repatriation

A-5. Why Destitute

Natural Disaster/Emergency Evacuation

No Available Funds Owed Fines

Robbed Unable to Work/No Visa Unemployed/Lost Job

Other

A-6. Please specify other reason for being destitute:

A-7. Mentally Incompetent Category

Certificate Health and Safety Exemption

A-8. Type of Group Case

Accompanied Minor Unaccompanied Minor Head of Household with Family

Individual Adult

A-9. Approximate Number Repatriated in Group

0-50 51-100 101-500

501 or more

A-10. Secondary Reasons for Repatriation

Medical Problems Mental/Emotional Illness Children Issues

Family issues External Factors Others

A-11. Specify Children Issues

Abuse or neglect Failed adoption Abandoned by parent

Mental illness of parent Others

A-12. Please specify other secondary reasons for repatriation:

Page 1 of 17April 10, 2018


A-13. Specify Medical Problems

Cerebral Hemorrhage Mobility Issues Dementia

Acute Illness Emphysema Complications due to Substance Abuse

Other

Please Provide Details:

A-14. Specify Mental/Emotional Illness

Schizophrenia Bi-Polar Depression

Other


A-15. Specify Family Issues

Domestic Violence Abuse of Adult Human Trafficking

Divorce




A-16. Specify External Factors

Natural Disaster War/Threat of War/Civil Unrest

Victim of Crime

Deportation Criminal/Legal Arrested

Release from Prison Release from Mental Institution


A-17. Referral Contains the Following

Privacy Act Waiver (PAW/DS-3072)

Cable Certificate of Mental Incompetence

Health and Safety Exemption SSN Medical Report

Psychiatric Report Passport Photo Passport Number

Final Destination Date of Birth

A-18. Department of State Barriers

Missing/Incorrect Documentation

No Current Medication No Psychiatric Diagnosis Provided

No Medical Diagnosis Provided

Repatriate Not Stable or Ready for Travel

New Worker or DOS Worker doesn't Understand Procedures

Less than 48 Hours Notice Other None

Arrived First and Opened Later

Less than 24 Hours Notice


A-19. What Documentation is Missing/Incorrect?

SSN PAW/DS-3072 Certificate of Mental Incompetence

Medical Report Health and Safety Exemption



A-20. Country/Post Requesting Action

Afghanistan Akrotiri Curacao

Georgetown Pohnpei State, Federated States of Micronesia

Scotland

South Sudan St. Martin The Northern Mariana Islands (Saipan)

Albania Algeria American Samoa

Andorra Angola Anguilla

Antarctica Antigua and Barbuda Arctic Ocean

Argentina Armenia Aruba

Ashmore and Cartier Islands Atlantic Ocean Australia

Austria Azerbaijan Bahamas, The

Bahrain Bangladesh Barbados

Belarus Belgium Belize

Benin Bermuda Bhutan

Bolivia Bosnia and Herzegovina Botswana

Bouvet Island Brazil British Indian Ocean Territory

British Virgin Islands Brunei Bulgaria

Burkina Faso Burma Burundi

Cambodia Cameroon Canada

Cape Verde Cayman Islands Central African Republic

Chad Chile China

Christmas Island Clipperton Island Cocos (Keeling) Islands

Colombia Comoros Congo, Democratic Republic of the

Congo, Republic of the Cook Islands Coral Sea Islands

Costa Rica Cote d'Ivoire Croatia

Cuba Cyprus Czech Republic

Denmark Dhekelia Djibouti

Dominica Dominican Republic Ecuador

Egypt El Salvador Equatorial Guinea

Eritrea Estonia Ethiopia

Falkland Islands (Islas Malvinas)

