excalibur roi examples
TRANSCRIPT
EXCALIBUR ROI Examples
LAST UPDATE: 8/12/2021 | EXCALIBUR ROI Samples | | PROPRIETARY AND CONFIDENTIAL | 1
RO
I Examp
les Tab
le o
f Co
nte
nts
TIER
CO
VER
AG
CH
AR
T
Click on the lead type to view ROI samples for that type of lead. You can return to the table of contents
at any time by clicking on the area shaded in gray on the right hand side of the page.
*Note: these are sample ROIs only. They are not all –inclusive of all required information. For complete
reporting guidance, refer to the EXCALIBUR Reporting Guide, Issue Resolution Guide, and/or the
Appendix for the tier case type you are working on.
LEAD TYPE Subject Interview
Birth Record
Citizenship Record
Fingerprints
Residence
Education
Employment/Military Service
Employment/Military Record
Security Files
Unemployment
Listed Character Reference (LCR)
Developed Character Reference (DCR)
Former Spouse
Local Agency Check (LAC)
Court Record
Bankruptcy Record
Mental Health
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SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUBJECT INTERVIEW IDENTIFICATION:
RESIDENCE:
EDUCATION:
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SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
EMPLOYMENT / SELF-EMPLOYMENT / UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS / COHBITANT:
FAMILY AND ASSOCIATES:
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SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
FOREIGN TRAVEL / PREFERENCE:
FOREIGN CONTACTS / INFLUENCE:
ILLEGAL ACTIVITY / POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
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SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
DRUG/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES / CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS / PRESCRIPTION MEDICATION:
SECURITY PRACTICES / HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS / PUBLICATIONS:
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SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
SUB
JECT IN
TERV
IEW
SU
BJEC
T INTER
VIEW
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL / FREE-TIME ACTIVITIES:
ALLEIGANCE / LOYALTY:
BLACKMAIL / COERCION / DURESS:
INTERVIEW IMPRESSIONS:
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BIR
TH
REC
OR
D
B
IRT
H R
ECO
RD
BIR
TH
REC
OR
D
B
IRT
H R
ECO
RD
BIR
TH
REC
OR
D
B
IRT
H R
ECO
RD
BIRTH RECORD EXAMPLE : BIRTH RECORD (BIRTH CERTIFICATE)
EXAMPLE: BIRTH RECORD (PASSPORT)
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CITIZEN
SHIP
REC
OR
D
CITIZEN
SHIP
REC
OR
D
CITIZEN
SHIP
REC
OR
D
CITIZEN
SHIP
REC
OR
D
BIR
TH
REC
OR
D
BIR
TH
REC
OR
D
CITIZENSHIP RECORD
EXAMPLE: CITIZENSHIP RECORD
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Finge
rprin
ts
Fin
gerp
rints
Finge
rprin
ts
Fin
gerp
rints
Finge
rprin
ts
B
IRT
H R
ECO
RD
FINGERPRINTS EXAMPLE: FINGERPRINTS (NOTE: BOXES INDICATED WITH ARROWS ARE PREPOPULATED)
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RESID
ENC
E
R
ESIDEN
CE
RESID
ENC
E
R
ESIDEN
CE
Co
verageC
hart
B
IRT
H R
ECO
RD
RESIDENCE
EXAMPLE 1: REPORTING RESIDENCE (BEST SOURCE) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
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RESID
ENC
E
R
ESIDEN
CE
RESID
ENC
E
R
ESIDEN
CE
Co
verageC
hart
B
IRT
H R
ECO
RD
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
EXAMPLE 2: REPORTING RESIDENCE (INDIRECT VERIFIER) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
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RESID
ENC
E
R
ESIDEN
CE
RESID
ENC
E
R
ESIDEN
CE
Co
verageC
hart
B
IRT
H R
ECO
RD
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
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RESID
ENC
E
R
ESIDEN
CE
RESID
ENC
E
R
ESIDEN
CE
Co
verageC
hart
B
IRT
H R
ECO
RD
ADDITIONAL INFORMATION:
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EDU
CA
TION
ED
UC
ATIO
N
EDU
CA
TION
ED
UC
ATIO
N
BIR
TH
REC
OR
D
EDUCATION
EXAMPLE: EDUCATION REFERENCE 1 (PROFESSOR) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
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EDU
CA
TION
ED
UC
ATIO
N
EDU
CA
TION
ED
UC
ATIO
N
BIR
TH
REC
OR
D
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
EXAMPLE: EDUCATION REFERENCE 2 (CLASSMATE) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
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EDU
CA
TION
ED
UC
ATIO
N
EDU
CA
TION
ED
UC
ATIO
N
BIR
TH
REC
OR
D
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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EDU
CA
TION
ED
UC
ATIO
N
EDU
CA
TION
ED
UC
ATIO
N
BIR
TH
REC
OR
D
EXAMPLE: UNSUCCESSFUL EDUCATION REFERENCE
Remarks: * Only enter Investigator’s Notes and reason(s) for unsuccessful leads in this box. Do NOT enter association period in this box. Enter N/A if no remarks
EDUCATION RECORD
EXAMPLE: EDUCATION RECORD
Remarks: *
- Unsuccessful Lead
Smith, John
Note: When the lead headers are entered as shown here and converted to the ROI, the ROI will show the following:
Reference Name: Smith, John – Unsuccessful Lead
Complete the Lead Details and Specific
Data sections in IRMA as detailed as
possible with the information
provided from the record.
