excalibur roi examples

EXCALIBUR ROI Examples

LAST UPDATE: 8/12/2021 | EXCALIBUR ROI Samples | | PROPRIETARY AND CONFIDENTIAL | 1

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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

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SUBJECT INTERVIEW IDENTIFICATION:

RESIDENCE:

EDUCATION:


SUB

JECT IN

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SU

BJEC

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SUB

JECT IN

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BJEC

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EMPLOYMENT / SELF-EMPLOYMENT / UNEMPLOYMENT:

MILITARY SERVICE:

MARITAL STATUS / COHBITANT:

FAMILY AND ASSOCIATES:


SUB

JECT IN

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SU

BJEC

T INTER

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SUB

JECT IN

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SU

BJEC

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VIEW

FOREIGN TRAVEL / PREFERENCE:

FOREIGN CONTACTS / INFLUENCE:

ILLEGAL ACTIVITY / POLICE RECORD:

NON-CRIMINAL COURT ACTIONS:


SUB

JECT IN

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SU

BJEC

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SUB

JECT IN

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SU

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DRUG/SUBSTANCE MISUSE:

ALCOHOL CONSUMPTION:

FINANCES / CREDIT REPORT:

PSYCHOLOGICAL CONDITIONS / PRESCRIPTION MEDICATION:

SECURITY PRACTICES / HANDLING PROTECTED INFORMATION:

MISUSE OF INFORMATION TECHNOLOGY:

MEDIA CONTACTS / PUBLICATIONS:


SUB

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SUB

JECT IN

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SU

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ORGANIZATIONAL AFFILIATIONS:

EXTERNAL / FREE-TIME ACTIVITIES:

ALLEIGANCE / LOYALTY:

BLACKMAIL / COERCION / DURESS:

INTERVIEW IMPRESSIONS:


BIR

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BIRTH RECORD EXAMPLE : BIRTH RECORD (BIRTH CERTIFICATE)

EXAMPLE: BIRTH RECORD (PASSPORT)


CITIZEN

SHIP

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CITIZEN

SHIP

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CITIZEN

SHIP

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CITIZEN

SHIP

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BIR

TH

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BIR

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CITIZENSHIP RECORD

EXAMPLE: CITIZENSHIP RECORD


Finge

rprin

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Fin

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Finge

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Fin

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Finge

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FINGERPRINTS EXAMPLE: FINGERPRINTS (NOTE: BOXES INDICATED WITH ARROWS ARE PREPOPULATED)


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RESIDENCE

EXAMPLE 1: REPORTING RESIDENCE (BEST SOURCE) ASSOCIATION:

RESIDENCE:

EDUCATION:

EMPLOYMENT/SELF EMPLOYMENT/UNEMPLOYMENT:

MILITARY SERVICE:

MARITAL STATUS/COHAB:


FOREIGN TRAVEL/PREFERENCE:

FOREIGN CONTACTS/INFLUENCE:

ILLEGAL ACTIVITIES/POLICE RECORD:


DRUGS/SUBSTANCE MISUSE:


FINANCES/CREDIT REPORT:


RESID

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ESIDEN

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RESID

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ESIDEN

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PSYCHOLOGICAL CONDITIONS/PRESCRIPTION MEDICATION:

SECURITY PRACTICES/HANDLING PROTECTED INFORMATION:


MEDIA CONTACTS/PUBLICATIONS:


EXTERNAL/FREE TIME ACTIVITIES:

ALLEGIANCE/LOYALTY:

BLACKMAIL/COERCION/DURESS:

ADDITIONAL INFORMATION:

EXAMPLE 2: REPORTING RESIDENCE (INDIRECT VERIFIER) ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:



RESID

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RESID

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ALLEGIANCE/LOYALTY:



RESID

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EDU

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EDUCATION

EXAMPLE: EDUCATION REFERENCE 1 (PROFESSOR) ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:










EDU

CA

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UC

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EDU

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ALLEGIANCE/LOYALTY:



EXAMPLE: EDUCATION REFERENCE 2 (CLASSMATE) ASSOCIATION:

RESIDENCE:

EDUCATION:



EDU

CA

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UC

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EDU

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UC

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BIR

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MILITARY SERVICE:
















ALLEGIANCE/LOYALTY:




EDU

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UC

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EDU

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BIR

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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.


EMP

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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:


MILITARY SERVICE:






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.


EMP

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ALLEGIANCE/LOYALTY:




EMP

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EXAMPLE: EMPLOYMENT REFERENCE 2 (COWORKER) ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:










EMP

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T/MILITA

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ALLEGIANCE/LOYALTY:




EMP

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EXAMPLE: MILITARY REFERENCE ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:












EMP

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ALLEGIANCE/LOYALTY:




EMP

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EXAMPLE: UNSUCCESSFUL EMPLOYMENT REFERENCE


EMPLOYMENT / MILITARY RECORD

EXAMPLE: EMPLOYMENT RECORD

Remarks: *

EXAMPLE: MILITARY RECORD (REMARKS) Remarks: *

- Unsuccessful Lead

Smith, Jane








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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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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.


EMP

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UNEMPLOYMENT

EXAMPLE: UNSUCCESSFUL UNEMPLOYMENT

EXAMPLE: UNEMPLOYMENT REFERENCE ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:








EMP

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ALLEGIANCE/LOYALTY:




EMP

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ENT/M

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EMP

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EXAMPLE: UNEMPLOYMENT RECORD


EMP

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EXAMPLE: UNSUCCESSFUL UNEMPLOYMENT REFERENCE


- Unsuccessful Lead

Smith, John




CHARACTER REFERENCES: LISTED REFERENCES (LCR)

EXAMPLE: LISTED CHARACTER REFERENCE ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:

















ALLEGIANCE/LOYALTY:




CHARACTER REFERENCES: DEVELOPED REFERENCES (DCR)

EXAMPLE: DEVELOPED CHARACTER REFERENCE ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:

















ALLEGIANCE/LOYALTY:




FORMER SPOUSES

EXAMPLE: EX-SPOUSE REFERENCE

ASSOCIATION:

RESIDENCE:

EDUCATION:


MILITARY SERVICE:








ALLEGIANCE/LOYALTY:




LOC

AL A

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ECK

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LOC

AL A

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ECK

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LOCAL AGENCY CHECKS (LAC)

EXAMPLE: POLICE/ARREST RECORD


LOC

AL A

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LOC

AL A

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COURT RECORDS

EXAMPLE: COURT RECORD

Remarks: *


LOC

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LOC

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BANKRUPTCY RECORDS

EXAMPLE: BANKRUPTCY RECORD


LOC

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DIVORCE RECORDS

EXAMPLE: DIVORCE RECORD Specific Data: *

Remarks: *






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.


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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