Faroe Islands Fiji

Finland France French Polynesia

French Southern and Antarctic Lands

Gabon Gambia, The

Gaza Strip Georgia Germany

Ghana Gibraltar Greece

Greenland Grenada Guam

Guatemala Guernsey Guinea

Guinea-Bissau Guyana Haiti

Heard Island and McDonald Islands

Holy See (Vatican City) Honduras

Hong Kong Hungary Iceland

India Indian Ocean Indonesia

Iran Iraq Ireland

Isle of Man Israel Italy

Jamaica Jan Mayen Japan

Jersey Jordan Kazakhstan



Kenya Kiribati Korea, North

Korea, South Kosovo Kuwait

Kyrgyzstan Laos Latvia

Lebanon Lesotho Liberia

Libya Liechtenstein Lithuania

Luxembourg Macau Macedonia

Madagascar Malawi Malaysia

Maldives Mali Malta

Marshall Islands Mauritania Mauritius

Mayotte Mexico Micronesia, Federated States of

Moldova Monaco Mongolia

Montenegro Montserrat Morocco

Mozambique Namibia Nauru

Navassa Island Nepal Netherlands

Netherlands Antilles New Caledonia New Zealand

Nicaragua Niger Nigeria

Niue Norfolk Island Northern Mariana Islands

Norway Oman Pacific Ocean

Pakistan Palau Panama

Papua New Guinea Paracel Islands Paraguay

Peru Philippines Pitcairn Islands

Poland Portugal Puerto Rico

Qatar Romania Russia

Rwanda Saint Helena Saint Kitts and Nevis

Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines

Samoa San Marino Sao Tome and Principe

Saudi Arabia Senegal Serbia

Seychelles Sierra Leone Singapore

Slovakia Slovenia Solomon Islands

Somalia South Africa South Georgia and the South Sandwich Islands

Southern Ocean Spain Spratly Islands

Sri Lanka Sudan Suriname

Svalbard Swaziland Sweden

Switzerland Syria Taiwan

Tajikistan Tanzania Thailand

Timor-Leste Togo Tokelau

Tonga Trinidad and Tobago Tunisia

Turkey Turkmenistan Turks and Caicos Islands

Tuvalu Uganda Ukraine

United Arab Emirates United Kingdom United States

Uruguay Uzbekistan Vanuatu

Venezuela Vietnam Virgin Islands

Wake Island Wallis and Futuna West Bank

Western Sahara Willemstad Yemen

Zambia Zimbabwe



A-21. Contact Info for All Relevant DOS Parties



A-22. Port of Entry (POE) into US

A.B. Won Pat Guam International Airport

Albany International Airport Alexandria International Airport

Albuquerque International Airport

Allentown-Lehigh Valley International Airport

Amarillo International Airport

Anchorage International Airport

Andrews Air Force Base Atlantic City International Airport

Atlanta Hartsfield International

Austin-Bergstrom International Airport

Bangor International Airport (BGR)

Baltimore/Washington International Airport (BWI)

Baton Rouge Metropolitan Airport (BTR)

Birmingham International Airport

Boston Logan International Airport

Bradley International Airport Bradley International Airport (BDL)

Brownsville, TX Brownsville South Padre Island International Airport

Buffalo Niagara International Airport

Charleston, SC International Airport

Charlotte Douglas International Airport

Chicago-O'Hare International Airport

Cincinnati/Northern Kentucky International Airport

Cleveland Hopkins International Airport

Corpus Christi International Airport

Dallas/Fort Worth International Airport

Dayton Interntional Airport (DAY)

Denver International Airport

Des Moines International Airport

Detroit Metropolitan Wayne County Airport

El Paso International Airport

El Paso, TX Fort Lauderdale/Hollywood International

Ft. Worth Meacham Intl., (FTW)

Fairbanks International Airport (FAI)

Fresno Yosemite International Airport (FYI)

General Edward Lawrence Logan International

General Mitchell International Airport (MKE)

George Bush Intercontinental Airport

Gerald R. Ford International Airport (GRR)

Greater Rochester International Airport (ROC)

Greenville-Spartanburg International Airport

Gulfport-Biloxi International Airport

Harrisburg International Airport (MDT)

Hilo International Airport (ITO)

Honolulu International Airport

Huntsville International Airport (HSV)

