Runaway Intake ---
Tennessee Interstate Compact for Juveniles
Complete information helps with the process for a successful return of the youth to the home/demanding state in a timely manner. Fill in as much information as you have.
Date:Date Form Completed
Person Reporting Information:
Name: / Title:Telephone Number: / Cell/Alt Number:
E-Mail Address: / Fax Number:
Youth Information (Please provide information about the runaway youth):
Youth’s Full Name:Status of Youth:
Probation/Aftercare (Parole) Status Offender Non-Custodial Non-Delinquent
Custodial
List any Alias Name(s) if applicable:Date of Birth: / Age: / Gender: Male Female / Race:
Height: / Weight: / Eye Color:
Tattoos/piercings/scars or visible birthmarks:
Social Security Number (if known):
Youth’s Address:
City: / State: / Zip:
Youth’s Home County:
Parent or Legal Guardian Information:
Name:Relationship to the youth:
Does this person have legal custody? Yes No
Phone Number: / Cell/Alt Number:Address:
City: / State: / Zip:
Has the Parent or Legal Guardian been contacted? Yes No
Warrant/NCIC for Youth:
Does the youth have a warrant? Is it in the NCIC system? If so, what is the NCIC Number?
#Did the youth incur new charges?
If there are new charges, please describe (attach petitions):
Is the county going to detain the youth and/or prosecute?
How was the youth discovered/apprehended?
Form III (Consent for Voluntary Return of Out-of-State Juvenile:
The ICJ Form III is required before a youth can be returned to the home/demanding state. Is there a Form III hearing scheduled? Yes No
Date & Time of Hearing:Is TN-DCS involved in this case? If so, list the name of the FSW, email and telephone number.
Is there an allegation of abuse? Yes No
Has a Child Protective Service (CPS) referral been completed? Yes No
If so, when?:List the CPS caseworker’s contact information:
Name: / Telephone Number:Is Human Trafficking suspected or been reported? Yes No
If yes, has law enforcement been notified (TBI, FBI)? Yes No
Physical and Clothing Description:
List clothing and shoes that the youth will wear when traveling home. Be specific:Youth’s Current Location:
Facility where youth is being held/detained:Address:
City: / State: / Zip:
Contact Person’s Name:
Telephone Number: / Fax Number:
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Distribution: RDA2982
CS-1094,03/17Page 1