Form 1 UAC Assessment

Office of Refugee Resettlement

Division of Children’s Services

UAC Assessment

UAC Information

Name:      

Date of Birth:      

A#:      

Country of Origin:      

City of Origin:      

Neighborhood of Origin:      

Current Placement:      

Previous Placement:      

Date of Admission:      

LOS:    

Case Manager:      

Clinician:      

Religious Affiliation:      

Journey and apprehension

Describe day to day life in home country:      

Why did you decide to travel to the U.S. at this time?      
Did the child mention any U.S. immigration policy or practice as a factor in his/her decision to travel to the U.S.? Yes No

For UAC aged 14-17 ONLY: Did the child mention economic, job, or educational opportunities as a factor in his/her decision
to travel to the U.S.? Yes No

When did you leave your home country (month, day, year)?      
How long did the trip take?      

How did you get to the U.S.?      

Who did you travel with?      

Who were you living with when you decided to leave your home country?      

Where were you planning on living in the U.S. and with whom?      

Where were you apprehended?      
At which U.S. Border Patrol sector did the child cross into the U.S.?      

Have you ever been to the U.S. before? Yes No If yes, when?      

The child’s experience and additional Information regarding the journey and apprehension:      

Family/significant relationships

Family in Country of Origin

Name	Age	DOB	Relationship
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

Family and Family Friends in the U.S.

Name	Age	DOB	Relationship
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

Parent’s whereabouts?      

Are you married? Yes No Spouse Name, Age, & Location:      

Children

Name of Child	Age	DOB	Current Location of Child	Name of Mother or Father
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     

Have you ever been hurt physically, mentally, or emotionally by someone taking care of you? Yes No

If yes, who and when?      

Have you ever been taken to the hospital/emergency room because you were hurt? Yes No

If yes, explain:      

What does the word “discipline” mean to you?      

Additional family information:      

MEDICAL

List any allergies:      

Do you feel unwell? Yes No

If yes, what are your symptoms?      

Additional medical information:      

Medical History

Condition		Date of Diagnosis/Clarification
Pregnant	Yes No	If yes, how far along?      
Tuberculosis	Yes No	     
Varicella	Yes No	     
Measles	Yes No	     
Mumps	Yes No	     
Rubella	Yes No	     
Asthma	Yes No	     
Diabetes	Yes No	     
Cancer	Yes No	     
Cardiac Issues	Yes No	     
Sexually Transmitted Disease	Yes No	Specify:      
Respiratory/Lung Disorder	Yes No	     
Physical Disability	Yes No	Specify:      

Medication History

Medication	Dosage	Timeframe	Medical Condition
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

education

What is the highest level of education you have completed?      

When was the last time you were in school? What age?      

Legal

Know Your Rights Presentation provided?	Yes No	Date:      
Legal screening completed?	Yes No	Date:      
Any possible legal relief identified?	Yes No	Specify:      

Criminal history

Any Criminal history? Yes No

List any Felony convictions:      

List any Misdemeanor convictions:      

List any Probation/Parole:      

List and describe any disclosed criminal activity:      

Additional information:      

History of Incarceration

Crime	Dates	Length of Sentence	Location
     	     	     	     
     	     	     	     
     	     	     	     

Mental health/behavior

Mental Status Evaluation

Attitude	calm and cooperative			other (describe):      
Behavior	no unusual movements or psychomotor changes other (describe):      
Speech	normal rate/tone/volume			other (describe):      
Affect	reactive and mood congruent labile tearful blunted other (describe):			normal depressed constricted flat
Mood	euthymic irritable elevated			anxious depressed other (describe):      
Thought Process	goal-oriented and logical disorganized other (describe):      
Thought Content	Suicidal Ideation				Homicidal Ideation
	None passive active				None passive active
	If active				If active
		Yes	No			Yes	No
	plan				plan
	intent				intent
	means				means
	delusions phobias			obsessions/compulsions other (describe):      
Perception	no hallucinations or delusions during interview other (describe):
Orientation	Oriented: time place person self other (describe):      
Memory/Concentration	short term intact distractable/inattentive			long term intact other (describe):      
Insight/Judgment	good fair poor

Mental Health

		When
Have you ever talked to a psychiatrist, psychologist, therapist, social worker or counselor about an emotional problem?	Yes No	     
Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your emotional problems?	Yes No	     
Have you ever been advised to take medication for anxiety, depression, hearing voices or for any other emotional problems?	Yes No	     
Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?	Yes No	     
Have you ever heard voices no one else could hear or seen objects or things that others could not see?	Yes No	     
Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and making decisions or thought about killing yourself?	Yes No	     
Did you ever attempt to kill yourself?	Yes No	     
Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare, gang fights, fire, domestic violence, rape, murder, accident, being killed (If yes, please specify)	Yes No	     
Have you ever given in to an aggressive urge or impulse on more than one occasion that resulted in serious harm to others or led to the destruction of property?	Yes No	     

Substance Use History

Substance	Used (even once)	Frequency of Use	Date of Last Use
Alcohol	Yes No	     	     
Marijuana	Yes No	     	     
Cocaine	Yes No	     	     
Other Stimulants (Meth, Ritalin, etc.)	Yes No	     	     
Heroin	Yes No	     	     
Other Opiates (Oxycodone, Morphine, etc)	Yes No	     	     
Nicotine	Yes No	     	     
Other (specify)	Yes No	     	     

Additional mental health/behavioral information:      

Trafficking

Who planned/organized your journey?      