Indianapolis International Airport

Jackson International Airport (JAX)

Jackson-Evers International Airport

Jacksonville International Airport

John F. Kennedy International Airport

Kansas City International Airport

Ketchikan International Airport (Alaska-KTN)

Kona International Airport (KOA)

LaGuardia International Airport (LGA)

Lambert-St. Louis International Airport

Laredo, TX

Little Rock National Airport Los Angeles International Airport

Louisville International Airport, KY(LJC)

Lubbock International Airport Luis Munoz Marin International Airport (SJU)

McAllen-Miller International Airport (MFE)

McCarran International Airport (LAS)

Myrtle Beach International Airport

McAllen Miller International Airport

Memphis International Airport

McCarran International Airport

Miami International Airport

McGuire Air Force Base Midland International Airport MN Minneapolis-St. Paul International



Missoula International Airport Nashville International Airport

Newark International Airport

New Hanover International Airport

New Orleans International Airport

Newport News/Williamsburge International Airport

Nogales, AZ Nogales, NM Norfolk International Airport

Norfolk International Airport (ORF)

Oakland International Airport Ontario International Airport

Orlando International Airport Palm Beach International Airport

Philadelphia International Airport

Phoenix Sky Harbor International Airport

Pittsburgh International Airport

Portland International Airport

Piedmont Triad International Airport

Port Columbus International Airport (CMH)

Richmond International Airport

Raleigh-Durham International Airport

Rickenbacker International Airport

Reno Cannon International Airport

Rio Grande Valley International Airport

Sacramento International Airport

Salt Lake City International Airport

St.Petersburg-Clearwater International

San Antonio International Airport

San Diego International Airport-Lindberg

San Francisco International Airport

San Jose International Airport

San Juan Puerto International Airport

San Ysidro, CA Sarasota/Bradenton International Airport

Savannah International Airport

Seattle-Tacoma International Airport

Southwest Florida International Airport (RSW)

Southwest Florida International Airport

Spokane International Airport Stapleton International Airport

Tampa International Airport

Tri-Cities Regional Airport Tucson International Airport Tulsa International Airport, USA

Valley International Airport (HRL)

Washington DC-Reagan National Airport

Washington Dulles International Airport

Washington National Airport Will Rogers World Airport (OKC)

A-23. Is POE the Final Destination?

Yes No

A-24. Opening Summary

A-25. Cable/Itinerary/Other Supporting Documents

A-26. PAW

A-27. Medical/Other Supporting Documents

A-28. Supporting Documents to PSC

Section B. *Assistance Requests at POE*



B-1. Meet and Greet Requests

Social Worker Police CPS

Mental Health Family Repatriation Representative

Escort Friend

B-2. Transport Requests

Ambulance Taxi Public Transport

Wheelchair Wheelchair Van Van

Family/Friend's Vehicle

B-3. Number of seats needed in van

B-4. POE Destination Requests

Emergency Room/Hospital Shelter Long Term Care/Nursing Home

VA Hospital Police Custody Psychiatric Hospital

Foster Care Hotel Kinship Placement (Extended Family)

Parents

B-5. Message/Instructions: Send the 1010EZ, DD214 discharge papers by post

B-6. Other Services Requested

Clothing Cash Assistance Food

On-Going Travel Public Benefits Other Services

Section C. *Assistance Requests at Final Destination*

C-1. Final Destination State

Alabama Alaska Arizona

Arkansas California Colorado

Connecticut Delaware District of Columbia

Florida Georgia Hawaii

Guam Idaho Illinois

Indiana Iowa Kansas

Kentucky Louisiana Maine

Maryland Massachusetts Michigan

Minnesota Mississippi Missouri

Montana Nebraska Nevada

New Hampshire New Jersey New Mexico

New York North Carolina North Dakota

Ohio Oklahoma Oregon

Ontario Canada Pennsylvania Puerto Rico

Rhode Island South Carolina St. Thomas Virgin Islands

South Dakota Tennessee Texas

The Northern Mariana Islands (Saipan)

