Form P-8 Care Provider Checklist for Transfers to Influx Care Fac

OMB 0970-#### [Valid through MM/DD/2020]

Office of Refugee Resettlement

U.S. Department of Health and Human Service

Care Provider Checklist for Transfers to an Influx Care Facility, Rev. 09/20/2016

OFFICE OF REFUGEE RESETTLEMENT

Division of Children’s Services

CARE PROVIDER CHECKLIST FOR TRANSFERS TO AN INFLUX CARE FACILITY

IDENTIFYING INFORMATION
UC’s Name:       A#:       UC’s Date of Birth:       UC’s Date of Admission to ORR:       UC’s Date of Transfer:      	Receiving Influx Care Facility:       Referring Care Provider:       UC Case Manager’s Name:       UC Clinician’s Name:       ORR Reviewer’s Name:      
ASSESSMENTS (initial completion within 5 days of admission)
		Fully Completed in UAC Portal	Completion Date
Initial Intakes Assessment (within 24 hours of admission)			     
UC Assessment (within 5 days of admission)			     
Assessment for Risk (within 72 hours of admission)			     
Individual Service Plan (within 5 to 6 days of admission)			     
LEGAL SERVICES
		Completed and Uploaded to UAC Portal	Completion Date
Legal Representation List (signed acknowledgement within 48 hours of admission)			     
Know Your Rights (presentation and signed acknowledgement with 14 days of admission or video and signed acknowledgement within 7 days of admission)			     
Legal Screening (within 7 to 10 days of admission)			     
MEDICAL SERVICES
		Completed and Uploaded to UAC Portal	Completion Date
Initial Medical Exam Form			     
TB Screening Ages 13-14: PPD or IGRA Ages 15-17: PPD or IGRA; and Chest X-ray			     
HIV Testing (document if UC opts out of testing)			     
Pregnancy Testing for Eligible Females (test prior to administration of vaccines; defer live vaccines during pregnancy)			     
Immunizations for 13-17 Year Olds (according to the ACIP catch-up schedule, administered at least 72 hours prior to physical transfer) Tdap (tetanus, diphtheria, pertussis) Hepatitis A Hepatitis B Varicella (chickenpox) IPV (inactivated poliovirus vaccine) MMR or MMRV (measles, mumps, rubella) MCV4 (meningococcal disease) HPV (human papillomavirus) Flu (when seasonably available – generally, September through June)			     
Follow-up laboratory tests and consultations completed (as indicated)			     
Medical Checklist for Influx Transfers completed (Medical Coordinator Initials: ­           )			     
		Confirmed	Date Confirmed
Child clear of all contagious conditions (includes scabies and lice)			     
No known medical, dental, or mental health issues requiring additional evaluation, treatment, or monitoring by a healthcare provider			     

TRANSFER REQUEST
	Completed in UAC Portal		Completion Date
Transfer Request			     
Program Exit			     
TRANSFER DOCUMENTATION AND ITEMS (ensure the following documentation and items accompany each UC at the time of transfer in a secure manner)
		Confirmed at Time of Physical Transfer
UC’s personal belongings including clothing, money, valuables, and items obtained during the UC’s stay at the referring care provider
Thirty (30) day medication supply
Care Provider Family Reunification Checklist
Care Provider Checklist for Transfers to Influx Care Facilities
Transfer Request and Tracking Form
Transfer Manifest
DHS Form I-862 Notice to Appear (NTA), if available
Copy of sponsor’s birth certificate
Copy of medical and vaccination documents
All original documents (e.g., birth certificates)
List any food allergies:      
FINAL MEDICAL CHECKS (done at time of physical transfer)
		Confirmed at Time of Physical Transfer
UC checked and determined to be clear of lice and rash (within 24 hours of physical transport)
UC’s temperature checked and found not to be elevated (immediately before the UC boards the transport vehicle)
CASE MANAGER AFFIRMATION (done at time of physical transfer)
I declare and affirm that the information contained in this checklist is true and accurate to the best of my knowledge. I attest that all assessments, legal services, medical services, and transfer request documentation have been fully and accurately completed and that they have been save in or uploaded to the UAC Portal. I attest that all transfer documentation and items have been physically provided to the UC in a secure manner. I attest that the UC was checked for lice and determined to be clear of lice within 24 hours of physical transport and that the UC did not present with an elevated temperature at the time they boarded the transport vehicle. I have noted below and given an acceptable explanation for any instances in which documentation has not been fully completed or documentation and/or items were not physically provided to the UC. List required documentation and/or items not available and explanation:       SIGNATURE OF CASE MANAGER: ­____________________________________________________ DATE:      

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to ensure that all criteria for transfer of a UAC to an influx care facility have been met. Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact [email protected].