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EMPLOYMENT/MILITARY SERVICE REPORTING: EMPLOYMENT REFERENCE COMPLETE THE LEAD DETAILS Make sure to obtain and report the correct organization for which SUBJECTs and Sources work(ed). Investigators must also make sure to obtain and report the correct work title for SUBJECTs and Sources, exactly as provided.
EXAMPLE: EMPLOYMENT REFERENCE 1 (SUPERVISOR) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
Remember, when entering the lead headers, the Company
Name is to identify the company for which Source is being
used as a reference, not Source’s current employer.
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: EMPLOYMENT REFERENCE 2 (COWORKER) ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: MILITARY REFERENCE ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: UNSUCCESSFUL EMPLOYMENT REFERENCE
Remarks: * Only enter Investigator’s Notes and reason(s) for unsuccessful leads in this box. Do NOT enter association period in this box. Enter N/A if no remarks
EMPLOYMENT / MILITARY RECORD
EXAMPLE: EMPLOYMENT RECORD
Remarks: *
EXAMPLE: MILITARY RECORD (REMARKS) Remarks: *
- Unsuccessful Lead
Smith, Jane
Note: When the lead headers are entered as shown here and converted to the ROI, the ROI will show the following:
Reference Name: Smith, John – Unsuccessful Lead
Complete the Lead Details and Specific
Data sections in IRMA as detailed as
possible with the information
provided from the record.
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: Employment Record Subject: Parson, Shawn Paul Inquiry Date: XX/XX/XXXX AIN: 12345 Investigator: Davis, Ellen Interview Method: In Person Source First Name: Sara Middle Initial: A. Last Name: Carson Source Title: HR Manager Company Name: Knowledge Technology Solutions (KTS) Address: 10210 Sunset Ave City: Reston State: VA Zip Code: 20109 Telephone: 703 330-XXXX Ext: Employment Start Date: 08/23/2015 Employment End Date: Present Employment Status: Full-Time Position: Project Lead Salary: $110,000.00 Salary Frequency: Annually Attendance: Not Shown Performance Evaluation: See Remarks Reason for Leaving: N/A Eligibility Rehire: N/A Remarks: SUBJECT was hired as full time Contract Administrator in Reston, VA on 08/23/2015 with a salary of $83,000.00. SUBJECT’s supervisor was Lindsay Roberts. On 09/27/2017, SUBJECT was promoted to Project Lead with a salary of $98,000.00. SUBJECT’s supervisor as of 09/2017 is Jonathan Pierrino. All of SUBJECT’s performance evaluations have a rating of “Above Average” and “Superior”. SUBJECT’s last performance appraisal resulted in a raise, bringing SUBJECT’s current salary to $110,000.00. SUBJECT has not had any breaks in service. No problems, security violations or disciplinary actions were noted in the file. A separate security file does not exist. There is no negative information in the record.