Utah Vermont

Virginia Washington West Virginia

Wisconsin Wyoming



C-2. Meet and Greet Requests

Social Worker Police CPS

Mental Health Family Repatriation Representative

Escort

C-3. Transport Requests

Ambulance Standard Vehicle Taxi

Public Transport Wheelchair Wheelchair Van

Van Family/Friend's Vehicle

C-4. Number of seats needed in van

C-5. Destination Requests

Emergency Room/Hospital Shelter Long Term Care/Nursing Home

VA Hospital Police Custody Psychiatric Hosptial

Foster Care Hotel Kinship Placement (Extended Family)

Parents

C-6. Send the 1010EZ, DD214 discharge papers by post

C-7. Other Services Required

Clothing Cash Assistance Food

On-Going Travel Public Benefits Special Needs

Section 1113 PL96-571 Police

Medical Other Services

C-8. Please specify other services required:

C-9. Have there been previous repatriations?

Yes No

C-10. How many previous repatriations?

C-11. Date of Previous Repatriation 1

__/__/____


__/__/____


__/__/____



C-14. Who Requested Repatriation?

Certificate of Mental Incompetence

Client Deportation

DOS (Health and Safety Exemption)

Section D. *Personal Information*



D-1. Country of Birth

Afghanistan Akrotiri Albania

Algeria American Samoa Andorra

Angola Anguilla Antarctica

Antigua and Barbuda Arctic Ocean Argentina

Armenia Aruba Ashmore and Cartier Islands

Atlantic Ocean Australia Austria

Azerbaijan Bahamas, The Bahrain

Bangladesh Barbados Belarus

Belgium Belize Benin

Bermuda Bhutan Bolivia

Bosnia and Herzegovina Botswana Bouvet Island

Brazil British Indian Ocean Territory British Virgin Islands

Brunei Bulgaria Burkina Faso

Burma Burundi Cambodia

Cameroon Canada Cape Verde

Cayman Islands Central African Republic Chad

Chile China Christmas Island

Clipperton Island Cocos (Keeling) Islands Colombia

Comoros Congo, Democratic Republic of the

Congo, Republic of the

Cook Islands Coral Sea Islands Costa Rica

Cote d'Ivoire Croatia Cuba

Cyprus Czech Republic Denmark

Dhekelia Djibouti Dominica

Dominican Republic Ecuador Egypt

El Salvador Equatorial Guinea Eritrea

Estonia Ethiopia Falkland Islands (Islas Malvinas)

