1.Name:                        2.Sex:

3.Date of birth:                    4.Place of birth:

5.Nationality/ies (initial indication):

6.Languages spoken:

7.Reason to perform screening:

A. Irregular entry

Please specify also, as appropriate:

no/forged/ falsified travel document,

no/forged/ falsified visa or travel authorisation,

other

B. Arrival via search and rescue

C. Application for international protection at a Border Crossing Point

D. no indication of a border check at an external border:

□    no stamp in a travel document/no entry in the Entry Exit System

□    no travel document

8. Identification using IT databases was carried out:        □    Yes    □    No

If yes, result of identification:

9. Results of the consultation for security purposes:    

□    Hit (add databases and reasons)    

□    No Hit

10. Immediate care provided:        □    Yes    □    No

11. Isolation on public health grounds:    □     Yes    □    No

If yes, please provide dates, specific grounds, location:

12. Itinerary:

a)places/countries of previous residence:

b)point of departure:

c)third countries and places (e.g. city, province) of transit and the duration of stay:

d)modalities of transit (e.g. means of transportation, with a group, individual), assistance received (e.g. facilitators, modes of communication used), payments made/to be made, etc.:

e)third countries where protection was sought:

f)third countries where protection was granted:

g)intended destination within the Union:

13. Assistance provided for remuneration by third person or organisation in relation to irregular crossing of the border and any related information in case of suspected smuggling:

14.    Start of the screening: [DD/MM/YY]

   End of the screening: [DD/MM/YY]

15. Authority to refer the person to:

16. Comments and other relevant information:

Signature

Person filling in the form

(Name + service)