Potential Support Interest Form ' U.S. Repatriation Program Services for U.S. Citizens Returning Home Due to HantaVirus

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Repatriation Interest Form 
U.S. Repatriation Program Services for U.S. Citizens Returning Home due to Hantavirus
Office of Human Services Emergency Preparedness and Response 
May 2026
Overview
Following the recent Hantavirus cases on the MV Hondius cruise ship and the potential evacuation/repatriation by U.S. Department of State (DOS)of American citizens to the United States, the Office of Human Services Emergency Preparedness and Response (OHSEPR) is anticipating an influx of U.S. citizens requesting services upon return to the United States via the U.S. Repatriation Program. 
OHSEPR is seeking to circulate a brief interest form to quickly capture potential repatriates’ requirements for Program services. This form will enable Program personnel to prioritize outreach and connect individuals to appropriate services promptly upon arrival in the United States. This form does not constitute direct enrollment in Program services but rather gauges potential interest to facilitate potential eligibility determination. 
This document includes front matter that provides instructions for completing the interest form, and the specific interest form questions OHSEPR intends to ask potential repatriates, as captured in Table 1.
Table 1: Potential Support Interest Form Document Contents
Document Section
Overview 
Section 1: Potential Support Interest Form 
This section includes all interest form materials to be shared with potential repatriates, including:
    • Potential Support Interest Form Landing Page
    • Potential Support Interest Form Questions


Repatriation Interest Form Landing Page 
The U.S. Repatriation Program (Program) provides immediate assistance to eligible U.S. citizens and dependents returning to the United States from a DOS-identified crisis location. Temporary assistance is provided in the form of a service loan repayable to the U.S. government.
Completing this interest form does not guarantee services or determine eligibility. Based on your responses to the interest form, representatives from the Program may reach out to discuss eligibility and Program services. 
Please contact [email protected] or 1-800-517-0525 with any questions regarding this form.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: ACF is gathering information to learn more about the repatriate experience and the temporary assistance provided to repatriates through the U.S. Repatriation Program. Public reporting burden for this collection of information is estimated to average 0.034 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0531 and the expiration date is 9/30/2028. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.



Repatriation Interest Form Questions 
Table 2: Repatriation Interest Form Questions
Part 1: Responder Circumstances
This section includes eligibility information for potential repatriates to provide a better estimation of support needs. 
#
Conditionality
Question (*Required)
Field Type
1
N/A
*Are you a U.S. citizen or dependent of a U.S. citizen?
Dropdown: 
    • Yes
    • No
1a
If “No” is selected in question 1
End Interest Form: Thank you. This interest form is intended for U.S citizens and dependents of U.S. citizens. Please consider reaching out to local human services providers in your state for potential assistance. For more information about the U.S. Repatriation Program’s eligibility criteria, please visit Eligibility & Assistance.
N/A
2
If “Yes” is selected in question 1
*Please select where your journey to the United States began. Note: Question refers to origin of travel. If traveler(s) experienced layover and/or connecting flights, please answer with respect to the location of the first departure. 
Dropdown:
    • St. Helena
    • Canary Islands
    • Other/Not Listed
2a
If “Other/Not Listed” is selected in question 2
End Interest Form: Thank you. At this time, this interest form is intended travelers whose origin is one of the listed DOS-identified, crisis-impacted locations. For more information about the U.S. Repatriation Program’s eligibility criteria, please visit Eligibility & Assistance.
N/A
Part 2: Anticipated Support
This section includes information related to the needs of the potential repatriate.
#
Conditionality
Question (*Required)
Field Type
3
N/A
*Do you currently have access to adequate resources (such as cash, bank funds, or credit) to meet your immediate basic needs (food, safe shelter, and local transportation)?

Dropdown: 
    • Yes
    • No
    • Not Sure



 
3a
If “Yes” is selected in question 3
End Interest Form: Thank you. At this time, this interest form is intended for those who are in need of immediate temporary assistance. 
N/A
3b
If “No” or “Not Sure” is selected in question 3
Please identify any potential areas for assistance. Note: Information gathering only, services may be provided upon final eligibility determination. Assistance may be provided in the form of a loan repayable to the U.S. government.
Select All That Apply: 
    • Food
    • Hygiene
    • Shelter/Accommodations
    • Cash 
    • Medical Services 
    • Mental Health Services
    • Local Transportation or Onward Travel
    • Other/Not Listed
Contact Information
Please note, “Contact Information” will only appear for those who selected “No” or “Not Sure” to question 3
4
N/A
Please include your full legal name (first and last)
Free text (long answer)
5
N/A
Please share the best method of contact if you would like a representative from OHSEPR to reach out regarding potential Program assistance.
Drop Down:
    • Phone 
    • Email
    • Other: Please List
6
N/A
Please share contact information if you would like a representative from OHSEPR to reach out regarding potential Program assistance. Note: If using a phone number, please include country code. 
Free text (long answer)
7
N/A
End Interest Form: Thank you for submitting the Repatriation Interest Form. If you have provided contact information, a representative from OHSEPR will contact you regarding potential Program assistance. For immediate assistance, please contact [email protected] or 1-800-517-0525. 
N/A