attachment 2: sample referral1. case intake/referral form iss-usa a-22. port of entry (poe) into us...
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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
1. Case Intake/Referral FormISS-USA
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:
Page 2 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Please Provide Details:
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
Please Provide Details:
A-19. What Documentation is Missing/Incorrect?
SSN PAW/DS-3072 Certificate of Mental Incompetence
Medical Report Health and Safety Exemption
Page 3 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 4 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 5 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
A-21. Contact Info for All Relevant DOS Parties
Page 6 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 7 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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*
Page 8 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 9 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
__/__/____
Page 10 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
C-14. Who Requested Repatriation?
Certificate of Mental Incompetence
Client Deportation
DOS (Health and Safety Exemption)
Section D. *Personal Information*
Page 11 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 12 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 13 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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
Page 14 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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:
Page 15 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
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?
Page 16 of 17April 10, 2018
1. Case Intake/Referral FormISS-USA
F-3. Why pending:
F-4. Please provide an explanation as to why this repatriate is ineligible for services
F-5. Why not approved?
Page 17 of 17April 10, 2018
IMAGE/PASSPORT PHOTO HERE
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