ISS-USA OUTGOING CASE REFERRAL FORM

FOR POTENTIAL RESOURCE FAMILY BACKGROUND CHECKS ONLY.

Instructions: Please type in each section, complete the information section which is specific to the service being requested. Attach any information that may be relevant to the request. ISS-USA requires a completed Case Referral Form before providing services.

Click the grey box to type over the text in the field.

New ReferralIf you do not have an OPEN case for this family, this is a new referral. / Case Name: for ISS-USA use
Additional service(s) for existing case / ISS-USA Case Number:for ISS-USA use
Country Service Being Requested In: This is where the background check is needed. / NJ Spirit #
Person Referring the CaseEnter your information here.
Name:
Address:
City/State/Country:
Phone:
Email: / Individual:
Agency (Please Specify): NJ DCP&P
Job Title:
Type I Services / Type II Services / Type III Services
Protective Service Alert
Home Study
Post Placement Follow-Up
Child Welfare Check / Criminal Background Check
Child Abuse Registry Check
International Adoption
Reference Report / Document Tracing
Person Tracing
Mediation
Other (Please Specify):
  1. Statement of the problem and origin of the request.Include names, ages, relationships of potential resource families. Include pertinent history and their qualifications to be resource parents.
  2. Name of person(s) who are the subject of the background checks.Provide all known data. Contact International Liaison to discuss strategies for obtaining additional information when necessary.

First person to be investigated:[Enter FAMILY NAME in CAPITALS, first name]

Gender: [Enter gender]

Date and Place of Birth: [Enter date and place of birth]

Civil status: [Enter single, married with X, divorced, etc.]

Nationality: [Enter nationality]

Address: [Enter full address]

Phone number: [Enter phone #]

Second person to be investigated:[Enter FAMILY NAME in CAPITALS, first name]

Gender: [Enter gender]

Date and Place of Birth: [Enter date and place of birth]

Civil status: [Enter single, married with X, divorced, etc.]

Nationality: [Enter nationality]

Address: [Enter full address]

Phone number: [Enter phone #]

  1. International address where the background check is needed: please include the city and the country. Provide all known data. Contact International Liaison to discuss strategies for obtaining additional information when necessary.

Location 1: [Enter city and country]

Street Address (no APO or PO BOX): [Enter street #, apartment #, postal code]

Dates of residence: [Enter dates]

Location 2: [Enter city and country]

Street Address (no APO or PO BOX): [Enter street #, apartment #, postal code]

Dates of residence: [Enter dates]

Location 3: [Enter city and country]

Street Address (no APO or PO BOX): [Enter street #, apartment #, postal code]

Dates of residence: [Enter dates]

  1. Service RequestedClearly outline the service that is needed in the other country/state. If time-specific, provide the date. Provide any additional details that may assist ISS-USA staff.

Please e-mail the completed form to.

If you require additional assistance with this form, or have any questions, please contact the International Liaison at 609-888-7120.