EXAMPLE: UNSUCCESSFUL EMPLOYMENT RECORD Remarks: *
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
SECURITY FILES
EXAMPLE: SECURITY RECORD Subject: Cumberson, Elena Inquiry Date: XX/XX/XXXX AIN: 12345 Investigator: Vanders, Thomas Interview Method: In Person Source First Name: Sam Middle Initial: B Last Name: Bryson Source Title: FSO Company Name: Catsons Data Solutions (CDS) Address: 10345 Kreeton Street City: Rockville State: MD Zip Code: 20642 Telephone: 301 254-XXXX Ext: Specific Data Security Violations/ Infractions: Nothing reported Foreign Travel: Mexico - 05/16/2015 to 05/26/2015. Reason for travel – Vacation. Dominican Republic – 06/02/2016 to 06/12/2016. Reason for travel – Vacation. Mexico - 06/05/2017 to 06/12/2017. Reason for travel - Vacation Foreign Contacts: Maria Sanchez, citizen of Mexico; Jose Sanchez, citizen of Mexico; Michael Sanchez, citizen of Mexico Financial: Nothing reported Legal/Criminal: Nothing reported Medical: Nothing reported Other: Nothing reported Remarks: SUBJECT has a TS-SCI Clearance that was granted on 07/15/2015. The investigating agency was the Office of Personnel Management. The granting agency is not provided. SUBJECT’s 2015 SF-86 is in the file along with a copy of his 01/15/2020 SF-86. No other investigations are noted. SUBJECT’s travel request forms for the three trips listed above are in the file, in addition to copies of the Foreign National Contact forms for each of the three listed foreign contacts. No security violations or issues were noted. There are no discrepancies between SUBJECT’s current SF-86 and the record. There is no other information in the record.
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
UNEMPLOYMENT
EXAMPLE: UNSUCCESSFUL UNEMPLOYMENT
EXAMPLE: UNEMPLOYMENT REFERENCE ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: UNEMPLOYMENT RECORD
LAST UPDATE: 8/12/2021 | EXCALIBUR ROI Samples | | PROPRIETARY AND CONFIDENTIAL | 30
EMP
LOY
MEN
T/MILITA
RY
EM
PLO
YM
ENT/M
ILITAR
Y
EMP
LOY
MEN
T/MILITA
RY
MILITA
RY
B
IRT
H R
ECO
RD
EXAMPLE: UNSUCCESSFUL UNEMPLOYMENT REFERENCE
Remarks: * Only enter Investigator’s Notes and reason(s) for unsuccessful leads in this box. Do NOT enter association period in this box. Enter N/A if no remarks
- Unsuccessful Lead
Smith, John
Note: When the lead headers are entered as shown here and converted to the ROI, the ROI will show the following:
Reference Name: Smith, John – Unsuccessful Lead
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CHARACTER REFERENCES: LISTED REFERENCES (LCR)
EXAMPLE: LISTED CHARACTER REFERENCE ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
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ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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CHARACTER REFERENCES: DEVELOPED REFERENCES (DCR)
EXAMPLE: DEVELOPED CHARACTER REFERENCE ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
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PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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FORMER SPOUSES
EXAMPLE: EX-SPOUSE REFERENCE
ASSOCIATION:
RESIDENCE:
EDUCATION:
EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:
MILITARY SERVICE:
MARITAL STATUS/COHAB:
FAMILY AND ASSOCIATES:
FOREIGN TRAVEL/PREFERENCE:
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FOREIGN CONTACTS/INFLUENCE:
ILLEGAL ACTIVITIES/POLICE RECORD:
NON-CRIMINAL COURT ACTIONS:
DRUGS/SUBSTANCE MISUSE:
ALCOHOL CONSUMPTION:
FINANCES/CREDIT REPORT:
PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:
SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:
MISUSE OF INFORMATION TECHNOLOGY:
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MEDIA CONTACTS/PUBLICATIONS:
ORGANIZATIONAL AFFILIATIONS:
EXTERNAL/FREE TIME ACTIVITIES:
ALLEGIANCE/LOYALTY:
BLACKMAIL/COERCION/DURESS:
ADDITIONAL INFORMATION:
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LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
LOCAL AGENCY CHECKS (LAC)
EXAMPLE: POLICE/ARREST RECORD
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LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
COURT RECORDS
EXAMPLE: COURT RECORD
Remarks: *
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LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
BANKRUPTCY RECORDS
EXAMPLE: BANKRUPTCY RECORD
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LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
LOC
AL A
GEN
CY
CH
ECK
S / CO
UR
T REC
OR
DS
DIVORCE RECORDS
EXAMPLE: DIVORCE RECORD Specific Data: *
Remarks: *
Complete the Lead Details and Specific
Data sections in IRMA as detailed as
possible with the information
provided from the record.
