ATTACHMENT 2: SAMPLE REFERRAL
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:
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 Form ISS-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 Group Repatriation Incompetent A-5. Why Destitute Natural Disaster/Emergency No Available Funds Owed Fines Evacuation 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:
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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 Please Provide Details:
A-15. Specify Family Issues Domestic Violence Abuse of Adult Human Trafficking Divorce Please Provide Details:
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A-16. Specify External Factors Natural Disaster War/Threat of War/Civil Victim of Crime Unrest Deportation Criminal/Legal Arrested Release from Prison Release from Mental Institution Please Provide Details:
A-17. Referral Contains the Following Privacy Act Waiver Cable Certificate of Mental (PAW/DS-3072) 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 No Current Medication No Psychiatric Diagnosis Documentation Provided No Medical Diagnosis Repatriate Not Stable or New Worker or DOS Worker Provided Ready for Travel doesn't Understand Procedures Less than 48 Hours Notice Other None Arrived First and Opened Less than 24 Hours Notice Later Please Provide Details:
A-19. What Documentation is Missing/Incorrect? SSN PAW/DS-3072 Certificate of Mental Incompetence Medical Report Health and Safety Exemption
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A-20. Country/Post Requesting Action Afghanistan Akrotiri Curacao Georgetown Pohnpei State, Federated Scotland States of Micronesia 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 Faroe Islands Fiji Malvinas) Finland France French Polynesia French Southern and Gabon Gambia, The Antarctic Lands Gaza Strip Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Holy See (Vatican City) Honduras Islands Hong Kong Hungary Iceland India Indian Ocean Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Jan Mayen Japan Jersey Jordan Kazakhstan
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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
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A-21. Contact Info for All Relevant DOS Parties
April 10, 2018 Page 6 of 17 1. Case Intake/Referral Form ISS-USA
A-22. Port of Entry (POE) into US A.B. Won Pat Guam Albany International Airport Alexandria International International Airport Airport Albuquerque International Allentown-Lehigh Valley Amarillo International Airport Airport International Airport Anchorage International Andrews Air Force Base Atlantic City International Airport Airport Atlanta Hartsfield Austin-Bergstrom Bangor International Airport International International Airport (BGR) Baltimore/Washington Baton Rouge Metropolitan Birmingham International International Airport (BWI) Airport (BTR) Airport Boston Logan International Bradley International Airport Bradley International Airport Airport (BDL) Brownsville, TX Brownsville South Padre Buffalo Niagara International Island International Airport Airport Charleston, SC International Charlotte Douglas Chicago-O'Hare International Airport International Airport Airport Cincinnati/Northern Kentucky Cleveland Hopkins Corpus Christi International International Airport International Airport Airport Dallas/Fort Worth Dayton Interntional Airport Denver International Airport International Airport (DAY) Des Moines International Detroit Metropolitan Wayne El Paso International Airport Airport County Airport El Paso, TX Fort Lauderdale/Hollywood Ft. Worth Meacham Intl., International (FTW) Fairbanks International Fresno Yosemite General Edward Lawrence Airport (FAI) International Airport (FYI) Logan International General Mitchell International George Bush Intercontinental Gerald R. Ford International Airport (MKE) Airport Airport (GRR) Greater Rochester Greenville-Spartanburg Gulfport-Biloxi International International Airport (ROC) International Airport Airport Harrisburg International Hilo International Airport Honolulu International Airport (MDT) (ITO) Airport Huntsville International Indianapolis International Jackson International Airport Airport (HSV) Airport (JAX) Jackson-Evers International Jacksonville International John F. Kennedy Airport Airport International Airport Kansas City International Ketchikan International Kona International Airport Airport Airport (Alaska-KTN) (KOA) LaGuardia International Lambert-St. Louis Laredo, TX Airport (LGA) International Airport Little Rock National Airport Los Angeles International Louisville International Airport Airport, KY(LJC) Lubbock International Airport Luis Munoz Marin McAllen-Miller International International Airport (SJU) Airport (MFE) McCarran International Myrtle Beach International McAllen Miller International Airport (LAS) Airport Airport Memphis International McCarran International Miami International Airport Airport Airport McGuire Air Force Base Midland International Airport MN Minneapolis-St. Paul International
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Missoula International Airport Nashville International Newark International Airport Airport New Hanover International New Orleans International Newport News/Williamsburge Airport Airport International Airport Nogales, AZ Nogales, NM Norfolk International Airport Norfolk International Airport Oakland International Airport Ontario International Airport (ORF) Orlando International Airport Palm Beach International Philadelphia International Airport Airport Phoenix Sky Harbor Pittsburgh International Portland International Airport International Airport Airport Piedmont Triad International Port Columbus International Richmond International Airport Airport (CMH) Airport Raleigh-Durham Rickenbacker International Reno Cannon International International Airport Airport Airport Rio Grande Valley Sacramento International Salt Lake City International International Airport Airport Airport St.Petersburg-Clearwater San Antonio International San Diego International International Airport Airport-Lindberg San Francisco International San Jose International San Juan Puerto Airport Airport International Airport San Ysidro, CA Sarasota/Bradenton Savannah International International Airport Airport Seattle-Tacoma International Southwest Florida Southwest Florida Airport International Airport (RSW) International Airport Spokane International Airport Stapleton International Tampa International Airport Airport Tri-Cities Regional Airport Tucson International Airport Tulsa International Airport, USA Valley International Airport Washington DC-Reagan Washington Dulles (HRL) National Airport 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*
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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 Utah Vermont (Saipan) Virginia Washington West Virginia Wisconsin Wyoming
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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-12. Date of Previous Repatriation 2 __/__/____ C-13. Date of Previous Repatriation 3 __/__/____
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C-14. Who Requested Repatriation? Certificate of Mental Client Deportation Incompetence DOS (Health and Safety Exemption) Section D. *Personal Information*
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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 Congo, Republic of the 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
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Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Moldova of 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 Samoa Grenadines 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 Southern Ocean Sandwich Islands 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
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D-2. State of Birth Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii 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
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D-10. Open Warrants Yes No Unknown D-11. Warrant in What State? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii 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:
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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?
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F-3. Why pending:
F-4. Please provide an explanation as to why this repatriate is ineligible for services
F-5. Why not approved?
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IMAGE/PASSPORT PHOTO HERE