Form DHS Form 405 DHS Form 405 DHS Form 405

DEPARTMENT OF HOMELAND SECURITY

Office of the Immigration Detention Ombudsman

OMB Control No. 1601-0030
Expiration Date: 12/31/2021

CASE INTAKE FORM
The Office of the Immigration Detention Ombudsman (OIDO) reviews cases submitted by, or on behalf of, individuals affected by
misconduct, excessive force, or violations of law, rights, policy, or standards in immigration detention settings by the U.S.
Department of Homeland Security (DHS). It is an independent office within DHS and is not part of U.S. Immigration and Customs
Enforcement (ICE) or U.S. Customs and Border Protection (CBP). Please note that OIDO cannot provide legal advice.

PURPOSE OF THIS FORM
To receive assistance regarding a concern related to conditions of immigration detention or an incident that occurred while in
immigration detention, please submit this form. OIDO will examine your submission and, upon verification, seek to resolve the matter
and provide assistance or redress as appropriate.
The incident for which this form is being submitted must be related to an allegation of:
• Misconduct,
• Excessive force,
• Violation of an individual detainee’s rights, and/or
• Violations of law, standards of professional conduct, contract terms, or policy related to immigration detention.

AND
The alleged misconduct or violation(s) must have been committed by:
DHS (CBP or ICE) officers or employees, including contracted, subcontracted, or cooperating personnel, or a contract service
provider.
OIDO does not review or adjudicate requests to reconsider the determination to detain an individual, the reasons for such
immigration detention, the denial of a request for release from immigration detention (including parole or bond), or the
standards for considering requests for release.
If your situation does not meet these criteria, or to view a list of other DHS avenues for providing feedback or filing a complaint, visit
https://www.dhs.gov/how-do-i/provide-feedback-dhs.

WHO SHOULD SUBMIT THIS FORM?
• A current or former detainee who is seeking assistance regarding a concern related to conditions of immigration detention or an
incident that occurred, or is occurring, while in DHS custody.
• An individual submitting this form on behalf of a current or former detainee, as his or her representative, who has a concern related
to conditions of immigration detention or to whom an incident occurred, or is occurring, while in DHS custody. This includes, but is
not limited to, an acquaintance, family member or attorney/accredited representative.
• An individual submitting the form anonymously.
DHS employees who wish to file complaints related to allegations of misconduct may do so with the DHS Office of Inspector General
(OIG) and/or the DHS Office of Special Counsel. DHS employees are reminded that it is unlawful for agencies to take, or threaten to
take, a personnel action against an employee because she/he disclosed wrongdoing. DHS employees may contact the DHS
Whistleblower Protection Coordinator at [email protected] for questions regarding protected
disclosures or information regarding rights and remedies of whistleblowers.

GENERAL INSTRUCTIONS FOR THIS FORM
• Type or print legibly in black or blue ink.
• If extra space is needed, you may attach additional pages to this form.
• For questions that do not apply, please write “N/A.”
• Please attach copies of any documents or information that will help OIDO review the case. Do not send original documents.
• This form is not required to submit a case to OIDO, and it is not required that all fields be completed. However, a properly completed
form ensures that OIDO receives the necessary information to assist with your concern. If you do not use the form, or do not
complete all fields, you may encounter processing delays or we may be unable to assist with your case.
• There is no fee for submitting a request to OIDO.
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WHERE TO SUBMIT THIS FORM
Please submit your completed, signed, and dated form, including any supporting documentation, to the Office of the Immigration
Detention Ombudsman by one of the following means:
• E-Mail: [email protected]
• U.S. Mail and/or Expedited Delivery Services:
U.S. Department of Homeland Security
Office of the Immigration Detention Ombudsman, Mail Stop #0134
2707 Martin Luther King Jr. Ave. SE
Washington, DC 20528
Due to security measures with the U.S. Government mail system, cases mailed (even those sent by expedited delivery services)
may be delayed.

CASE INFORMATION
Information About the Person Submitting this Form
1. I am:

A current or former detainee who is seeking assistance regarding conditions of immigration detention or an incident
that occurred, or is occurring, while in DHS custody.
An individual submitting this form on behalf of a current or former detainee, as his or her representative, who has a
concern regarding conditions of immigration detention or to whom an incident occurred, or is occurring, while in DHS
custody.
An individual submitting the form anonymously.

Information About the Detainee
2. Name (Prefix, First Name, Middle Name, Last Name):
3. Other names used or spelling variants:
4. Date of Birth:

5. Sex
Male
Female

6. Alien Registration Number (A-number) (if any):

Other:

7. Country(s) of Citizenship or Nationality:

8. Country of Birth:

9. Preferred Language:

10. Location:
a. Is the individual currently in custody?
Yes:

1. Name of Detention Facility (If unsure of the name, provide general information, such as city or state, or
descriptive information, such as large building or holding cell, or personnel uniform colors.)