Did a family member or family friend pay for your travel to the U.S.? Yes No

What were you told about the arrangements before the journey?      

Did the arrangements change during the journey? Yes No

If yes, how?      

Does your family or family friend owe money to anyone for the journey? Yes No

If yes, how much?      

To whom is the money owed?      

Who is expected to pay?      

What do you expect to happen if payment is not made?      

Coercion Indicators

Did anyone threaten you or your family? Yes No

If yes, who made the threats?      

Were you ever physically harmed? Yes No

If yes, how?      

Was anyone around you ever physically harmed? Yes No

If yes, who?      

Were you ever held against your will? Yes No

If yes, where?      

Did anything bad happen to anyone else in this situation or anyone else who tried to leave? Yes No

What happened and to whom?      

Did anyone ever keep/destroy your documents? Yes No

If yes, who and what?      

Did anyone ever threaten to report you to the police/immigration? Yes No

If yes, who?      

Are you worried anyone might be trying to find you? Yes No

If yes, who?      

Debt Bondage/ Labor Trafficking

Did you perform any work or provide any services? Yes No

If yes, what and where?      

Who arranged the work?      

What type of work did you perform?      

What was the work schedule?      

Did work conditions change over time?      

Is there a debt? Yes No

If yes, has any debt amount increased?      

By how much?      

When did it increase?      

Why did it increase?      

Have you or your family ever been threatened over payment or work for the journey? Yes No

If yes, who threatened you and how?      

What did you expect would happen if you left the job or stopped working?      

Were you ever made to work or do anything you did not want to do? Yes No

Did you receive pay or did someone else keep the pay?      

Were you paid what was promised when you started working?      

Were expenses taken out of the pay? Yes No

If yes what?      

How did you get to the work site?      

Where did you live while working?      

Commercial Sex Indicators

Did anyone ever ask you to see you naked or in your underwear in exchange for money/anything of value? Yes No

Did anyone ever pay/accept money/anything of value from other people in order to see you naked or in your underwear?

Yes No

Did anyone ever ask to take pictures or record you naked or engaged in sex acts? Yes No

If so, did they offer you money/anything of value to do this, or did they accept money/anything of value from others in order to see these pictures or recordings? Yes No

Did anyone ever ask or expect you to perform sexual acts in exchange for money/anything of value? Yes No

Did anyone ever promise or give money/anything of value to you in exchange for sexual acts? Yes No

Based on the information provided above in the “Trafficking” section, is there a trafficking concern? Yes No

If yes, date of trafficking referral:      

Additional information:      

Sponsor information (list by priority)

Current Sponsor	Cat (1,2,3)	Sponsor Name	DOB	Address	Phone/Email	Legal Status	Relationship
	     	     	     	     	     	     	     
	     	     	     	     	     	     	     
	     	     	     	     	     	     	     

Sponsor Risk Assessment (must be completed for all current sponsors)

Substance abuse concerns? Yes No

If yes, explain:      

Domestic violence concerns? Yes No

If yes, explain:      

Child abuse or neglect concerns? Yes No

If yes, explain:      

Mental health issues? Yes No

If yes, explain:      

Does the sponsor have any family support? Yes No

Specify:      

Does the sponsor have any identified special needs? Yes No

If yes, explain:      

Does the sponsor have adequate financial means? Yes No

Explain:      

Does the sponsor have adequate housing? Yes No

Explain:      

Are there any concerns with the disciplinary practices/philosophy of the sponsor?      

Does the sponsor have any criminal history? Yes No

List any Felony convictions:      

List any Misdemeanor convictions:      

List any Probation/Parole:      

List and describe any disclosed criminal activity:      

History of Incarceration
Crime	Dates	Length of Sentence	Location
     	     	     	     
     	     	     	     
     	     	     	     

Are there any parent/child relational issues? Yes No

If yes, explain:      

Does the sponsor have an Order of Removal Yes No

If yes, date issued:      

Has the sponsor sponsored any other UAC in DCS care? Yes No

Name of UAC	Alien Number	Relationship	ORR Facility Sponsored From
     	     	     	     
     	     	     	     
     	     	     	     

Additional sponsor information:      

mandatory tvpra 2008

Based on the most recent trafficking screening, is the child a victim of a severe form of trafficking in persons? (Indicate ‘yes’ only if ORR has issued a trafficking eligibility letter for the UAC.) Yes No

Date eligibility letter issued:      

Based on the most recent screening for disabilities, does the child have a disability as defined in section 3 of the Americans with Disabilities Act of 1990, 42 U.S.C. § 12102(1)? Yes No

If yes, specify disability:      

Based on the most recent screening, has the child been a victim of physical or sexual abuse under circumstances that indicate that the child’s health or welfare has been significantly harmed or threatened? Yes No

If yes, provide a short summary :      

Based on the sponsor risk assessment, does the sponsor clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the UAC? Yes No

If yes, provide a short summary:      

Additional information

     

Certification

Signature:

     

Date:

     

Print Name:

     

Title:

     

Signature:

     

Date:

     

Print Name:

     

Title:

     

Signature:

     

Date:

     

Print Name:

     

Title:

     

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