Attachment_No.3-_participant_enrollment_form.pdf

ATTACHMENT 3

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

ATD PARTICIPANT ENROLLMENT FORM

ICE Form 71-015(Page 1 of 2) (9/13)

ATD Location: Case DCO: EARM Case ID: A-Number:

Referral Source:

☐CAP ☐Fugitive Ops ☐Detained ☐Non-Detain ☐HSI ☐CBP ☐USCIS ☐Other ______________________(Explanation Required)

Participant Biographical Information Last Name:

First Name: A-Number:

DOB (under 18 not eligible)

COC Gender: ☐M ☐F ☐Unknown

Alien Address

City State Zip Code

Phone Number ( ) Cell Phone ( )

☐Pre-Order (Notice to Appear) ☐Post-Order (VD/Final Order of Removal) ☐Appeal (Pending with the BIA)

Technology Options (Selection of a Technology is a Requirement):

☐GPS or ☐Monthly Telephonic Reporting

Service Options (where Available) with Frequency:

Y N ☐ ☐ Office Visits* (Once Every): ☐Week ☐2 Weeks ☐4 Weeks ☐ 8 Weeks

☐ ☐ Home Visits* (Once Every): ☐2 Weeks ☐4 Weeks ☐8 Weeks

☐ ☐ Program Enrollment, Residence Verification & Orientation* (Installation of Technology and Program Explanation)

☐ ☐ Court Tracking* (Tracking of Court Case and Reminder Call to Participant before Court)

☐ ☐ Alert Management* (GPS & Telephonic Alerts)

*If not contracted, this function is the responsibility of the ATD Officer.

ERO Case Officer Authorizing Enrollment (Name and Title) Date

Alien appeared at Intake/Orientation for enrollment on ____________ at __________ (Date) (Time)

Officer to Determine Supervision Levels on a Case by Case Basis

ATTACHMENT 3

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

ATD PARTICIPANT ENROLLMENT FORM

ICE Form 71-015(Page 2 of 2) (9/13)

ATD Location: Case Docket Control Office: EARM Case ID: A-Number:

Submit all two (2) pages to contractor office.

Relevant Information (Criminal History, Special Vulnerabilities, Risk to Public Safety or Risk of Flight):

Please note behavioral issues, next court date, employment eligibility, travel document status, special notifications such as medical needs or any other relevant case information.