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MEN
TAL H
EALTH
MEN
TAL H
EALTH
MEN
TAL H
EALTH
MEN
TAL H
EALTH
MENTAL HEALTH
EXAMPLE: MEDICAL REFERENCE
SUBJECT NAME: JULIE O’TOOLE AIN: 12345 INQUIRY DATE: XX/XX/XXXX INVESTIGATOR: ALLISON DREGGER
SOURCE FIRST NAME: MARYANNE
MIDDLE INITIAL: R
LAST NAME: CONNELLY
SOURCE SPECIALTY/TITLE: GENERAL PSYCHIATRY/PHD
ADDRESS: 1850 LEXINGTON ROAD
CITY: LEONARDTOWN
STATE: MD
ZIP CODE: 20650
TELEPHONE: 301 224 3332
ASSOCIATION STATE DATE: 03/22/2016
ASSOCIATION FREQUENCY: MONTHLY
ASSOCIATION END DATE: 09/24/2017
NO OF VISITS: 18
DIAGNOSIS: SITUATIONAL DEPRESSION (DUE TO DEATH OF PARENT)
TREATMENT PRESCRIBED: MONTHLY TALK THERAPY; FLUOXETINE – 40 MG DAILY
(TO INCLUDE MEDICATIONS)
PROGNOSIS: VERY GOOD TO EXCELLENT
COMPLIANT WITH TREATMENT: YES
REFERRED FOR ADDITIONAL TREATMENT?: NO
HOSPITALIZATION?: NO
DOES SUBJECT HAVE A CONDITION THAT COULD IMPAIR HIS/HER JUDGMENT, RELIABILITY, OR ABILITY TO PROPERLY SAFEGUARD NATIONAL SECURITY INFORMATION?: NO
REMARKS:
SUBJECT’S PRIMARY CARE PHYSICIAN REFERRED HER FOR TREATMENT OF SITUATIONAL DEPRESSION DUE TO THE UNEXPECTED PASSING OF HER MOTHER. SUBJECT COMPLAINED OF CONSTANT SADNESS, ANGER AND INSOMNIA. IN ADDITION TO MONTHLY ONE ON ONE COUNSELING SESSIONS, SUBJECT WAS PRESCRIBED PROZAC (40 MG DAILY). SIGNIFICANT IMPROVEMENT WAS OBSERVED IN SUBJECT AFTER THREE MONTHS. SUBJECT CONTINUED WITH PRESCRIBED THERAPY UNTIL SHE FELT SHE WAS ON SOLID GROUND AND CONFIDENT THAT SHE NO LONGER NEEDED THERAPY. SUBJECT’S LAST 30-DAY PROZAC PRESCRIPTION WAS WRITTEN ON 08/21/2017 AND HER LAST COUNSELING SESSION WAS ON 09/24/2017. SUBJECT’S PROGNOSIS IS VERY GOOD TO EXCELLENT.
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MEN
TAL H
EALTH
MEN
TAL H
EALTH
MEN
TAL H
EALTH
MEN
TAL H
EALTH
EXAMPLE: MENTAL HEALTH RECORD EXCALIBUR MEDICAL RECORD ROI EXAMPLE (NO CONDITION IMPACTING JUDGMENT, RELIABILITY, OR TRUSTWORTHINESS) SUBJECT Name: Harrison, David Inquiry Date: XX/XX/XXXX AIN: 12345 Investigator: Dyson, Alfred Interview Method: In Person RECORD Source First Name: Harold Middle Initial: G. Last Name: Robinson Source Title: Psychiatrist Medical Facility/Organization: Prince William Family Health Services Address: 105 Sudley Road City: Manassas State: VA Zip Code 20112 Telephone: 703 254-2233 Ext: Specific Data Clerk Last Name: Jamison Clerk First Name: Katrina Clerk Title: Administrative Assistant Clerk Phone Number: 703 254-2233 Records: Released Remarks: SUBJECT does not have a condition that could impair his judgment, reliability, or trustworthiness.
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REP
OR
TING
GU
IDE
R
EPO
RTIN
G G
UID
E
REP
OR
TING
GU
IDE
R
EPO
RTIN
G G
UID
E