Border Crossing Survey

U.S. Embassy Jerusalem Incident Reporting Form

Recent Entry or Entry Request at an Airport, Land Border Crossing, or Seaport Where the Government of Israel Administers Security and Immigration Controls

Thank you for visiting our webpage. Please use this form to report any instances where you were denied entry or subjected to discriminatory treatment at an airport, land border crossing, or seaport where the Government of Israel administers security and immigration controls. The U.S. Embassy may follow up as needed.

PRIVACY ACT STATEMENT:

Authorities: The information is sought pursuant to 5 U.S.C. 552a (Privacy Act), 22 U.S.C. 2656 (Management of Foreign Affairs), 22 U.S.C. 3904 (Functions of Service), and the Vienna Convention on Consular Relations.

Purpose: The information solicited on this form will be used by the Consular Section of U.S. Embassy Jerusalem to assist U.S. citizens located overseas.

Routine Uses: This information may be disclosed to U.S. and foreign government authorities in connection with your case and when we work with various entities and individuals in accordance with certain approved routine uses. More information on the Routine Uses for the system can be found in System of Records Notices State-05, Overseas Citizen Services Records and other Overseas Records, State-26, Passport Records, and the Department’s Prefatory Statement on Routine Uses.

Disclosure: Providing information to the U.S. Embassy or Consulate is voluntary, but without it the Department may find it difficult to assist you.

OMB Control Number: 1405-0260

Expiration Date: 05/31/2024

0. 1- Are you a U.S. citizen (pick one)?

1. a. Yes

2. b. No

2. 2- Do you have a valid U.S. passport (pick one)?

3. a. Yes

4. b. No

3- Please write out your full name exactly as it appears on your U.S. passport.

4- Please write your date of birth (please input MM/DD/YYYY) as it appears on your U.S. passport.

5- Please write your place of birth as it appears on your U.S. passport.

0. 6- Which gender below best matches you (pick one)?

1. a. Female (F)

2. b. Male (M)

3. c. Nonbinary (X)

0. 7- What document did you present to Israeli officials to enter the country (pick one)? Please pick the document that most closely matches what you presented. a. My U.S. passport

1. b. My passport from another country

2. c. My Palestinian Authority passport/ID or East Jerusalem ID

3. d. Other

0. 8- Did you have a valid visa or permit for entry?

1. a. Yes

2. b. No, I was denied for not having a valid visa or permit

3. c. No, a visa or permit was not required for my stated purpose of travel

0. 9- I am a dual citizen or national of or hold travel documents from (please select all that apply):

1. a. Israel

2. b. Palestinian Authority

3. c. Other

4. d. Not Applicable

10- What is the purpose of your visit (pick one)?

0. a. Short term visit to Israel not to exceed 90 days for business or tourism

1. b. Transit through Israel to or from the West Bank

2. c. Long term visit to Israel for more than 90 days

3. d. Resident of Israel

11- Please write the name of the airport, land border crossing, or seaport where you crossed or tried to cross.

12- Date of interaction - when did the incident occur? (Please input date MM/DD/YYYY)

13- If you were denied entry, were you provided with a reason for denial?

a. Yes, I was provided with a letter explaining why I was denied

b. Yes, I was verbally told why I was denied

c. No, I do not know why I was denied

d. I was not denied entry

14- Please describe what happened, and if applicable, include how you were discriminated against and by whom. Please include any biographic data that you think is relevant to the discrimination including but not limited to your ethnicity, nationality, or religion.

15- If you would be willing to discuss this incident with a U.S. Embassy Jerusalem official, please enter your e-mail or telephone number below.

Thank You For Your Submission

We want to thank you for the information regarding a denial of entry or report of discrimination connected to an entrance into Israel through the airport, seaport, land border, or through one of the West Bank or Gaza crossings.

The American Citizen Services (ACS) Unit from either the U.S. Embassy in Jerusalem or the Branch Office in Tel Aviv may follow up with you by email or via

telephone.

Please hit the submit button below to finalize the submission.