2. Date Range at Facility (If unsure of the exact dates, provide approximate dates.)
3. What is the preferred method of contact after release from detention? Select one.
Mailing Address: Street Address, Apartment/Suite, City, State, Zip/Postal Code, Country

Email Address:
Phone Number:
No:

1. Current Mailing Address: Street Address, Apartment/Suite, City, State, Zip/Postal Code, Country

2. Email Address:
3. Phone Number:
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Information About Where the Incident or Concern Occurred
11. Did the incident or concern occur at a detention facility?
Yes:

a. Name of Detention Facility (If unsure of the name, provide general information, such as city or state, or
descriptive information, such as large building or holding cell, or personnel uniform colors.)

b. Date Range at Facility (If unsure of the exact dates, provide approximate dates.)

No:

a. Provide explanation:

Information About the Incident or Concern
12. Category (Select one category that best describes the incident.):
Abuse or Assault

Medical/Mental Health or Health Care Concerns

Detainee Locator

Property

Disability Accommodations

Religious

Facility Environment

Special Consideration for Children and Families

Legal Access

Translation and Interpretation Services

13. Description of Incident or Concern (Please provide a detailed explanation and specify the preferred remedy or redress.)

14. Incident Date(s) (If unsure of the exact dates, provide approximate dates.)

Actions Taken to Report the Incident and Seek a Remedy or Redress
15. Was the incident or concern discussed with personnel at the facility?
Yes:

a. Was a grievance or formal complaint filed?

Yes

No

b. If medical, was a sick call request made?

Yes

No

c. Other:
No

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16. Was the incident or concern reported to one of the following?
ICE Detention Reporting and Information Line (DRIL) (888-351-4024)
Office of Professional Responsibility Joint Intake Center (JIC) (877-2INTAKE)
DHS Office for Civil Rights and Civil Liberties (CRCL) (866-644-8360)
DHS Office of Inspector General (OIG) (800-323-8603)
U.S. Health and Human Services, Office of Refugee Resettlement (if incident occurred while in DHS custody)
Other (e.g., Chaplain):
None of the above
17. Describe any other offices contacted or actions taken to address the incident or concern:

Identity of the Person Submitting this Form
I am:
The aforementioned detainee who is seeking assistance regarding an immigration detention conditions concern or an
incident that occurred, or is occurring, while in DHS custody.
I certify, through my signature, under penalty of perjury under the laws of the United States of America, including 28 U.S.C.
§ 1746, that the information provided is true and correct, and that I am an individual who encountered or is encountering
difficulties while in immigration detention with the U.S. Department of Homeland Security. I understand that any falsification
of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more than $10,000 or by
imprisonment of not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is
punishable under the provisions of 5 U.S.C. § 552a (i)(3) by a fine of not more than $5,000.

Signature:

Date:

An individual submitting this form on behalf of a current or former detainee, as his or her representative, who has a concern
regarding conditions of immigration detention or an incident that occurred, or is occurring, while in DHS custody.
Please note that OIDO strongly recommends that it receive a notice of written consent, signed by the detainee (or the
detainee's legal guardian if under the age of 18) for whom this Case Intake Form is submitted to allow OIDO to release
information to you. If, however, you are unable to receive written consent from the detainee, your signature below certifies
that, under penalty of perjury under the laws of the United States of America, including 28 U.S.C. § 1746, you are an
individual submitting this form on behalf of a detainee, as his or her representative, to whom an incident occurred, or is
occurring, while in DHS custody. You understand that any falsification of this statement is punishable under the provisions
of 18 U.S.C. § 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that
requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. § 552a (i)(3) by
a fine of not more than $5,000). Without proper consent, OIDO may not be able to provide the submitter with information
regarding the case and/or outcome.
a. Representative Name (Prefix, First Name, Middle Name, Last Name):
b. Mailing Address:

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c. Relationship to Detainee:
Parent/Legal Guardian
Spouse
Child
Attorney

An accredited representative of a religious, charitable, social service or similar
organization established in the United States and recognized by the Department
of Justice pursuant to 8 C.F.R. § 1292.1.
Other

d. Name (Prefix, First Name, Middle Name, Last Name):
e. Mailing Address: Street Address, Apartment/Suite, City, State, Zip/Postal Code, Country:

f. Law Firm/Organization (if applicable):
g. Mailing Address: Street Address, Apartment/Suite, City, State, Zip/Postal Code, Country:

h. Email Address:

i. Phone Number:

j. Signature:

k. Date:

An individual submitting this form anonymously. Due to the anonymous nature of the submission, no information regarding
the case and/or outcome will be provided to the submitter.

