Form 1652 0044 – Fill Out and Use This PDF

Traveler Inquiry Form

I. Your Travel Experience

Thank you for contacting the Department of Homeland Security Traveler Redress Inquiry Program (DHS TRIP). Please check ALL scenarios that describe your travel experience:

I am always subjected to additional screening when going through an airport security checkpoint

I was denied boarding

I was unable to print a boarding pass at the airport kiosk or at home

I am directed to the ticket counter every time I fly

The airline ticket agent stated that I am on a Federal Government Watch List

I was detained during my travel experience

A ticket agent took my identification and called someone before handing me a boarding pass

I missed my flight while attempting to obtain a boarding pass

I am repeatedly referred for secondary screening when clearing U.S. Customs and Border Protection

I was denied entry into the United States

I am a foreign student or exchange visitor who is unable to travel due to my status

I was told my fingerprints were incorrect or of poor quality

I feel my civil rights have been violated because I was discriminated against on the basis of my race, ethnicity, religion, disability, or gender

I feel my civil rights have been violated because my questioning or treatment during screening was abusive or coercive

I feel my civil rights have been violated because a search of my person or property violated freedom of speech or press

I believe my privacy has been violated because a government agent has exposed or inappropriately shared my personal information

I was given an information sheet by a CBP Officer

I was told by CBP at a U.S. Port of entry that my fingerprints need to be corrected by US­VISIT

Other travel related issue

II. Personal Information

Full Name:

FirstMiddleLast

Date of Birth:

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/

Place of Birth:

mm/dd/yyyy

City or Town/Province/Country

Male

Sex:

Female

Height:

Weight:

Hair Color:

Eye Color:

III. Contact Information

Mailing Address:

Street or PO Box

Apt No.

City or Town

State or Province

Zip or Postal Code Country

Physical Address (if different):

FORM APPROVED OMB No. 1652­0044

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Traveler Inquiry Form

NEXUS

Number:

Date: (mm/dd/yyyy)

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/

Number:

Border Crossing Card

Date: (mm/dd/yyyy)

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SEVIS

Number:

Date: (mm/dd/yyyy)

/

/

VI. Incident Details

Please briefly describe your travel experience:

VII. Acknowledgement

The information I have provided on this application is true, complete, and correct to the best of my knowledge and is provided in good faith. I understand that knowingly and willfully making any materially false statement, or omission of a material fact, on this application can be punished by fine or imprisonment or both (see section 1001 of Title 18 United States Code).

I understand the above information and am voluntarily submitting this information to the Department of Homeland Security.

PAPERWORK REDUCTION ACT STATEMENT: Through this information collection, DHS is gathering information about you to conduct redress procedures, as an individual who believes he or she has been (1) denied or delayed boarding, (2) denied or delayed entry into or departure from the United States as a port of entry, or (3) identified for additional screening at our Nation’s transportation hubs, including airports, seaports, train stations and land borders. The public burden for this collection of information is estimated to be five minutes. This is a voluntary collection of information. If you have any comments on this form, you may contact the Transportation Security Administration, Office of Transportation Security Redress, TSA-901, 601 South 12th Street, Arlington, VA 20598-6901. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0044.

PRIVACY ACT NOTICE AUTHORITY: Title IV of the Intelligence Reform and Terrorism Prevention Act of 2004 authorizes DHS to take security measures to protect travel, and under Subtitle B, Section 4012(1)(G), the Act directs DHS to provide appeal and correction opportunities for travelers whose information may be incorrect. Principal Purposes: DHS will use this information in order to assist you with seeking redress in connection with travel. Routine Uses: DHS will use and disclose this information to appropriate governmental agencies to verify your identity, distinguish your identity from that of another individual, such as someone included on a watch list, and/or address your redress request. Additionally, limited information may be shared with non-governmental entities, such as air carriers, where necessary for the sole purpose of carrying out your redress request. Disclosure: Furnishing this information is voluntary; however, the Department of Homeland Security may not be able to process your redress inquiry without the information requested.

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FORM APPROVED OMB No. 1652-0044