Faroe Islands Fiji Finland

France French Polynesia French Southern and Antarctic Lands

Gabon Gambia, The Gaza Strip

Georgia Germany Ghana

Gibraltar Greece Greenland

Grenada Guam Guatemala

Guernsey Guinea Guinea-Bissau

Guyana Haiti Heard Island and McDonald Islands

Holy See (Vatican City) Honduras Hong Kong

Hungary Iceland India

Indian Ocean Indonesia Iran

Iraq Ireland Isle of Man

Israel Italy Jamaica

Jan Mayen Japan Jersey

Jordan Kazakhstan Kenya

Kiribati Korea, North Korea, South

Kosovo Kuwait Kyrgyzstan

Laos Latvia Lebanon

Lesotho Liberia Libya



Liechtenstein Lithuania Luxembourg

Macau Macedonia Madagascar

Malawi Malaysia Maldives

Mali Malta Marshall Islands

Mauritania Mauritius Mayotte

Mexico Micronesia, Federated States of

Moldova

Monaco Mongolia Montenegro

Montserrat Morocco Mozambique

Namibia Nauru Navassa Island

Nepal Netherlands Netherlands Antilles

New Caledonia New Zealand Nicaragua

Niger Nigeria Niue

Norfolk Island Northern Mariana Islands Norway

Oman Pacific Ocean Pakistan

Palau Panama Papua New Guinea

Paracel Islands Paraguay Peru

Philippines Pitcairn Islands Poland

Portugal Puerto Rico Qatar

Romania Russia Rwanda

Saint Helena Saint Kitts and Nevis Saint Lucia

Saint Pierre and Miquelon Saint Vincent and the Grenadines

Samoa

San Marino Sao Tome and Principe Saudi Arabia

Senegal Serbia Seychelles

Sierra Leone Singapore Slovakia

Slovenia Solomon Islands Somalia

South Africa South Georgia and the South Sandwich Islands

Southern Ocean

Spain Spratly Islands Sri Lanka

Sudan Suriname Svalbard

Swaziland Sweden Switzerland

Syria Taiwan Tajikistan

Tanzania Thailand Timor-Leste

Togo Tokelau Tonga

Trinidad and Tobago Tunisia Turkey

Turkmenistan Turks and Caicos Islands Tuvalu

Uganda Ukraine United Arab Emirates

United Kingdom United States Unknown

Uruguay Uzbekistan Vanuatu

Venezuela Vietnam Virgin Islands

Wake Island Wallis and Futuna West Bank

Western Sahara Yemen Zambia

Zimbabwe Curacao Saint Croix

Saint Martin Saint Thomas



D-2. State of Birth





Idaho Illinois Indiana

Iowa Kansas Kentucky

Louisiana Maine Maryland

Massachusetts Michigan Minnesota

Mississippi Missouri Montana

Nebraska Nevada New Hampshire

New Jersey New Mexico New York

North Carolina North Dakota Ohio

Oklahoma Oregon Pennsylvania

Puerto Rico Rhode Island South Carolina

South Dakota Tennessee Texas

Utah Vermont Virginia

Washington West Virginia Wisconsin

Wyoming Guam Saint Thomas

Haiti Virgin Islands Antigua

D-3. City, State Zip Code of Last Residence

D-4. Veteran

No Yes

D-5. Former Adoptee

No Yes

D-6. Employed?

Yes No

D-7. Employment Type

Government/Military Employee/non-government Employee/government contractor

Please describe employment type:

D-8. Last Known Profession/Employment

D-9. Criminal Record

Yes No



D-10. Open Warrants

Yes No Unknown

D-11. Warrant in What State?





Idaho Illinois Indiana

Iowa Kansas Kentucky

Louisiana Maine Maryland

Massachusetts Michigan Minnesota

Mississippi Missouri Montana

Nebraska Nevada New Hampshire

New Jersey New Mexico New York

North Carolina North Dakota Ohio

Oklahoma Oregon Pennsylvania

Rhode Island South Carolina South Dakota

Tennessee Texas Utah

Vermont Virginia Washington

West Virginia Wisconsin Wyoming

D-12. Fluent in English

No Yes

D-13. Other Languages Spoken

Arabic Farsi French

German Japanese Korean

None Other Portuguese

Russian Spanish Swahili

Tagalog Turkish

D-14. Current Location (in foreign country)

Long term care facility Medical facility Psychiatric facility

Hotel Jail/detention Homeless

Foster Care Orphanage Relatives/friends

US compound/embassy Shelter Other

D-15. Please specify other location:

Section E. *Medical Information*

E-1. Is the Repatriate pregnant?

Yes No

E-2. Number of months pregnant:



E-3. Diagnosis

E-4. Prognosis

E-5. Medications

E-6. Has DOS Provided an Updated Medical Report?

Yes No

Summary of medical report information:

E-7. Attending Physicians

E-8. Conditions

Cerebral Hemorrhage Mobility Issues Dementia

Acute Illness Emphysema Complications due to Substance Abuse

Mental/Emotional Illness Other

E-9. Hospitalized

Yes No

E-10. Specify Mental/Emotional Illness

Schizophrenia Bi-Polar Depression

E-11. Present Medical Location

Section F. *Approval*

F-1. Approved by ORR?

Yes No Pending

F-2. Approved by ORR?



F-3. Why pending:

F-4. Please provide an explanation as to why this repatriate is ineligible for services

F-5. Why not approved?


IMAGE/PASSPORT PHOTO HERE