LEGAL NOTICES
Penalties for Submitting Incorrect Information
Whoever willfully and knowingly falsifies a material fact, makes a false statement, or makes use of false documents will be fined up
to $10,000, imprisoned for up to five (5) years, or both. 18 U.S.C. §1001. Requesting or obtaining any record(s) under false
pretenses is punishable under the provisions of 5 U.S.C. §552a(i)(3) by a fine of not more than $5,000.
Authority for Collecting Information
The functions of the Office of the Immigration Detention Ombudsman are to:
(1) Establish and administer an independent, neutral, and confidential process to receive, investigate, resolve, and provide
redress, including referral for investigation to the Office of Inspector General, referral to U.S. Citizenship and Immigration
Services for immigration relief, or any other action determined appropriate, for cases in which Department of Homeland
Security (DHS) officers or other personnel, or contracted, subcontracted, or cooperating entity personnel, are found to have
engaged in misconduct or violated the rights of individuals in immigration detention;
(2) Establish an accessible and standardized process regarding complaints against any officer or employee of U.S. Customs and
Border Protection or U.S. Immigration and Customs Enforcement, or any contracted, subcontracted, or cooperating entity
personnel, for violations of law, standards of professional conduct, contract terms, or policy related to immigration detention;
(3) Conduct unannounced inspections of detention facilities holding individuals in federal immigration custody, including those
owned or operated by units of State or local government and privately-owned or operated facilities;
(4) Review, examine, and make recommendations to address concerns or violations of contract terms identified in reviews,
audits, investigations, or detainee interviews regarding immigration detention facilities and services;
(5) Provide assistance to individuals affected by potential misconduct, excessive force, or violations of law or detention standards
by DHS officers or other personnel, or contracted, subcontracted, or cooperating entity personnel; and
(6) Ensure that the functions performed by the Ombudsman are complementary to existing functions within DHS Homeland
Security Act of 2002, Pub. L. No. 107-296, § 405(b) (codified at 6 U.S.C. § 205(b)), as added by Consolidated Appropriations
Act, 2020, Pub. L. No. 116-93,§106 (2019).

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Privacy Act of 1974
All information submitted to the Office of the Immigration Detention Ombudsman (OIDO) is collected and protected under the
provisions of the Privacy Act of 1974, 5 U.S.C. § 552a. By submitting this information to OIDO, your consent allows OIDO to
investigate any potential misconduct or violations in relation to immigration detention.
AUTHORITY: DHS is authorized to collect the information requested on this form pursuant to section 405 of the Homeland Security
Act of 2002, Pub. L. No. 107-296 (codified at 6 U.S.C. § 205), as added by Consolidated Appropriations Act, 2020, §106, Pub. L. No.
116-93, 133 Stat. 2504.
PURPOSE: DHS Office of the Immigration Detention Ombudsman (OIDO) is requesting this information to resolve cases brought
forth by individuals or investigations regarding potential violations of law, individual rights, standards of professional conduct,
contract terms, or policy related to immigration detention by any officer or employee of CBP, ICE, or any contracted, subcontracted,
or cooperating entity personnel.
ROUTINE USES: The information requested on this form may be shared within DHS based on a need to know basis and externally
pursuant to routine uses to assist the DHS in reviewing and resolving complaints. A complete list of the routine uses can be found in
the system of records notices associated with this form, including DHS/ALL-020 Department of Homeland Security Internal Affairs
and DHS/ALL-025 Law Enforcement Authority in Support of the Protection of Property Owned, Occupied, or Secured by the
Department of Homeland Security System of Records. Additionally, DHS plans to publish a new SORN to cover the records and
uses with OIDO’s collection, named DHS/OIDO-001 Office of the Immigration Detention Ombudsman System of Records. For those
individuals not covered by the Privacy Act, additional information can be found in the Privacy Impact Assessment, DHS/OIDO/
PIA-001 Immigration Detention Case Management System. All can be found at: https://www.dhs.gov/privacy.
CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION: Providing this information is voluntary. However, failure to provide
this information may result in the inability of DHS to process or investigate the complaint.
Paperwork Reduction Act Notice
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of
information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The public reporting
burden for this collection of information is estimated at 1 hour per response, including the time for reviewing instructions, completing
the form, and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to: U.S. Department of Homeland Security, Office of the Immigration
Detention Ombudsman, Mail Stop #0134, 2707 Martin Luther King Jr. Ave. SE, Washington, DC 20528, OMB No. 1601-NEW.

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